Reaction to Acts of Terror
My day at the psychiatric department at the general hospital in Tel Aviv, Israel, started quite routinely. In my room I had a young woman suffering from fear of flying and in the waiting room was a client suffering from allergies. The phone rang. The ringing of the phone during a session, especially in the middle of a relaxation exercise, always disturbs me. I had explained to my secretary several times that she should refrain from transferring calls during treatment sessions. I knew from experience that a phone ring makes the deeply relaxed client jump up and may sometimes cause additional anxiety. However, I had no choice but to answer the phone. I asked my client to continue imagining that she was very relaxed while flying to her vacation destination. During the flight she looks through the window and enjoys the view. I suggested that she treat the phone call as if her neighbor on the flight was using a satellite phone and that it does not take anything away from her enjoyment of watching the view from the plane.
The secretary's voice was very tense: "Go to the emergency room immediately! There was another suicide attack in the Tel Aviv Carmel market and numerous people have been hurt. The psychiatrist on duty asked for your help."
With lightening speed I made my client land the imaginary airplane safely and ended her relaxation exercise. I explained to her that I had to go to the emergency room and we set up another appointment. I also rescheduled my other client's appointment and ran to the emergency room. I felt fear and anger flooding me. Another mass suicide attack! Horror photos on television again, blood in the streets, people with severed limbs, interviews with eyewitnesses, family members crying
In the entrance to the emergency room dozens of people were milling around. They wanted to know about the condition of their relatives.
I pushed my way through the crowd and got inside. I was well familiar with this chilling picture: doctors running to and fro, stretchers everywhere, tension in the air. I approached the nurse in charge. We were old friends, having been through many similar events. She sent me over to two female patients that were lying next to each other, each surrounded by family members. The psychiatrist was standing next to one of the beds and he motioned for me to approach him. He wanted to share with me the information received from a family member of one of the patients. "The woman is in a state of Hypertonia. It's a hysterical reaction to trauma" the psychiatrist went on to explain, "Her husband tells me that about a year ago she was hurt by a fragment of a grenade thrown at them by a terrorist while they were waiting in line to a movie. Since then she has suffered from PTSD (Post-Traumatic Stress Disorder). She has difficulty falling asleep at night. When she does fall asleep, she is awakened by nightmares in which she sees dead people. After her injury she would not leave the house. For the last few months she has been undergoing psychological treatment, which has helped her. In the last few weeks she started going out of the house but only when accompanied by her husband. Unfortunately for her, she found herself again in the vicinity of a suicide attack."
I thanked the psychiatrist for the information and approached the woman's bed. She was lying with her eyes closed. She was about 40 years old. I introduced myself. The man introduced imself as her husband, and the three women next to her, as her mother and sisters. He told me that they went to the outdoor market to do some shopping when all of a sudden there was a suicide attack. The woman started to panic and fell to the ground. Since then she has been unconscious, lying in bed motionless. The husband said with tears in his eyes, "It has been three hours since she went into this state. She's not responding to anything. She looks like a corpse. The doctor says she's alive, that it's only the shock. Doctor, maybe she's alive but maybe her brain is dead." Her mother and sisters started crying too.
I tried to initiate verbal contact with the patient but she did not respond. I lifted her hand about four inches and then dropped it. The hand landed like a heavy rock. I felt embarrassed. I had treated numerous cases of panic but have never seen anything like this. From my experience in dealing with traumatic experience, the physical reaction is high muscle tone - the body puts itself into a state of emergency and is ready for
"Fight or Flight."
This woman's muscle tone is close to zero. I was at a loss to understand her psychological and physical reaction.
The psychiatrist looked at me full of expectation that I will do something. I am recognized in the department as the expert for treating anxiety. The husband and two sisters had also been looking forward to my arrival in the emergency room. Everybody awaited my decision but I did not know what to do. I recalled seeing several patients who suffered a brain injury and as a result looked like this patient; they did not react to their surroundings. They were dubbed "vegetables." Their relatives would sit next to them day and night and talk to them, although the patients did not react at all. There were cases in which the patient would wake up after a while and claim that he remembered being spoken to but not being able to react. I decided to employ a similar method. If it did not help the patient, at least it would help the family members feel less helpless. I suggested to her family members that they talk to her, reassure her. Tell her that all her family members are well, that they love her and await her awakening. They gladly accepted my suggestion.
I turned my attention to the woman in the next bed, who was visibly agitated. Her entire body was shaking incessantly. I asked her name. She did not react. Her husband answered in a heavy Russian accent, "We have been in Israel for only close to a year. I learned basic Hebrew due to my work but she stays home most of the day taking care of our little son. She was on her way to the Carmel market when the suicide attack took place. She has always been afraid to go to the market. She said it was a place that invited attacks. In the past, whenever we were shopping there, she would be very tense. She wanted to finish shopping as quickly as possible and go back home. When she heard the explosion and saw people running, she went into a state of shock. Somebody took her to where the injured were being taken and from there she was brought to the emergency room. Since the time of her admission, she was confused and unable to provide her personal information. The admissions clerk found my phone number in her purse and this way I made it to the hospital within a short time. The doctor who had examined her for a few minutes promised to come back when he had time. However, there are many serious injuries and I understand that the doctor has been very busy. I don't know how to calm her down. Maybe you do."
"Is she typically a strong woman or is she sensitive and easily frightened?" I asked the husband. "She is a very strong woman. In Russia she was always very self assured. She knew how to demand what was due her with great assertiveness. She even studied karate. Since we came to Israel she has changed. She lost her self confidence. Due to her difficulties with the Hebrew language, she cannot make friends with the neighbors and even avoids going to the grocery store. She became very dependant on me, which makes it hard on both of us. But I know that deep inside she is still a very strong woman."
"What am I supposed to do with her," I ask myself. Thoughts race through my mind with lightening speed. I have never seen such an extreme physical reaction. All her limbs are shaking non-stop. Is this a sign that her body is flooded with stress hormones? Obviously, in this condition relaxation exercises are out of the question. Perhaps the way to stop the shaking is by activating the muscles even more vigorously? Many times I explained to patients complaining of shaking limbs that their body works like a car. In this car the driver steps on the gas pedal and the brake pedal at the same time. The car shakes due to the excessive energy pushed on it but does not budge. To stop the car from shaking, the brake must be released and the car must be allowed to go forward at great speed. Maybe this is the treatment method for this patient as well?
I turned to the patient and told her to shake her body even harder, to lift up and then drop her arms and legs, to move her head in all directions, to move her body with greater force. She obeys. I urged her to exaggerate her movements. Again she obeys. Since I saw that she began to control her muscles that previously she could not control, I decided to intensify the force of her movements. I suggested to her to clench her fists and punch the bed with force. She did it. She was a strong woman; she punched forcefully. I ask her name and she replies in a heavy Russian accent.
She told me, in her poor Hebrew, that she immigrated to Israel from the Soviet Union a year ago. She still feels foreign in this country. She cannot get a handle on the language. She cannot deal with the summer heat, the fear of terrorists. I turned to her husband and told him to ask her what she felt towards the suicide bomber.
"I hate him, I'm glad that he's dead," she responded in Hebrew with a heavy Russian accent. "If you could send him in the after-world some Russian words that express your feelings towards him, what would you tell him?" Her husband translated my question into Russian. She mumbled softly some Russian phrases. Although I did not understand a word, I needed no interpreting. Her tone and body language indicated to me what she wished on that terrorist. The wide smile on the husband's face showed me that he liked the message she sent the terrorist and maybe he identified with her feelings.
I decided to continue in the direction I began and to intensify the effort. I addressed the husband again and asked him to encourage his wife to express verbally the pent up anger she felt towards the suicide bomber. He should direct her not to scrimp on Russian curses. The husband hesitated. He indicated that many of the emergency room employees were new immigrants from Russia and it would sound strange to them to hear her curse in Russian out loud. I calmed him down. I told him that some of my clients had cursed that way in Hebrew. In fact, the employees enjoy it because they identify with the patient's anger; the patient expressed out loud what the staff would like to say but could not afford to do so. The husband agreed to convince his wife to go ahead and apparently it was a big success. The woman started cursing in Russian with all her might. Although I still do not understand a word, I identify with the expressions of anger she put forth.
Since I noticed that her legs and arms are still shaking, albeit not as vigorously, I decided to direct her towards an even more physical expression of anger. I asked the husband to instruct her to kick the air as if she were kicking the terrorist's head, to squeeze her fists tightly and hit the bed as if she were punching his body. She performed these activities with great intensity. Two Russian nurses who happen to be nearby came closer and egg her on in Russian to continue cursing, hitting and punching. I decided to increase her physical activity even further. I asked the husband to help her get out of bed and walk around the room while moving her entire body. She did so willingly. She started walking around the room and throwing karate kicks in every direction, while sounding the typical battle cries of a karate fighter. The Russian nurses applauded her and she started smiling. I suggested to the husband that he take her home and encourage her to write a letter in Russian to the suicide bomber's parents. In her letter she should express her anger towards him and his parents who brought him up to commit suicide and kill innocent people.
Before saying good-bye I explained to the husband the reasons for his wife's behavior, so that he would be able to explain to her what she had gone through in the convenience of their home. It was important for me to make them understand that her reaction was completely normal, though more extreme than usual, mainly due to her being a new immigrant.
"Your wife's reaction is based on a ancient instinct that helped the survival of our forefathers in the forests," I told him. "We, human beings, belong to the territorial type of animals, i.e. those that live in a determined living space. Every territorial animal feels more secure moving around in its own living space, where it is familiar with its surroundings. It knows where the predators are hiding, where there are tall trees it can climb or deep caves it can hide in during times of danger. When such an animal is transferred to another living space, when it is separated from its primary group, it feels insecure. In such a situation the level of stress hormones in its blood rises as the animal is preparing for a survival reaction. This is what happened to your wife. From the time you immigrated to Israel your wife has felt like an animal transferred to a territory. On the one hand, she has lost contact with her family and friends in Russia and on the other hand, she has not yet developed new connections with the people surrounding her to instill in her a feeling of safety and belonging.
These emotions cause her to be overly cautious. When she heard the explosion in the market, her survival instinct caused her body to be flooded with a very high level of stress hormones. All her body muscles contracted, ready to pounce on the "predator from the market," or to flee and climb the nearest tree. The problem is that without a proper outlet, the muscles get tired and start trembling. This reaction is proper for coping with dangers of the forest. In that situation the energy was immediately used for
"Fight or Flight."
However, in the modern world things are much more complex. "The wild animal from the market" has already blown himself to smithereens and
there is no use for climbing a tree anymore. If she ever goes through a similar experience in the future, you should encourage her to engage in an imaginary war against the agent that caused her to feel afraid. It is important to encourage her to express her anger both verbally and
physically."
The husband thanked me for the explanation and said, "In Russia we studied the theory of evolution a lot. When you told me about
"Fight or Flight."
I came up with an explanation for another phenomenon. My wife told me that when she heard the explosion boom, her body froze in place. After
several minutes she started shaking all over. Many animals, when they are startled by a sudden noise freeze in place. Maybe the survival
purpose of freezing in place is to camouflage them, so that the predator would not notice them." I thank the husband for his comment, say
good-bye to the couple and they were released home.
I turned again to the first woman who was still lying motionless. It seemed that the screams in Russian had a beneficial effect on her. Her eyes are now open and her husband was stroking her hair gently. The husband said that his wife woke up and was feeling much better. He said that he and her two sisters kept telling the woman over and over that her children were well and waiting for her at home, that all her family members love her and are looking forward to her return home.
I ask the woman to share her experience with me. In a soft voice she told me that from the moment of the explosion and until she opened her eyes at the hospital she did not remember what had happened to her. She vaguely heard her husband talking to her but she did not remember what he was saying. She also told me that a year ago she had witnessed a mass attack. She saw dead and seriously injured people. Since then she has been in psychological treatment due to her fear of leaving her house and excessive worrying about her family members. I asked her to contact her therapist and tell him about her current experience. I also explained to her and her family members that in my opinion her subconscious was doing the right thing for her. It protected her from reliving the previous trauma. Her subconscious activated a survival mechanism customary among some wild animals. When a small animal stands vis-à-vis a large and strong predator which it cannot fight or escape, the small animal plays dead. Most predators do not eat dead animals. This primordial instinct can still be found within us and causes us to faint at times of an extreme death threat. It seemed to me that this evolutionary explanation convinced her. Instead of considering herself weak and frail, she will go home with the knowledge that her body reacted in a positive way to the circumstances she was in.
On my way back to my room I decided that I should add to
"Fight or Flight"
two more methods of survival at times of danger: "Freezing" and "Playing Dead." When I reached my room I sat in a soft armchair, put on
a Relaxation CD and closed my eyes. I was in great need of deep relaxation.