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
himself 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.
