Trauma care in crisis: war trauma and mental health funding

ABSTRACT

Background: Israel is currently under a state of continued unrest and state of war. There has been an influx of financial aid to treat the mental health fallout both from within Israel and abroad. Despite increased research into resilience, treatment and wide-scale interventions, there is a concern that this is not significantly influencing mental health aid allocation.

Objective: This letter to the editor aims to describe the current situation and address current difficulties in regard to the relevant literature from recent conflicts and national traumatic events.

Method: A consortium of national and international trauma experts pooled together their knowledge to produce a working statement based on evidence from clinical and research findings.

Results: As opposed to wider, short-term psychological interventions which have limited long-term proven efficacy, lessons from previous war zones, wide-scale exposure to trauma and current war-torn countries highlight the importance of targeting and assessment, addressing barriers to care, strengthening existing systems and promoting community resilience and care.

Conclusions: In addition to acute care, funding should be allocated to long-term care, enhancing treatment accessibility and community follow-up and additionally support long-term research to assess effectiveness and contribute to international knowledge.

HIGHLIGHTS

• Immediately following widescale attacks, national disasters and outbreaks of war there is a tendency for an outpouring of aid, and in recent years, mental health aid.

• Despite an increase in research in the field there are still significant gaps in the literature and a disconnect between the evidence and economic and philanthropic policy with short-term initiatives often favoured over long-term strategic planning.

• It is recommended that greater attention be paid to targeting and assessment, addressing barriers to care, strengthening existing systems and promoting community care.

Antecedentes: Israel se encuentra actualmente bajo un estado de disturbios continuos y en estado de guerra. Ha habido una afluencia de ayuda financiera para tratar las secuelas de salud mental tanto desde dentro de Israel como desde el extranjero. A pesar del aumento de la investigación sobre la resiliencia, el tratamiento y las intervenciones a gran escala, existe la preocupación de que esto no esté influyendo significativamente en la asignación de ayuda para la salud mental.

Objetivo: Esta carta al editor tiene como objetivo describir la situación actual y abordar las dificultades actuales en relación con la literatura relevante de los últimos conflictos y eventos traumáticos nacionales.

Método: Un consorcio de expertos nacionales e internacionales en trauma aunaron sus conocimientos para elaborar una declaración de trabajo basada en las evidencias de los hallazgos clínicos y de investigación.

Resultados: A diferencia de las intervenciones psicológicas más amplias y a corto plazo, cuya eficacia demostrada a largo plazo es limitada, las enseñanzas extraídas de anteriores zonas de guerra, de la exposición a traumas a gran escala y de los actuales países desgarrados por la guerra ponen de relieve la importancia de la selección y evaluación y el abordaje de los obstáculos a la atención, el fortalecimiento de los sistemas existentes y la promoción de la resiliencia y la atención comunitaria.

Conclusiones: Además de la atención aguda, se debe asignar financiamiento a la atención a largo plazo, mejorando la accesibilidad al tratamiento y el seguimiento en la comunidad y, además, apoyar la investigación a largo plazo para evaluar la eficacia y contribuir al conocimiento internacional.

KEYWORDS:

• Funding
• mental health care
• ongoing crisis
• war
• mass trauma
• PTSD

PALABRAS CLAVE:

• Trauma masivo
• guerra
• trastorno de estrés postraumático
• financiamiento
• atención de salud mental
• crisis actual

Since the incursion by Hamas on 7 October and the resulting Iron Swords war, millions of philanthropic dollars have been donated to disaster-related mental health care in Israel (Jewish Federations of North America, 2024). Locally, mental health care has been stepped up for combat soldiers (Ghert-Zand, 2024) and to provide and finance psychological care for those returning from reserve duty, (for example, a reservists’ grant for individual and couples therapy) (IDF, 2024). Provisions are being made for a mental health epidemic (Katsoty et al., 2024), though social systems which were failing prior to the war are still suffering from the same inadequacies (Almog-Bar et al., 2024).

Since psychological debriefing was debunked at the turn of the century (Wessely & Deahl, 2003), there has been little long-term follow-up delineating the effectiveness or superiority of specific mental health interventions in the immediate aftermath of trauma (Figueroa et al., 2022; Ironson et al., 2021). A recent review of psychiatric care in Israel (Strous & Monovich, 2024) reflected on the ethical implications of giving psychiatric care to individuals in times of war and disaster, but in addition to these valid issues, a wider public-health discussion is warranted surrounding what mental health care is offered, to whom and when.

Following 9/11 and in the wake of more recent disasters, we note that despite increased research, lessons in resilience and treatment have not been applied to future responses. For example, experts summarised that efficient screening, the targeting of specific at-risk groups, and proactively addressing barriers to care and social dimensions are crucial characteristics to successful long-term outcomes (Reifels et al., 2013). These recommendations are in line with those originally published by Hobfoll and colleagues highlighting the importance of promoting self- and community-efficacy, connectedness and hope (Hobfoll et al., 2007). More recently, expert reflections on the Ukraine and Syrian wars state that rather than focus on short-term volunteer initiatives, strengthening struggling mental health systems should be a priority (Bellizzi et al., 2022; Seleznova et al., 2023). We question whether these key findings are being translated into the provisions being designed for the current population in Israel. Indeed while new organisations and charities are popping up to offer immediate care and support for specific trauma-affected populations, others are still woefully underserved.

The development of new interventions, which happens so often in the aftermath of collective disasters, sometimes ignores the need to re-establish a sense of safety and self-efficacy which existed prior to the trauma in original communities. New interventions are often driven by representatives on the ground, noting immediate need (often termed ‘emergency funding’) and propelled by funders desires to contribute concretely and offer immediate change rather than long-term strategising. The wild growth of initiatives brings up many questions about the professional and ethical background of providers and the long-term strategies for strengthening familial and community support while offering targeted care. For example, retreats which take survivors to local or international locations should not be delineated as treatment or prevention for PTSD, a claim not grounded in a sufficient evidence base, and one which can induce guilt and shame for those who later develop PTSD symptoms, (whether they accepted or declined the offer of the ‘treatment’). Additionally, while the influx of volunteers and grassroot organisations, specifically those integrating peer and community group models, may be appropriate for earlier stages of acute stress and depressive reactions, later stages of PTSD and prolonged traumatic or traumatic grief reactions, as have now been established in the current population, require both highly trained professionals and a staged treatment approach (Burback et al., 2023; Hasson-Ohayon & Horesh, 2024). We note that there is a need to both delineate which interventions are designed to emotionally strengthen and promote functioning, which are designed for prevention and treatment of PTSD and which are designed for later stages of persistent or recurring PTSD. This impacts the target population and accompanying research to determine efficacy.

Furthermore, reaching out has also been ominously applied by non-professional bodies, specifically bolstered by the lack of clarity in efforts to provide immediate care for large populations. For example, in the grant given to reservists, loosely defined alternative therapies and wellness centres are eligible for funding in addition to professional family and individual therapists. Treatment allocation should be a collaboration between a professional and service user rather than rely on newly exposed service-users to successfully navigate all the potential services available. A similar phenomenon was witnessed in hotels set up to house refugees from southern and northern communities, with an influx of well-meaning, one-off volunteers flooding these locations whilst professional bodies, at times, took a more cautious approach. Indeed, in the face of ongoing trauma and continuous stress, there is a need to consider the appropriate timing and settings for support, regulation or trauma processing work both for those with exposure and sub-clinical symptoms and those with clinical and in turn, unremitting PTSD (Burback et al., 2023).

In these two different populations, reservists and trauma-exposed civilians, the recommendation is similar: Rather than inundate the field with an abundance of interventions and one-off treatments, greater funding and attention are recommended to be given to effective treatment assessment and allocation and the reduction of barriers to care (Reifels et al., 2013). Funding should be utilised to implement and update existing recommendations (Hobfoll et al., 2007) and channelled to those most in need of acute and long-term care. The long-term consequences of mass-traumatisation need to begin during the acute or emergency phase and should be executed and funded in parallel to acute care options. This requires balancing the pressure to immediately act with a slower, assessment of needs and follow-up accompanied by the establishment of long-term interventions which will be available when needed rather than during a funding determined timeline. This is particularly relevant when those affected by trauma exposure are not isolated individuals, rather active members of familial and social units (e.g., a combatant father who has both individual needs and the needs of his partner and children, who experience the unpredictable separations and the resulting impact on play, relationship functioning and communication and whose needs develop at differing stages (Creech et al., 2014)).

Israel is currently a country in survival mode (Brom, 2014; Pat-Horenczyk & Schiff, 2019), expressions such as ‘the whole country is traumatized and everyone needs treatment’ are common and have become strong attraction for philanthropy but the real challenge will be when, for the majority, the survival mode retreats and processing becomes possible and, in a minority, psychopathology becomes more evident. Rather than bursts of intensive care, as in Ukraine, it is important to act now to strengthen existing systems, both within the mental healthcare framework and within wider community systems. While short-term and widespread psychological ‘emergency’ interventions may be the most attractive for donors they also may be perpetuating a cycle of non-evidence-based care with little incentive or financial stability needed for long-term planning. Indeed, the current period is crucial for the funding of evidence-based interventions, novel interventions which integrate existing knowledge and enhance effectiveness for unresponsive populations, and finally, for accompanying all interventions with intensive research and assessment. As recent wars demonstrate, along with increased awareness of mental health difficulties, we need to gain vital knowledge to effectively treat vast numbers of people and their communities and to mobilise rapidly to strengthen systems which will be in demand long after the wars’ cessation. This is true both for the Israeli population and the Palestinian and worldwide populations affected by ongoing war.

Disclosure statement

No potential conflict of interest was reported by the author(s).