1. Department of Psychiatry Rambam Medical Center, Haifa, Israel
Traumatic exposure and its sequelae in Bedouin members of the Israel Defense Forces
Yael Caspi, Sc.D., M.A.
Department of Psychiatry
Rambam Medical Center, Haifa, Israel
Presented at the WFMH Conference on Transcultural Mental Health Minneapolis, MN October 2007

2. Co-authors:
Ortal Saroff, PhD Department of Psychology, University of Haifa, Israel
Najla Suleimani, SW Department of Social Services, Zarzir, Israel
Ehud klein, MD Department of Psychiatry, Rambam Medical Center, Haifa, Israel

3. Related publications
Caspi, Y., Saroff, O., Suleimani, O., Klein, E. (in print). Trauma exposure and posttraumatic reactions in a community sample of Bedouin members of the Israel Defense Forces. Depression & Anxiety
Caspi, Y., Carlson, E., Klein, E. (2007) Validation of a screening instrument for posttraumatic stress disorder in a community sample of Bedouin men serving in the Israeli Defense Forces. Journal of Traumatic Stress, Vol. 20, No. 4, August 2007, pp. 517–527

4. Project Partnership مُـشارَكَ שותפות
The Bedouin Community Needs Assessment Initiative
The Rambam Medical Center
UJA-NY
Municipality of Zarzir
In October 2002 UJA-NY issued a call for trauma-related concept papers for community-based programs that would impact underserved communities affected by the stress and trauma caused by the complex political circumstances and constant threat of terrorist attacks that have beleaguered the State of Israel during the past few years.
We suggested a study of the trauma-related needs of a specific, underserved, cultural minority in Israel. The Bedouins.
The project started in the summer of 2003.

5. The Bedouins Nomadic tribes
Historical alliance with the State of Israel
A distinct minority among the Arab citizens of Israel
Lifestyle combines traditional customs with modern Western practices
Northern tribes are primarily secular
Voluntary-based service in the IDF
These traditionally nomadic tribes, reside in communities across the Middle-East, are of Arab ethnicity and Muslim faith.
Northern tribes settled in permanent villages under the British Mandate in what was then the north of Palestine; fought with the Jewish forces in the struggle for independence.
Villages consist of several tribal families; marriages take place within the tribe with a few exceptions, always supervised by elders; deliberate segregation from other Arab factions (Druze and non-Bedouin Muslim and Christian).
Important for understanding of impact of trauma: several generations reside under the same roof, the wife joins her husbands’ family – everyone is related..
Service in the IDF: officially recruited since 1990’s, serve primarily in combat units, renowned for their specialized skills as trackers.

6. Reasons for the study
Limited but striking examples of severe mental health problems in Bedouin veterans
Known risk factors:
Indications of greater vulnerability during service and post discharge
Affinity to the enemy
Complex socio-political circumstances
Religion becoming prominent, military service condoned
The case of N – 40-yrs old, m+4 to his childhood sweetheart, described by his wife as a caring, loving, involved father, more anxious that she was before the deliveries…Tracker for 12 years. Hospitalized in a psychiatric ward with a diagnosis of PTSD with psychotic features.
History taking was difficult. Finally, the story emerged – two combat episodes, killing a Palestinian warrior from close range. His mother tried to come after him..
Bad dreams are reported to have started months before he became sick and unable to function following an explosion and a short hospitalization. Started to see the mother of the boy in his waking ours as well. Belief in her right for revenge – eye for an eye…
Shame, avoidance of family members and friends, irritability when close to his children and wife, alcohol consumption to facilitate poor sleep, 3 packs of cigarettes a day…

7. Barriers to care
Misdiagnosis: PTSD with Psychotic Features or culturally-specific response?
Shame as the overriding factor
Inappropriateness of treatment (talk therapy, group sessions)
Spiritual bind - need for forgiveness?
Known risk factors:
Minority status in the military
Ethnic and religious affinity to the ‘enemy’
Volunteer recruitment dropped by half in the first Intifada, representing the community’s response to political events
Misdiagnosis:
Biases in system of care: case of a veteran arriving for disability assessment wearing his uniform, apparent inconsistencies in report and presentation…
Lack of familiarity with cultural values
Somatic presentation  compensation motivated

8. Methods Relationship building
Door-to-door recruitment by local recruiters from the different tribal families
Measures included the Structured Clinical Interview for Axis I DSM-IV Disorders (SCID); List of traumatic events; HSCL-25; Screen for Posttraumatic Stress Symptoms (SPTSS; Carlson, 2001); substance abuse; physical health and related functioning.
Project Description Sheets in Hebrew and Arabic + contact sheets for those who agreed to participate. Participants were contacted by interviewers, signed informed consent forms and were compensated for their time.
Interviews were conducted in the participants’ home in Hebrew. All forms and measures were translated back-translated and printed in both languages side by side.
Interviewers were graduate students from the Dept of Psychology at the University of Haifa.
List of traumatic events listed events included in the wide definition of Criterion A of the PTSD definition of DSM-IV-TR, as shown in the results.

9. SPTSS (Carlson, 2001)
Self-report screening instrument for PTSD symptoms.
17 items, rated on a 10-point scale from “Never” (0) to “Always” (10).
Responds to “how much that thing has happened to you during the past two weeks”.
Not keyed to a single event.
SPTSS was specifically chosen because of its simple language and because it does not require responses to address only one event.
Substance abuse was assessed for cigarettes, beer, wine and hard liquor. Questions about drugs were avoided in consideration for those participants who were still in service and given that alcohol is considered to be the substance of choice in this community.
Physical health and health related functioning were assessed by eliciting information on the presence of somatic symptoms and self-perceptions of health and wellbeing.
Additional items inquired about health service utilization.

10. Background
372 Bedouin men were identified through community outreach efforts, of whom 348 (93.5%) agreed to participate.
317 (91%) completed the interview over 19 months.
Those who served in combat positions were (in descending order) trackers, in the infantry, in specialized units trained in urban fighting and in the border police.
Those enlisted in non-combat units were mostly in the education or transportation corps; only eight were with the civilian (‘blue’) police .

11. Background (continued)
Participants averaged 30 yrs of age, mostly married (57%) or single (41%) with more than 3 children; 75% served in combat units, most were discharged (58%) and of those 38% were unemployed.
Length of service (positively associated with traumatic exposure):
43% served 1-4 yrs, 28% 5-15, 10%
Half defined themselves as secular, half as traditional; none as religious.

12. Traumatic and Stressful Events
73.8
combat 67%, terror 4, Interpersonal violence 3, Domestic violence in childhood 15
Assaultive violence
25.5
Serious MVH accident 21, other 3, child with a life-threatening /incurable illness 3
Other injury or
shocking experience
61.2
Serious injury in MVH accident 23, military 18; diagnosed with a life-threatening illness 16; other 11
Learning about
trauma to others
83.0
[circles of loss]
Sudden death of
a close friend/relative
96.5
Any trauma
Because of the high prevalence of trauma in this sample, stringent definition was employed for the analyses restricted to experiences involving physical presence at the scene of the event, namely combat, serious MVH accidents and other accidents, terrorist attacks in civilian settings and interpersonal violence.

13. Psychiatric outcomes
Stringent definition of trauma yielded 75% exposed to Potentially Traumatizing Events, mostly combat.
Of the total sample, 27% had SCID diagnoses: 14.5% had PTSD, 12.5%: MDD, anxiety disorders, alcohol abuse.
PTSD was present in 20% of the trauma-exposed group, mostly comorbid with MDD and/or alcohol abuse.
Those with PTSD were significantly more likely to have been discharged from the military by the time of the interview (delayed onset?).

14. Reminder!
Our participants were recruited by community outreach efforts.
The PTSD rate of 20% found in our sample represents individuals who for the most part have not been recognized as suffering from trauma-related disability.

15. PTSD rates in other studies
8% among those exposed to war trauma from a general population sample in Israel1
17.8% among general sample of Palestinian refugees in the Gaza Strip and 28% among those exposed to armed-conflict-associated-violence2
Peacekeeping forces, where rates ranged from 3%3 to 16%4
15.8% among Ethiopian refugees resettled in Israel5
37% of Jewish veterans with combat stress reaction, 23% of former POWs, and 14% of comparison group6
16.7% among IDF soldiers with physical injuries from combat during combat between
1 Ben-Ya'akov, 2005; 2de Jong et al., Bramsen et al., 2000; 4Mehlum and Weisaeth, 2002; 5Finkelstein, 2004; 6Solomon et al., 1994; 7 Koren et al., 2005

16. Impact of PTSD
PTSD but not trauma exposure alone was associated with higher rates of alcohol and tobacco use, self-assessed and diagnosed health problems, somatic symptoms, self–perceived health-related impairment in daily functioning and more frequent use of primary and specialty medical care services.

17. Conclusions
Bedouin servicemen are a group at a higher risk for both trauma exposure and PTSD.
Possibly due to sample size, trauma exposure alone was generally not associated with psychiatric and health-related impairment.
Most of those with PTSD were never diagnosed or treated for trauma-related problems.
Most of those with PTSD were never diagnosed or treated for trauma-related problems IN SPITE of more frequent visits to primary care physicians!

18. Conclusions
Delayed onset and somatic presentation may affect ‘disease explanation’: punishment (patient) vs. malingering (provider).
Primary care providers are the natural agents of care in traditional communities.
Early detection of trauma-related problems in servicemen from minority backgrounds may necessitate deliberate outreach efforts.