Rabbi Dr. Dovid Halpern - Caring For Klal Yisrael in Times of War

my name is David Hal I I almost never go by Rabbi but it happens I figured this is a conference for ab so I'll use the the term now but um I'm a practicing both child and adult psychiatrist my family made Aliah uh in August right before the war um and I started transferring over I had a small Private Practice in the states and I worked in a psychiatric hospital there um very closely involved in the Jewish community in Philadelphia and now I came over here and I've essentially moved tried to move part of my private practice here just getting started and in order to get your uh Medical Specialties recognized you have to do a process called hatama in case anyone ever talks to anybody here about it uh depending upon what you give to the Israeli Medical Association they'll change being on the week how much they tell you you have to do so um I have to do I have to do three months for adult psychiatry and three months for child psychiatry uh and so that's my uh disclosures that you'll see right now I'm working at aanm psychiatric hospital uh during the day it's a small Psychiatric Hospital in town that's called aanm there's nothing else there it's just the hospital it's on the tiny on Lane Road that's between be chsh and I don't recommend driving on it unless uh you want to say so the um but the idea is uh I actually it's a shame that Bri what's left but I wanted to tell him that the truth is that I know a lot of people who tell me that they're NM all the time there but anyways okay tough um all right so um I just uh uh St reanim colleagues um B you thank you guys so much for um inviting me to come and speak um I definitely am not a Novi I say that to my patients all the time they ask me what's going to work and I tell them that Psychiatry is different than other areas of medicine there's not like I know if I give you antibiotic it's going to treat this infection which also by the way we don't really know but that's fine but I know if I give you antibi it's going to treat the infection but for Psychiatry it's much more complicated I'm definitely not a novy and nothing that I say here is uh not something that you could probably find elsewhere but I wanted to share with everyone my thoughts and my experiences and and um the evidence that exists uh to kind of give us all the tools as much tools as we can have together to try to navigate uh what's going on now here in arell people ask me all the time they say you came to ell you know how's it going with the war and I tell them I expected a war Jewish history you know anyone who's a student of Jewish history you come toel I expected there would be something but no one expected this like this is not uh this is not something that's that's normal even for for the Harden Israelis if you speak to them um okay so disclosures just before we get started so this presentation is going to be in the in the model of a medical style presentation if anyone knows there's like certain ways that it's done but um I have a private practice and I work currently at Aton psychiatric hospital I don't have any really other disclosures to make that are relevant to this presentation okay um so just an overview of what we're going to talk about we're going to talk about about war in general how War affects people from a from a mental health perspective um what it does to individuals uh we're not going to talk about other elements of War which there's many different uh topics we're going to talk about trauma definitions and interventions anxiety and fear differences and then Tas right what can we all do about these things I'm not expecting anyone here to end a war but what can we do for the individuals what can we do for the people um who we see every day okay so let's talk about war so War affects people differently and you could just give that statement and that would be it War affects people differently everyone's different and you have to talk to everyone on their own individual level that's not very helpful um I think it's helpful to kind of take a macro View and zoom in uh so there are just differences that I think we should point out for everyone here everyone pretty much who's here and the uniqueness of OU Israel is that we essentially straddle the Atlantic Ocean most of the time uh and that's something that most people uh in Israel don't do to be quite honest and when we talk about the different communities Israel versus there's many many different responses families right who have in the army versus families that do not many of us are ranim or related in some way in a pastoral sense to people who do not have people directly serving in the Israeli Army as R Bri had mentioned there's different levels of kind of experiencing a trauma and there's different ways that people relate to that and then there's the individual level additionally but how people respond under these sorts of uh L stress situations um okay and some of the images are are are very emotionally moving and and can be um difficult for people but I'm giving you a warning now just in terms of what we're going to see so this is in terms of the you talk about arus versus outside of arus right so the codes family from Kaza this is an entire family right that's here in coffins post October 7th this is happening in Artis this is the Jews of Israel acutely are aware right that there was not like there's that the concept there's the general we call existential fear of being Jewish right that someone could ever come and hurt me but in Israel for many many for many many people that didn't exist that was the specialness of what meant to be Israeli that you could live in our and you could be safe because we have a Jewish Army that's going to protect us and this picture is showing that that that did not happen that was stripped away and ripped out that experience of having that that type of safety ripped out is not the same for Jews andar Jews ands particularly the Jews in America although before everything that's happened in current events felt like we are in our own Community existing in many ways kind of everyone knows we're different and separate and there's always this mild anxiety of us being different from everybody else but we can continue to exist in the way that we do um and then things like this start happening right so this is Berlin April 19th 2023 this is not Berlin before World War II this is Berlin people are screaming out death to Jews and you have to think about you know when we when we talk about uh how everything relates I think of it in some ways um how do the Jewish people relate to What's Happening Here people who live in arell who have grown up here in ell who identify with Israel as as their Homeland in a way that's much more intense than people who would be living in they they're going to take from the perspective of when you when you read through Nim right Yeshua the concept of that there's that there are Wars to fight to get our land our land our home this is what we are doing right if you listen to any speeches in Hebrew for sure you're going to hear lots of people talking about that this is our land the Jewish people are here together we are here to stay we're going to have right you'll see the big signs right that concept of us being a nation here together in that's the rallying point around when someone comes to try to take that away from us we stop them is very different the Jews andar and even the Jews who have come fromsar who haven't yet fully integrated are going to have kind of mixed feelings about this it's the concept of what's coming up of Esther right of that we are amongst people who we know at any point wouldn't be good to us but we thought things were better but things are not better so I'm from Philadelphia someone uh went into the Acme Supermarket in Philadelphia and put 100 um on every single Sabra kumus container um put like a paride stickers I think they caught them I don't know but it was like but these are regular events that are occurring throughout throughout cities where Jews thought before like we're just one of the many respected minorities that are here and it's going to be fine and that's no longer the case that was stripped away and that's a separate kind of warry that people are going to have that we're going to have to deal with then you talk about soldiers and families okay so Mission says right sorry so says so we're talking about but Mitzvah everybody goes out right I separate question right why why are we adding women right so one shot actually is that the women went and helped with Support Services um but I there's a I think there's a very simple shot what do you think it means when you take a husband out of his home and you send him to the Army and you leave the women at home with all of her kids right or a newly married couple and you tell the wife sorry your husband's going off to war you think she's not going to war I she's of course she's going to war I from a basic a health perspective she's at War whether she's going physically to the battlefield or not she's at War and the hardest part is when you don't know where someone is right talk we talk about the the sh about the the the captives people who are missing those questions are the Imagine just sitting there and it's like you never know right why is it that that yakob refuses to be comforted when ysep is taken right famous uh Rashi quotes M Raba because somehow he knew that ysf wasn't dead and when someone is not dead and you don't know what's happened to them you cannot be comforted and Yakov essentially becomes based on nonfunctional for many many years because of that and that's that's just one example in in the of what's Happening regularly to to the families who are here in artisol and and the ongoing saga and the hope that things will change and things are going to get better and every day it's a new day and every day there's something else and it doesn't change we could do as many marches as we want it's not going to make the families really feel feel better right we'll talk about what people do in response and how that works in a few moments the other piece and the reason why there's a thing for time for change and Sh sh Greenberg here on the bottom is why currently my family was in be ches there are recently elections and then elections again uh if anyone is following the news they had to redo them because they no one won 40% of the vote so he actually won he's now the mayor of Beamish but um the reason why I bring this up is because beish is a very unique town and I think we all have uh people that we know who live in various communities such as this so in Israel there's this very strong divide between Ked and nonari because of the army it culturally creates that in America that's not the case things are much more kind of on a spectrum where people can can cross different boundaries and be together in different ways but definitely uh what I saw after after the war started there were two weeks which I call them like covid flashback weeks for everybody where everyone was locked in their homes and no one could do anything and then in addition afterwards all the husbands are gone they're in miluim you go to any of the Yu any other towns It's Just Women and Children very very few other people in the beginning particularly and only now people are starting to really come back from the milim in large numbers um but in bees in raat bees that was not the case and it highlights the reason why there's so much politics now around what's going on right and so you see that someone's experience if their whole family and their whole Community continues to exist while the war is going on is very different I have patients here I had a Yeshiva guy in Yim told me uh the war doesn't really bother me things are kind of the same Mya keeps the same I have the same storm everything's the same the falafal place across the street is open right and we talk here as if like everyone is impacted by the war in the same way and it's important for everyone to understand that every person right is going to have a different response but particularly when someone's family is putting their lives on the line that's going to be a very different experience fundamentally different not different in degree but different in kind and that leads us to individuals people respond very differently to stress okay there's this famous line that we all that we say psychiatrist will say right when you're stressed you regress everybody does that okay some people regress to things that are positive like more basic F fundamentals for them some people regress to being like children I'm sure everybody knows an adult who is in a stressful situation and you watch them behaving in a way that was very uncustomary and not dignified and sometimes what happens is people go back to a way of acting that's not appropriate um and sometimes people will actually do what's called a you know a flip well they'll they'll do the opposite of what of what is they're expecting or wanting to do like a reaction formation is the formal term because what they want is they want to succeed and they want to push all this energy into a place where they know what to do with it so shimron story is similar to that Shimon has been totally disgraced he gives over his he gives over his secret he's lost his energy and what does he do he like rallies his strength for a last push right to go through and the reason why I use shimon's story to do that is because shimon's ending is not great it's not great right actually in Israel people sing that song all the time that's not a great song because in the end he dies he does kill a lot of pisan but that's not our goal suicide bombing is like not a Jewish thing we do not believe in that right so shim has no choice right these people feel they have no choice and some people who are under so much stress push and push and push themselves to Rally that way because they have no other choice in terms of how to manage you know what the problem with doing that is let's say you're uh you're someone living in uh in your sh and you really want to help the Army and you're stressed and stressed and stressed and you push yourself to volunteer and do all these things you still have kids who are going to school who are at home you still have a family that's looking for you you still have other obligations and those Fall by the wayside and then you end up coming to see me that so that's the goal is that the goal is that is to prevent those things from happening for individuals and many other people do what do um especially nowadays because everyone learned how to do this really well in Co which is you shut down the the house is is closed both literally and figuratively the figurative house is closed you may not enter hi how you doing good barash have a nice day I go home I don't talk to anybody I sit on my computer if I'm working remotely to the United States right or if I'm working here I go to my job that's it I go through my day I don't have K that's a line I hear all the time now Al I don't have K to do anything else and the truth is they don't have K to do anything else right it's a basic concept that is not good to behave this way long term short-term stress fine five months plus two years previously not good especially because it's going to bring back all those things Le okay it's very it's a basic like one of the basic principles in bous it's like okay but people don't know what to do because when you're under stress you don't know what to do and then you're definitely not going to reach out for help that's not happening but you are in a very unique position where you're you don't need to be the mental health provider you're someone who's there as a figure right who is approachable and who people relate to and who you will notice things that other people may not notice in friends and family and constituents it all depends and then there's a question of what we do and our bra mentioned this at the end about applying meaning right so what does D say on and Y son's death right it's a famous line people will quote this is where it's from okay it's not a happy he's very upset there's nothing positive in these Pim when he talks about it D is legitimately upset and mourning over what has happened we mourn and are upset over losses right when someone passes away this is the first part I think is the second answer was saying is that you you don't have an answer you're just gripped by mourning if anyone's everever been to a Levi here in Artis it's much more powerful I think than many levas in in uh in America right the mace is not in a coffin they're covered in aalis and especially if you've been to levv someone young especially uh I have a clear memory of when I was younger going to levv after the amav uh attacks people balling screaming unbridled pain and anguish that type of of raw emotion is not something that you give you give an answer to you just it's there you know and then flip that to to to when you're sitting in a shiv house with someone and some of these families to be honest even I personally don't understand how they're able to do this but some people will really try and understand what they can do right and it's it's right that somehow are taking from us because there's a purpose behind what is doing and people find great in that there was this video going around for a little while like dumb things that people say at a Shiva house this is one of those things don't go don't go into into sh house right and say like ah it's because they your your son passed away in order to be part of like that's that's a terrible thing to say but if the person themselves bring that out and I've seen it many times here people are able to derive tremendous tremendous k um from Arora and it's something that we should should keep in mind but all of these things are impacted directly by War because war is what makes us think and keep these things in our mind all the time a standard day for most people all the stuff I just talked about is not there except for families who have had active Trauma from someone being taken or someone being killed in the past everybody else kind of tries to move on with their lives but right now that's not possible fully because things are still happening so let's talk about trauma so Everyone likes to talk about trauma but trauma is not like one thing because if it was one thing it would be easy I would just have like one little pamphlet on trauma you would read it and then everyone would be good and good to go right okay so the issue is this the issue is that trauma uh happens in many different ways right so there's emotional and physical trauma they're most common people have physical physical trauma people have this is the most common trauma that started off this whole conversation but everything was um PTSD when it was first discovered post soldiers from Vietnam they realized that traumatic uh experiences can be ingrained inappropriately in the brain and it leads to significant problems with processing but that was just a start then we started thinking like maybe it doesn't have to be such a strong like boom Vivid onetime event maybe there are things that happen over time and things that affect how people behave and think and I mean the truth is that we actually know now that everything that happens even me speaking to you right now is changing the way that you behave and think and altering the way that the neural Connections in our brains work and I'm not going to talk about like epiphenomenon versus Consciousness versus that's a separate year for a different time but the idea is is that what's happening is is that you have an acute response then you have chronic responses right in in Psychiatry we talk about acute stress versus PTSD but we have other things then there's complex trauma where there's layers of things that may or may not be related you might see people or you might yourselves feel like sometimes I don't know why I'm so angry today nothing happened today why am I so short fused today people will say my my my kid spilled the cereal on the on the table and like usually it's like okay not a big deal but today I just lost it and I don't know why and if we think that that's just because St it happens it's not why and that's happening more often and those are the small pieces that we should all be aware of because those are the pieces that uh we have really a k that we can tap into right and a lot of times people like to think like that's why I have this little comic here on the top people like to think oh your trauma is really like let's talk about your like psych like Psychiatry psychologists will say oh let's talk about the things that happened in the past I bring it up but the truth is that things are happening now also right that people need to talk about what what's happening too and they relate to many things that have happened in people's past but sometimes it's not time to get to that yet and then there's the very famous um Jewish jewishly coined trauma which is vicarious trauma which is everyone loves to talk about um all the Jews in America even the secular Jews like to talk about that their grandparents were traumatized from Europe and they gave them trauma and it's been inherited for many years of trauma but what does that mean it means what it means really is poor ability for family members to cope with stress who give that over to their family because they don't deal well with their family members and the family members then inherit not genetically but through behaviors ways of coping that are poor also now literally vicarious trauma can mean that you experien trauma through somebody else having something bad happen to them so that's not literally the definition but that's something that uh that we see all the time and it's something that we should be aware of because if you see someone getting upset either at their child or yelling at someone or I don't know just for example let's say you were driving to Jim and a Truck Cuts you off and the truck driver honks the horn and screams curses at you and throws his hands up at you from the window not that that might have happened to me as I was driving here from M this morning but if such a thing would have happened right immediately we immediately think like what a jerk right some people will tell me that's Israel like that's not a good thing to think right you should realize if that person is doing that it's because even if they're not aware and most people are not aware something is driving them to let out anger road rage is a very good example it's been going up everywhere not just here but here in particular you'll get to see a lot of it but the um the question is why and the answer is that we have responses to trauma and then these these responses we're going to talk about first are acute responses and everyone should be aware of them but then there's also um like long-term responses so people talk about like the four FS 5 FS but this is just something people should be aware of right fight flight free spawn some people right respond to trauma by getting angry and attacking I feel stressed I'm going to attack you right some people do the flight is a is a classic uh you know you run you start worrying and get concerned they Panic people freeze is the shutdown we talked about and the Fawn is when you start being becoming very passive but you also do things where you go over to people and you say you feel stressed so then like someone's stressed at home this is a classic example I'll see it's like suddenly my son is cleaning up all the toys in the house I usually tell he usually doesn't want do anything his room is perfectly neat everything is organized he listens to everything we say there's no problem doc he's great what are you talking about this traumatic situation he's dealing with it fine I said well how was he before his room was a mess he didn't care he used to have a good time with his friends does he go out a lot not so much he says it doesn't bother him now he's just happy to stay home and be with us so that should be a warning sign we should think about that and say okay maybe the person change in Behavior it doesn't need to be a change in behavior only to negative behavior but a change in behavior is something that people should be aware of what is happening now the thing is about trauma is we talk about it as if it's like a terrible thing and it is a terrible thing but something that people don't think about is that trauma is actually part and parcel of our existence period it's not one of those things that we can say like you can't have actually if you talk to many israelit uh I would say that Israel is behind the United States in terms of its mental health awareness just is it's a statement you can try and argue with me later but I'm going tell you that's that's how I feel in terms of working here and many Israelites will tell me like that wasn't a mental health issue that's just how they are like that's a way of life so we'll have discussions about exactly what that means but in particular we have to understand that trauma is part of people's lives and we all have some of it um this is a great quote I'm not going to read the whole thing but this is a great quote from RX right the broken luos after mosha breaks the luos Bas they go in the Aon why do they go in the iron trauma the trauma of what happened is part of the continuation of the Jewish people it doesn't need to Define Us in the sense that we have to constantly be thinking and worrying and have all the terrible emotional reactions from the trauma but what it has to do is we have to recognize that it creates a sense of who we are right the fact that kids have their parents go off to the Army and come back and some don't come back is part of living in this country we don't want to undo the fact that that happen the question is how you process and work through it when you process trauma you don't remove it when you process trauma it becomes a part of how you describe yourself and your existence removing trauma actually is the problem when we try to remove it so there was a very famous study we no longer give benzo deines you'll probably know a lot of people who take them but Adavan clopin Xanax here you'll hear lauran or clonex from people those are specific benzo medications they used for acute anxiety and panic the problem is they used to give them to people all the time post traumatic events and what happened was that like there was a 50% increase in PTSD uh post those people taking those medications even though we thought we were helping them when we gave them these medications and the answer is if you prevent Trauma from being encoded if you prevent memories from being encoded you create the split that we're trying to prevent when you when you separate out components of who you are and you don't integrate them you create a problem we need to be integrated in general in our lives people who keep secrets doesn't go well for them long term right you have to find a way to integrate all the different experiences that you have so how do we do that how do we recover in drama how does it work so basic First Step safety and stabilization right so if someone is in a dangerous situation right if you're a family living in St Road it's incredibly difficult to recover from trauma because you're always hearing Sirens all the time so if you develop a system which the rest of the country was able to do a little bit more when you have enough time to get to a shelter and the people who are around you are not panicked which is very important and you're able to explain okay now it's a calm time let the siren is on let's all go to the shelter you give a sense of safety and stabilization for everybody and people know this is what I do once people feel safe and stable then you can work on processing things that have happened after you feel safe you can think back to what happened and how upsetting it was you can't do that while you're not feeling safe right when you're running from the line you can't be like I feel so terrible that my friend was killed by the line you're still running from the lion right while you're in the Army right the soldiers who are in AA they don't have it's not a good time for them to do like long Memorial services and to and to think through things they can come to a levah but if they go right back they're not it's not time to process and there can be problems with that if it takes too long but it's important for us to remember right and then the the third part is to reconnect and when you Rec this is the hardest part reconnecting is after you felt how terrible things are you find a way to rejoin this is the most difficult part this is the part that most people have a lot of trouble with how do I rejoin Society how do I come back to being a functional person that's not just about um survival and that's why I think one of the concepts of righto is because if you fall if you have a break and you recover from that your ability to withstand the vicissitudes of life is much stronger you gain a right that's not that's not really uh not really something that people who have never had that experience can understand I heard something actually very uh very powerful a couple weeks back on shabbaton that line right you can understand people like to use that line to tell people not to bother them but the truth is the response to that is that nobody can never understand someone who is in Bay cannot understand some right someone who's in St Ro can't understand someone who's in Bay and someone who is in uh ashon can't understand someone in St Road maybe someone who's in y bees can't understand someone who's in any of those cities somebody who's in America can't understand someone who's in Israel there's every single step you go every experience that a person has you could always say you can't understand because it's such a different experience for you that's true for everybody so if someone comes to you and they're saying and they're saying like you can't help me let's say you're sing something they say listen you can't help me Rabbi I've had this I've had this conversation with people before you can't help me you weren't there you don't know don't know what it's like um I say you're right I don't know what it's like but most people are never there right kids bullied at school most people aren't there people have had similar experiences but we lie if we say we've had the same experience every experience is different it's always through the lens of the person who is having it so I think it's something that that we should be aware of so okay so practically when you're having trauma you know what is yeah of course somebody says you weren't there what's the answer so the answer is I wasn't there after that the answer is I wasn't there and I know that there are parts of what you've experienced that I'll never be able to fully understand but that's true for everything that you experience in your life to some extent it's more true about what happened now and I'm here to speak with you and talk to you in whatever way that you find that will be helpful and I think that if we continue to work together you'll see that maybe this could be helpful and that's true both from a therapist perspective for anyone here's a therapist room but also for just a basic pastoral being there for someone intervention the person knows that you aren't in their experience especially if you're rough because being a rough has as as was talking about a little bit of like a a certain like a m complex but being a RV the the people who are part of your congregation or people who view you as a r are going to look to you that way also they view they view you even subconsciously in some way as more than a regular person now in many ways that's just not true we're regular people we have our own struggles but the idea that someone is coming to you and thinks that you have you know a third eye to understand what's going on is something that we do gain over many years of experience in working with people but we also have to be cognizant that that means that sometimes they think that we can experience and know things that we cannot know and we have to be humble enough to tell them that that's that's true for sure practically when you're talking about trauma and interventions immediate is just care right it's more loss than healing it's basic care even physical like taking care of the person just Basics about two weeks to a month is about just being there for the person kind of like we talked about if you're talking about like the Shiva experience right it's just being there 6 months to a year is when you try to help someone craft a narrative of what happened there's a reason why only now even though this has just happened now with the war but only now people are talking about their experiences of Co it's taken this long post that whole time for people to really craft a narrative of what was my life like then it was a black box where something happened many people are like my life was fine but many people are not and they don't talk about it because they don't know because it's a weird thing to have a long long period which you felt was traumatic and then to try to craft a narrative for that usually people have short periods a war is actually easier in this way because everyone knows a war is supposed to be traumatic right but people don't know so much what to what to make of the fact that I was stuck in my house with my family for two months and shouldn't that be a good thing because it was part of building our experience together and or if I was alone by myself right or if I felt like I was disconnected from any ability for me to give shum or feel like I was contributing to the Jewish Community because all I was was stuck on a computer talking to heads and all the screens were off I didn't even know people were paying attention to me and no one ever pays attention on zooms anyways so what was the point of all that okay so there's all of those things all of those thoughts right the fact that people are chuckling when I say it is because all these things are things that people think and feel an experience and we don't talk about them because we don't know how to talk about them because you have to create a narrative and then lifelong there's a lifelong process when something has happened in your life about processing loss anyone here who took a second closed their eyes and thought about a grandparent or a parent who has passed away who was important in their lives or a ROV sometimes people might suddenly feel like a tear why that experience of that the person was there and that you don't have them anymore that will never go away that's always there the part of the fact there's something missing that sense of loss will always be there it fades with time usually it's a good thing if it fades with time if it doesn't Fade with time it's a problem but the question is how do you plan for a future where you no longer have your time and all of your emotional energy taken up by that once someone has made it past that how do they reintegrate what are the paths to doing that how do they get involved what can they do and this is where I actually think there are only two experiences um where we talk about in terms of the process for a person experiencing something which I would say is akin to like a spiritual kind of milu only two times in like the mission Tor really talk about this chuva and Fila those are the two main ones when we talk about them everything else is pretty formulaic in terms of like how we do mitzvos if you're like a brisker you can create many complicated intellectual and emotional experiences from all the things ra says but but the fish words it's it's Tila and it's uh and it's chuva and and if you look right for Al Chua I'm not going to read this out loud but you can look it's that essentially chuva as healing is is it's a cathodic process but it's also quite um destructive in a way because you're create you destroy the current self that you have and this is why you may you may have a question sometimes people are struggling and you say why are they still struggling why can't they let go of something that's happened in the past they seem stuck why do they keep being stuck I see all the stuck cases no one comes to psychiatrist if you're not stuck okay but why are they stuck because being stuck means you can't let go of something because you view it as part of yourself chuva is about creating yourself as a new person and the idea there and the reason why I actually talk about chuva a lot with many of my patients is that our masora has within it the guidelines for how people can improve their mental health to be able to recreate yourself in a way that is new to think that there is a possibility for change it's like a basic CBT principle right you're automatic thought okay tells you that you cannot get better this will be bad things will get worse I am a bad person I cannot change something bad will always happen chuva teaches us that there is a radical possibility of something being totally different and that it's there every day now to say that one time to a person is not going to work to say that over and over again to a person and the person to take that in and to repeat it and to ingrain it and to make it part of how they think does help doesn't need help 100% just 20% 30% so they can get outside so they can do more things they can start feeling better and then they the process continues okay that's our overview that was just the overview okay that's the overview for uh for war and for trauma any questions about war and Trauma in general okay yeah just the balance between I mean I'm a teacher in school rather than on the one hand being honest on the other being seen as a spiritual gu role model I felt a tension between that so there's going to be a tension 100% so what I would say is as a teacher in particular um so it's it's going to be uh it's going to be different depending upon what age you're referring to right so i' one of students so in situations where so in that situation when there's actual trauma and that everyone has been exposed to um we'll talk about it but the the answer is honesty the answer always lean towards honesty as opposed to um being above and things will be okay uh in in the immediate in the long in the in the immediate it's honesty and and that things will continue not that things are all going to be great the way they were but that things continue things continue here this is what happened this is what we're doing about it we are here for you but things have to continue especially in in larger settings like a school or in larger uh institutions Israel actually happens to do this very well in terms of like how they guide people to do it whether whether or not it practically happens on the smaller level is unclear but the ideas are there which is that when you have a trauma you have to continue now when individuals who are adults have traumas they don't continue that's part of the problem but particularly um in schools or in other communal areas the most important thing is to continue um similar actually what re bra said in terms of of PM people ask should we lower our experiences for PM so when people ask me things like that I tell them you know actually the gar says that we should limit our Sim post theas in general so I think that all of our general things that we do are are are Sim limited and they say I don't feel that I said that's cuz you don't know what it was like when we had the Bas of MDES so you can continue what you're doing it's still limited that's why I tell you I said because otherwise what ends up happening is if you limit and you limit things keep happening in life you'll eventually not do anything because there'll be too many things to mourn over and then you get stuck avalus is important but avalus is only important as a cathartic way to process to learn and to grow quick um you mentioned Chua and I like that because of the recreation of the self but how do you avoid that becoming about guilt perhaps me cha sounds like it's talking you know about you did something wrong right right so guilt right so that depends on on the particulars when someone feels that they've done something wrong so it's we we we're going to talk a little bit more about the specifics for therapy and I'll bring it up as an example um okay so in terms of anxiety and fear people let as a psychiatrist I get very upset when people misuse the the terminology but people misuse the terminology all the time but I I stopped getting upset because I realized that it's just people aren't psychiatrists or mental health professionals they not using it that way very popular now is to say that someone's bipolar you'll hear that among like teenagers and young adults they'll call someone bipolar what it means is that they have a very rapidly changing mood during the day they can be angry or set actually a lot of times it's because of trauma it's not bipolar disorder bipolar disorder has a very specific definition uh but the same thing here some someone can say I have anxiety so if you say I have anxiety it can mean many different things to have a formal diagnosis of generalized anxiety disorder requires both physical symptoms and cognitive thoughts for a six-month period of time that creates impairment in your functioning so someone's going to look at me and be like I don't know I just said I have anxiety like why like I don't know I feel stressed out I was like okay so you're stressed out are you afraid of something yes I'm afraid of this of something happening I was like well that's actually seems like a legitimate fear so do you do you not go out because of it no I I go out I do all the things I do but I'm afraid I said then that's not that's not the same thing as what we call anxiety anxiety right that's a fear you can call it anxiety but I separate them because of that and the reason why it's important to understand them is because there are different ways we respond right fear is like the shark is coming to eat me I need to go right now something is right A Haunted House Is Not anxiety provoking unless you have a fear of haunted houses right you see how I use the word fear unless you have fear right but a haunted house is fear-provoking something pops out at you you get afraid that's what happens anxiety is a learned response to be on edge because I know that something bad is going to happen it is adaptive if I know right that if I go to this area right someone might do something bad to me that I know to be on edge and watch myself when I go to that area it's better to be on edge if you end up in silwan of East Jerusalem right then to not be on edge just was probably a good idea so that makes sense however what happens with anxiety when it becomes maladaptive is when it starts to broaden and generalize or becomes put in areas that it's not supposed to be in okay physiologic okay here means that you have bodily Sensations just those bodily Sensations without any thought around it at all is a fear and it can be a conditioned learn response that needs to be treated but without any thought behind it or worries it's not officially anxiety now does that matter not really okay but it's just important for us to understand when people talk about that all right so I'm going to do the doctor part okay so let's talk about how the relevance is to trauma so here this is in our brains make a little model so if you think of this as like a brain and this is on the top of your brain If you ever seen a picture of a brain there's like a lot of little rug all the little like bumps on it so when you open up a brain there's the inside part of the brain and the brain stem that leads into it right is what we call like the basil animal part controls our breathing our Circ circulation if people have strokes in the lower part that's when they're not able to do anything but then you'll have stories where the top part of the brain still functions and the person's still there there's a terrible syndrome called locked in syndrome where someone can't can't speak or do anything but they're actually totally conscious and aware of what's happening it's very rare it's what led to all the fights about brain death and brain stem death and lots of things like that but the idea we're not getting into that today okay but the idea is that if um if you open up right if you I call it flipping the lid because this is when people say they get angry they flip their lid right so if you flip the lid of the brain up and you see here here in the in the middle of the brain you have the amydala and the hippocampus the central parts of the brain that are basic emotions and memory storage okay now we now know that memories are stored in some ways diffusely through the brain in many other areas but still a primary memory area is the hippocampus now that's what this hes okay hippocampus and prefrontal cortex so what happens with stress so the when when a stressful situation happens immediately you get an amydala response the amydala sends off neurons it goes down to the brain stem you get sympathetic nervous system activ heart increases breathing increases you're like okay all right so that's an immediate fear response while that's happening your eyes are taking in what's happening your ears are hearing you're smelling your everything that's around you is part of your hippocampal memory storage that's coming in at the same time so those things are happening together right so if you have it happen and it's super excited you get excessive fear in the amydala if you have right what's happened is you get a stress and you get a stress for a little while you actually get what's called a Hy inhibition of the hippocampus and prefrontal cortex where they start to shut down a little and it actually leads to resilience in dealing with a stressful situation because otherwise you would just be overwhelmed by stress in the short term that's very helpful if the stress continues such as an ongoing War people continually missing people fighting ongoing if the stress continues you lose you you burn out the brain you burn out the process that's used that way and you end up right with an excessive stimulation that leads to a cycle of chronic stress because it's no longer inhibited between the amydala and hippocampus and it now becomes fused the circuitry becomes fused so that they're not separable so that's what we think is the nature of a flashback because if you have a memory something triggers right a smell a sight talking about something being near somewhere if it triggers a memory that reminds you of something that happened in the past the connection to your amydala is so strong you have an immediate emotional response and the memory feels kilu it's happening right now now some people don't have full flashbacks actually a lot of people don't a lot of people will tell you that I don't know why it's not a full flash but I feel very uncomfortable when certain things happen and I stop functioning and the reason can be because there certain things remind them of certain things for example it used to be that I would listen to music and it wouldn't be a problem but a lot of music actually even in Israel has in the beginning of it this sound uh as soon as that happens in the car I was like and then I realized it's because my body has been attuned to now be in a to have an automatic like stress response when I hear a siren and even though it was part of like some sort of instrument I don't know exactly what it was but I've heard it like three or four times in different songs and it happens to all my kids in the back of the car too they're like that was a siren I was like no there's no siren that was the music but then I'm like make sure was it really not a siren I'm not sure right so that that concept everyone's always looking okay so so what happens when these things happen is that that's what happens in terms of in terms of how we how we think for trauma and fear let's talk about anxiety as a cognitive component okay so this is the CBT circle of automatic thoughts I love this circle okay so what happens is let's see let's see if I can do this what happens is usually when you talk to people they say something happens and it makes them feel a certain way right I I uh a classic example is right I heard about some terrible thing happening in Artis right there was an attack people were hurt and I feel terrible I feel awful right but let's turn it into someone who's who's struggling right I I heard about something happening and I felt like I am I I just feel so sad and I was crying crying crying and then that led the person to not be able to go to the supermarket that day CU they were so sad and then a new situation happened where their kids came home from school and there wasn't enough food for dinner that they wanted and then their kids yelled at them and then they felt like they were a terrible person and then they became more sad and then they stopped functioning and you see how I'm going with that right so that's that's a basic circle now this is true for things that are that happen in life too right I came to speak to you today and I felt a little anxious and then I became more active in my speaking because I came to speak to you today and then people seem to smile and respond and then I felt like better and then I continued speaking right you see how I could make this circle for anything but because this circle is how um cognitive behavioral therapy thinks about how we think things but what it says is that this thing that people talk about about the situation feelings piece that that's not what happens there's a third step which is the thought step and it can be subconscious it can happen afterwards consciously but there's this thought that happens beforehand and the thought is the important part because in general people tell you always to try to stop this but it's very hard to stop feelings we actually don't really know how to do that very well at all that's when people talk about like teaching people to do like breathing exercises meditation mindfulness they're all very helpful but if the thoughts continue those emotions will continue to keep coming back so some people can control them enough with with various physiological interventions but sometimes you need to also think about what is the person thinking why are they on edge I don't know why I'm on edge well let's talk about it I'm on edge because I think that any time there could be there could be a a siren at any time okay so that's true you can validate that thought but then the question is does it help you to be on edge like this all the time the person's being honest with you after some conversation they'll probably tell you no actually tends to make everything worse and has not been helpful and the extra two seconds for when there might be a real siren if I was calmer that might actually make me make better decisions and help people just that thought process of going through that most people don't do especially people who are stressed out don't do if you can do that it creates what I call a new pattern of thinking right if this first Circle was the negative way and this is a new pattern physiologically what Happ there is what we call Neural reinforcement so ignore all the meth okay but what's happening here is all of these different neurons are interconnected and they create higher and higher structures and connections between the inner layers of the cells what's cool about this is you don't gain brain cells they don't grow or die actually this is unless at the end if you have neuro neur degenerative disease okay but other than that brain cells don't grow into new brain cells they they change and alter their structure of the connections and connections can grow and you can have additional connections and stronger connections and as this happens over time you create new ways of thinking that's why if anyone right people like to talk about like geser's concept of B that there's like a b point and you can choose a point at a different spot and it's higher or lower so I think that this applies to this when you're thinking about something if you have a certain level of connectivity you can't choose other options because it's so foreign radical choice is possible but it's a very very small percent most of the time it's within a certain structure so when you're dealing with someone who's who's not functioning to expect them to then start attending a dfom every day is just not it's not appropriate you should talk first about basic things like let's talk about how you need to make sure to get up in the morning to help your wife with the kids just basic things and and you work through that and you make up to the levels that you need okay so chronic fear what happens is is it stresses out the system people burn out right and we have to talk about what kind of what kind of support can we do to help people right now what happens if you're ring anything but the tail you're in a school you're in your community right most people right most people don't have Pulpit jobs in Israel so anyone who's here you you may have a you know the title RV but the question is what that means so here it means something different than it does in America here people still view you as a RV some communities where a lot of people are abundant maybe not as much but usually people still view you as some sort of leader in some way and the issue is that as I talked about when they have what I call like the the Moshe complex and most people have it which is the r is MOS right and so the r is supposed to be the person who's supposed to explain to me everything from Hashem so the problem that happens with that it happens much more if you're a r of of a Sho but it happens to everybody is that if you are trying to help someone sometimes you will get this you will get a lot of anger okay and the reason why you'll get anger is because people are turning to you and they're saying right he he didn't know I was going to quote but that's what happened so he didn't know if he will turns you in they'll say right he so angry he's he's like what's going on you God right but most people some people do like just talk to God and just yell at him but some people will be like instead they'll just switch it and they'll be like today you happened uh like whoever is closest to me happens to be a a replacement for all the things that bad that happen in my life yelling at Hashem does not seem to be working for me okay I go through my doing like robotically like I do what I need to do and then I see something happens and I scream at my friend or I yell at my neighbor or I stop talking to somebody and I don't think that they're related but they're probably related and the reason why they're related is because we have a lot of anger right and it's not that the person is to blame that's why I brought this people are not uh they're not this they're not able to like recognize what's happening when they're when they're overcome with that type of emotion okay all right so now we get to the important part it's like that was great thank you D we really appreciate it spent all this time talking through everything most of this we knew already some of the science stuff maybe not okay so what to do so as a psychiatrist I tell people just because I'm a psychiatrist doesn't mean that I know what to do better than anybody else okay I went to medical school most of medical school was not about mental health it was about Anatomy physiology biochemistry then I had to learn all this stuff about the GI system right neurology OBGYN there it's great very important things I'll I'll call you up if I have a medical question doc or I'll call you up if I have a psychiatric emergency right whatever that means we'll talk about that but you know what what is how did I learn what to do so the reason what I'll tell you is the reason why I think that it's appropriate for me to talk about it is because these are things that come up when you're a psychiatrist and the truth is that the reason why I ended up going to Psychiatry is probably because I was a rough before so I didn't have a pulit but I did SM and I was interested in communal work and I worked in U both adult and youth nonformal education for many years and then when I went to medical school every single rotation I went on they said you did a great job be really connected with all the people and that's the most important thing about being a doctor I was like oh that's funny I think that's the most important thing about being a human being okay so that's that's why um I decided to do Psychiatry but that's why when you talk about how to help with people it's some of the stuff is pretty basic the most basic thing and the thing that people forget all the time right selfcare okay if your glass I like this if your glass is overflowing and full right if you wake up every day feeling sad and crying that is not the time to start volunteering and doing things and helping people who are stressed you can do that it's a way of distracting yourself from your problems I have patients who are abun who spent years in the pulpit and they were really effective in the Pulpit why they had to spend 24/7 working non-stop being a r is a 24/7 job especially if you have a large enough sh you don't you don't see your family you don't speak to anybody I mean it's not good if you do that okay but if there are people who do that and they do that because they have this problem and then afterwards when they finished completely broke down there have been a lot of Articles and discussions about a lot of people actually who left the pulpit to make alah because they had a dream of living how difficult that is why is that more difficult for aside from the fact that you need a parasa right because when you come and you've been so used to pushing yourself pushing yourself sometimes are things that come up that we never talked about if your cup is full you cannot pouring your cup into other people that's going to therapy right that's not if your cup is full you can't take other people's water and put it in so either you have to do one of two things either you have to drink some water or pour some out that's about processing and getting rid and moving your emotions or you have to get a bigger cup they're both good options getting a bigger cup means learning better skills to be able to handle stressful situations to be able to manage things to move things right now you don't get rid of all the water that's there but that's okay if you have a large enough cup don't get a temporary Israeli large plastic cup because that's going to crumble in your hands and then all the kids are going to start crying that you got everybody wet and you didn't get them the water so but just be aware so that's the it's just important things to think about right you have to make sure to take care of yourself first and that's actually very hard here because no one knows how to do that there are no weekends in Artis it's not something people think about now if you have children you're like oh it's great they go to school on Sunday now they're in school all day but guess what I used to spend weekends with my family I would have once in while a Sunday where I'd go out with my kids I could learn with them during the day we would do something special it never happens anymore because they're in school every day school's great but the other experiential components right are not there now actually has amazing other experiential components other is like filth every night there's something else happening there's lots of great things right for people there's sharum there's lots of amazing things but it's just things to think about people should be aware right how are you doing things beyond the regular things that are meaningful for you such as coming to a conference on how to help people that's a great idea it's a great idea to come here yeah okay so but anyways fine all right so I'm GNA pick it up a little bit so practical steps so there are basic practical steps and then there are therapeutic steps these basic ones you should be able to like know for yourselves tell everybody routin routin routine if people get out of their routines Things Fall Apart I can't tell how many times people came to me and they said I stopped going because it was too hard for me and then everything fell apart you have to keep going routine and sleep Ram says roughly eight hours okay eight hours and we've actually seem to find that that's probably true now if you can't sleep8 hours you can't sleep eight hours but get the sleep that you're able to get if you see right if someone tells you it's late at night and I don't want to go to bed right 10 p.m. is not the the time for most people to do a late night seder it's just not a good plan when you were in yiva and you wanted to stay up late and learn B SAR if you have other responsibilities and you stay up until midnight preparing a presentation for the next day it's not going to go well so just just to be aware right nutrition and say war time is not the time for the ran eating so the ran has this long thing about eating that you should eat when you're hungry right so he was a different time period you should have COA times to have meals because other times if you're stressed during a war especially people either eat all the time or they don't eat at all right it's called like either graze eating or like you just stop eating because you like stress like you're stressful get it stressful okay but the idea is that if you don't set up times where the person takes care of themselves it doesn't work movement is very important okay you have to make sure that if the person isn't getting exercise in a real way they have to at least be going for a walk outside every day the amazingness about being an a to now is that you can go outside it's not like a people in America they're like there was a blizzard I can't get out of my like it's freezing cold I don't want to go outside it's raining it's gross most of the time here it's actually very nice people can have routines outside even if it's cold you can wear a jacket people should get out they should be able to keep themselves moving going to things socialization people don't always like to do this and people shut down but basic basic things of like go to schan Chavis one night one one day a week go out with your spouse to do something every couple weeks have a COA time where you and Old Friends get together and do something like if you don't have regular meetings with people make sure that you have something and then resp bits when things get overwhelmed and you feel overwhelmed it is a good idea not to push through it's a good idea to take a five minute break people don't like people hate doing this okay but it's actually better instead of just ignoring and pushing through to reather yourself because otherwise that feeling will continue now if you're in the middle of a meeting there's something you can do there's nothing you can do you have to push through it but if you have the opportunity to take a break from whatever it is you're doing and spend 5 minutes doing um you can look up diaphragmatic breathing exercises progressive muscle relaxation whatever it is just to calm yourself down from whatever it is that you're feeling it can be very helpful and it applies to everything chronic pain this that all these types of things can be helpful these are the six practical steps I think that are very helpful let's talk about therapeutic steps this is like the H for doing right so first we talk about over and over again being there for the person right being there for the person just the presence of having someone cares about them then you can ask after you've been there for a long enough time and they start talking to you then you can ask do you want help how can I help you if they say I don't know but I I think I need help I don't know what I need to do right then you have to talk about most important thing which is about resources versus Saving right as a RV you're not a mental health professional when people come to you and they say I'm thinking of killing myself I have recurrent thoughts of wanting to do something to to young children now is the time to refer them to somebody who can help if you continue to see them independently aside from opening yourself up to lawsuits which is never a good thing but you also uh that person needs a team when someone is at the point where they are what I call in the Red Zone the red zone is where one more step and there will be an irreversible damage that's the Red Zone One Step irreversible damage you can name an irreversible damage it could be many things loss of life savings physical harm to people any of those things severe emotional trauma that can never be undone Lots things like that those things make sure that you have the resources now I actually this that packet was amazing the booklet from get help Israel I never saw it before it's amazing so many resources in there I'm not in there because I just mean alah okay but there are many many great resources in there um okay so then sometimes people will sometimes this will come slowly but sometimes you'll get the aha moment okay right is trying to like find all the reasons why things aren't working and he realizes that he has to figure out what he has to do and that when the person realizes I need to do something now they may not be able to do all the things that you want them to do but if someone comes to you and says Rabbi or a friend name whatever I I I think that I I want to do something I want to make a change I want to do something different that's when you have to say right it makes sense that things were so difficult for you you have to normalize the fact that it was okay to struggle I used to call this um Facebook culture now I call it like uh you can call it like it's not really WhatsApp but like for the kids it's like I'll be like Instagram culture where you put on all these pictures and things that everything is great but that's not really what's happening that's not what's happening you're not going to post the fact that you lost it at your kids this morning you're going to post the picture of everyone nicely all dressed like going on your teal for like that's but that's that you know that took two hours of everyone losing it in the house in order to get them already for that picture and lo and behold you're not in the picture and they like I never get to be in a picture with my kids H so that but the idea is that those things are nice snapshots of of Ideal things that you would like to have but that are not really the everyday life of what people have and so you have to recognize that it's okay to feel like things are not okay all the time and then at the end the final process that people really can work with is sublimation that's where the person has processed they recognize that things are hard they want to do something different so then let's turn our energies let's talk practically how we can do something positive right how can I volunteer how can I do the right thing how can I be there for someone so these are the steps I think that are important you have to know when things get past that line when to refer right what I would say is that when someone is in yellow this is very important when someone is in yellow which is where they're in a state where they feel very stressed they stop functioning well and it seems like they're in like a semi crisis you can intervene then but you should refer them then and the reason why you should refer them then not to me to a psychologist or a therapist okay that point is the time for therapy why because if you don't refer them then they're not it's going to take months before they probably gets even if it takes only a few weeks things progress quickly you don't know what's going to happen they have to get into to see someone so that if things progress they have the framework to catch them because if you try and intervene on your own and it doesn't work then you're going to be coming to see me in the emergency room and that's what I would prefer to avoid and I think that's what we all would prefer to avoid we don't want people to be in a crisis that extreme so the idea is that when people are struggling and stressed and upset that we we go and we work with them to give them that Health now another group of resources aside from the book that you got there's um there is a great resource um a has this has on their website it's a list of all it includes get help Israel everything in every area of Israel for English speakers so I highly recommend looking at it they have their own stuff but um this is that's really for like if people are looking for like Crisis lines to call and things to work get help Israel also has all of those things um but it's important this number here please do not share with anybody this is not my work phone I put this number here because I want everyone to have it because because I'm a psychiatrist and there aren't a lot of us okay so and I recognize that everyone here works with people who might need it but this is my private cell feel free to call me or text me or Whatsapp me or whatever if you need if if you feel like there's something that you need or you don't know how to navigate the system the system in Israel is very complicated in terms of how Mental Health Works um any questions please feel free to reach out I'm also happy to give you my work number that you can give to people if you want but recognizing that I ideally it would be great if they could get into SE therapist before they're coming to see me um so my Braha is with all this that we can take all the the tools and things that we just talked about and use them uh to for all the people that come uh to see us who work with us to help us understand where where we need to take care of ourselves to help us understand what limits we need to set for ourselves and how we can be a resource to people to know when to refer um and that's all any [Applause] [Music] questions