Introduction

Since the onset of the second Palestinian uprising against Israel and its occupation of Palestinian territories (October 2000),Footnote 1 thousands of Qassam rockets have been fired from the Palestinian Gaza Strip at the city of Sderot and other settlements in southern Israel. In June 2004, the rockets claimed their first fatalities: a young boy, Afik Ohayon, and his friend’s grandfather, Mordechai Yosifov, were killed when a rocket hit Lilakh preschool in the Neveh Eshkol neighborhood. Their deaths sparked fear and angry protest in Sderot; the residents complained that the state had abandoned them and had failed to provide them with any protecting shield. A few weeks later it seemed that their protest had borne some fruit: funded by the Jewish Federations of North America, experts in posttraumatic stress disorder (PTSD) from Israeli nongovernmental organizations (NGOs)—which had acquired their skills in northern Israel with the Hizbullah’s rocket attacks and in central Israel during the frequent Palestinian suicidal attacks—offered their help through a program they called “community resilience” (Hebrew: tokhnit hosen kehilati). In a document distributed to government offices, North American Jewish federations, and municipal offices in southern Israel, they announced their program as follows:

In the course of the last four years, the forty thousand residents of Sderot, Sha’ar Hanegev, Hof Ashkelon, Sdot Negev, and Eshkol have become the frontline facing ongoing Palestinian violence. Since year 2000, over four hundred Qassam rockets have been launched from the Gaza Strip into the area, and many have hit playgrounds, schools, and other population centers. These rockets have not broken the spirit of the residents of Sderot and its neighboring communities. Despite four years of terror and uncertainty, the grave socioeconomic situation, and the high unemployment rate, the city’s residents have remained stable and committed to their community…. [The goals of the program are] to build a resilient community and empower Sderot by providing immediate aid in order to manage the intense reactions of the residents to the situation and strengthen their coping skills.

The proposed assistance is mainly psychological (managing reactions and strengthening coping skills). It contains two paradoxes that aptly express the complexity involved in this reshaping of trauma. First, although the experts describe the residents as desperately in need of help (due to terror, economic problems, and unemployment), they state that the population spirit is unbroken. Second, although their goal is to strengthen the community as a whole, their intervention is targeted toward individuals. Still, how precisely do these experts view the designated recipients of their new resilience program? A document published two years later (December 2006), clarifies matters:

We anticipate that at least thirty percent of the city’s population was seriously affected by the events, and between ten to twenty percent already suffer long-term and chronic effects of post-trauma symptoms…. In addition to the cases that require direct treatment, we will provide others with psychosocial interventions for the purpose of strengthening their personal and family resilience.

The trauma experts draw a connection between the psychiatric discourse on posttrauma and their intervention. They note a widespread (and differentiated) impact of the rockets on the entire population living next to the Gaza Strip. They thus associate themselves with the recent travel of PTSD from U.S. psychiatric institutions to other nation-states where civilians are subject to violent political conflicts (Breslau 2004). Similarly to international PTSD interventions in Bali (Dwyer and Santikarma 2007), Ethiopia (Zarowsky 2004) and Haiti (James 2004), the Israeli experts base their program on statistics (percentage of PTSD sufferers)—thus incorporating the universal with the local (and the political) to allow for a numerical prediction that reflects a “victim portfolio” (James 2004, p. 132).

However, the application of PTSD in Sderot bore a special character, which is the focus of our inquiry. According to the document, 30% of the city’s residents were gravely affected by the events, with 10–20% displaying long-term symptoms of PTSD. The other 70%, although not displaying these symptoms, were still presented as requiring professional intervention to build up their personal, family and community resilience. The population targeted by these professionals included a minority clinical group, which displayed pathological symptoms, as well as a majority group described as preclinical and in need of fortification as a preventive measure. This site marks a new social expansion of PTSD. Instead of retrospective intervention, the experts suggest intervening in advance. This new application of PTSD thus offers an opportunity to examine an important shift in its medicalization: the broadening of its use from a sign of pathology borne solely by individuals to anticipated clinical symptoms around which pre-emptive actions are taken to immunize the entire social body against possible trauma.

By focusing on the new social construction of PTSD, we do not undermine the distress, anxieties and traumas of local residents. Suffice it to quote the musician Haim Uliel, a resident of Sderot who recently moved to the country’s center, who describes life under the Kassams’ threat: “The stress and tension take control of your entire life,” he says. “When I take a shower, with the shampoo on my head, I need to wash quickly, or soap myself swiftly, so, Heaven forbid, the siren [rockets alert] won’t catch me in the middle; or in the restroom. You can’t even urinate peacefully anymore” (Mula 2009, p. 26). We do not deny, then, the possible far-reaching (traumatic and other) effects of the Qassams on perhaps the entire population. Instead, we try to understand how the professional discourse on PTSD was articulated and implemented—both pragmatically and politically: How is the transformation of PTSD taking place? Which specific intervention practices are used to build the resilience program? and How do competing groups in the public sphere of the nation-state negotiate this intervention?

Medicalizing Trauma: Globalization and Localization Processes

The anthropological study of PTSD in the 1990s focused on the diverse ways in which politics has figured in this psychiatric diagnosis: its institutionalization in the DSM-III, as a result of various social players’ work within psychiatry and, especially, the strong Vietnam veterans’ lobby (Young 1995) and its use in medicalizing and depoliticizing social problems. Victims are, in this paradigm, treated as individuals; there is no wide reference to the broader political context of collective suffering (Kleinman 1995). In recent years, anthropologists have pointed to the politics involved in the globalization of PTSD: “how social agents… make use of the category of trauma and the notion of post-traumatic stress disorder, appropriating, reformulating or even twisting them” (Fassin and Rechtman 2009, p. 12). Thus, its migration from U.S. psychiatric institutions into many national sites around the world has made it, anthropologists argue, essential in calling the world’s attention to political violence and natural disasters. Further, PTSD discourse has become a preferred rhetorical and practical tool for treatment of suffering around the world and for promoting international humanitarian aid programs. PTSD thus serves as a magnifying glass to observe different forms of suffering around the globe, and it is closely intertwined with local sociopolitical processes (Breslau 2004, p. 120; Fassin and Rechtman 2009).

Several studies have dealt with the ways in which PTSD is presented as having scientific and universal validity, and how it is worked out in local contexts. Researchers argue that the latest PTSD discourse has transformed the disorder into an axis around which local social inequality is organized. For example, the introduction of PTSD discourse in Haiti between 1995 and 2000—a period characterized by the regime’s instability, including an attempted military coup—created new relationships between the humanitarian aid organizations and the service recipients, and between these organizations and their sources of funding. Thus, the professionals authorize aid mainly on the basis of biographical events that presumably induced trauma among local residents. The very act of diagnosis became a social resource and a focus of social negotiations, for it allowed access to material and symbolic assistance as well as national and international recognition. In light of these implications, the mental health professionals become “trauma brokers”: gatekeepers who gain personal and institutional profit by deciding who is entitled to aid (James 2004, p. 140).

Furthermore, the spread of PTSD discourse was made possible by efforts to “raise consciousness” and increase knowledge among local residents regarding the disorder. For instance, following the terror attacks in Bali, Indonesia, in October 2002, the U.S. Agency for International Development introduced this discourse through the work of mental health professionals who treated hundreds of the island’s residents whom they identified as suffering from posttrauma symptoms. PTSD has thus become part of the local vocabulary used to describe personal and community suffering. These processes, however, were not free of social negotiations and political implications. The residents of Bali were ambivalent about the professional intervention. Although PTSD has become an important instrument for gaining recognition in their suffering, and as a first step in the relief of clinical symptoms, it was also perceived as a repressive discourse that overshadows alternative narratives. Some residents described their suffering as rooted in Bali’s unacknowledged political discourse, which differs from the apparently universal PTSD discourse. Thus, symptoms such as depression, anxiety and desperation due to the loss of income in the wake of terrorism were ignored. Moreover, many complained that even though the 2002 terrorism awakened memories of the 1965–1966 political violence, the interventions offered were directed toward victims of the latest attacks alone (Dwyer and Santikarma 2007).

Thus, when experts implement PTSD discourse in new local settings, the mental suffering of individuals is highlighted, while broader social-political questions are pushed aside. The latter problems are often alternative idioms through which local residents express their distress. In trauma stories of ethnic Somali refugees in the Ogaden Province of Ethiopia, for example, issues of injustice and social rift, and not private, emotional suffering, are prominent (Zarowsky 2004). Similarly, distress narratives told by political activists of low socioeconomic status in the city of Santiago, Chile, reveal that trauma, history and memory are mixed together, and are retrospectively processed as part of negotiating a political-ethical position. Trauma was not understood in individualized and mental terms but, rather, as a “dissonance of relations” that was nourished by the tension between the socialist language of the past and the neoliberal language of the present (Han 2004).

In this article, we join these critical discussions of social control and inequality involved in the globalization and localization of PTSD by examining another dramatic change in its accelerated expansion: from treatment of suffering individuals to development of resilience in the entire social body. PTSD was already used to raise awareness to the possibility of psychological damage due to exposure to violence (Breslau 2004; Dwyer and Santikama 2007). In this case, however, a full transition is taking place—from the clinical to the preclinical. Thus, the experts in Sderot offer a comprehensive therapeutic intervention aimed at the entire population. Furthermore, the activities aimed at mentally strengthening Sderot were not initiated by international humanitarian aid organizations but by local NGOs that operate from central Israel (supported, though, by philanthropic organizations in North America). These experts operate as private actors but, nevertheless, in the framework of the nation-state with its bureaucracy and its geopolitical and ethnic tensions. Accordingly, differences are constantly exposed between state agencies (like the National Insurance Institute of Israel) and the NGOs that lead the assistance program regarding the presumed PTSD vulnerability of the city’s residents. For example, whereas the former tend to downplay PTSD incidents, recognizing for insurance benefits a rather small number of injured (approximately 14%), the latter claim a much higher percentage, actually about double (Weiler-Pollack 2009). These gaps show that the PTSD project in Sderot, though national in scale, is carried out by local PTSD experts that are separate from, and at times in clash with, the state. Furthermore, this resilience program is articulated through power relations among different groups within the nation-state. The new medicalization of PTSD is not limited, then, to the imposition of pathology on suffering individuals. It includes management of the population along ongoing geopolitical and ethnic contestations between professionals from the country’s center and their colleagues in the periphery, and between the professionals and the community.

The issue of ethnicity (and class) in Jewish Israeli society is prominent here. Despite their reference to the general population around Gaza Strip, the professionals differentiated (e.g., in the documents cited earlier) between Sderot’s residents and those of the kibbutzim and moshavim (agricultural settlements) in its vicinity. Contrary to the latter, the founding of Sderot in 1953, and later on, involved ethnic hierarchies, for it has been part of a nationwide state project of establishing “development towns,” primarily aimed at populating areas near the Israeli borders with Jewish immigrants (Yiftachel 2006). Ashkenazi Jews (of European origin) who constituted the dominant group among the state’s founders sent groups of new immigrants to settle these towns. In the first decades, Mizrahim (Jews of Middle Eastern and North African origin), especially from Morocco, were sent to live in Sderot. Later the authorities sent to Sderot Jews from Ethiopia and the former Soviet Union, particularly the “less European” Jews, from Caucasus and Bukhara. As early as the 1950s and 1960s, the welfare discourse referred to the city’s population as “disadvantaged,” and in need of special resources to narrow down the ethnic Ashkenazi–Mizrahi gaps (Mizrachi 2004). The semantic field used by professional changed over the years—for example, from references to “distressed youth” to “children at risk”—but the stigma remained the same. As we point out below, the recent use of PTSD has not replaced previous layers of labels but added more layers on top of them.

Our inquiry is based on fieldwork conducted by the first author from September 2005 to March 2007 in the city of Sderot. The research included participant observations in professional forums of two of the NGOs that lead the aid activities in Sderot, the Israel Trauma Center for Victims of Terror and War (NATAL; Hebrew: nifga’eh trauma al reka leumi)Footnote 2 and the Israel Trauma Coalition (ITC; hako’alitsia haisraelit letrauma),Footnote 3 and in various interventions with elementary school teachers, educational counselors, caregivers and groups of residents that took place as part of the Program for Building Community Resilience, including “solidarity visits” made to the city in February and August 2006 by representatives of the United Jewish Appeal (UJA) Federation of New York. In addition, conversations and interviews were held with 15 local professionals and local residents.

In what follows, we examine how the change from retrospective treatment of individuals to building of resilience in the social body takes place. Which specific discursive and nondiscursive practices enable professionals to occupy new social spaces for action? How do they transfer PTSD from a clinical label to a preclinical therapeutic principle? What happens in the course of this process in terms of sociopolitical relations between different groups in the nation-state? What are the reactions, for instance, of caregivers and other members of this peripheral community to the new resilience program offered to them by the PTSD professionals coming from the country’s geopolitical center?

Expanding PTSD: From the Clinic to the Public Space

The diffusion of PTSD in this national context entails transferring the disorder from the private sphere at the clinic to the public space (see Fassin and Rechtman 2009). Since the leaders of the relief program are not international humanitarian organizations but Israeli professionals who believe they know the place intimately enough, they allow themselves to creatively improvise and offer various long-term interventions. Their sense of control and presumed knowledge is expressed in ambitiously targeting the entire population in light of the PTSD diagnosis. Furthermore, they make fine distinctions within the local population, splitting it into three focal groups, each serving as a new object of therapeutic intervention, and each offered a different kind of treatment. First, the experts operate a “mobile unit for treatment of traumatized families” (nayedet letipul bemishpahot traumatiyot) throughout the city. Second, they have been forming “haven rooms” (hadreh shalvah) in elementary schools. Third, they have been running workshops for “developing personal resilience” (pituakh hossen ishi) in elementary schools, in education and welfare departments and in the city neighborhoods. These interventions correspond to different levels of proximity to the perceived clinical core of trauma—from identification of individuals within families suffering from PTSD, to intervention in groups exposed to anxiety experiences that precede PTSD, to groups that are immunized against future PTSD.

Bringing Treatment into the Community: Mobile Clinics

From the onset of the resilience-building program in Sderot, efforts were made to spot and treat children and adults manifesting symptoms of PTSD. However, in January 2007, after several weeks of increasing Qassam attacks, these activities took a form that reflected the extension of the intervention into new realms. At the initiative of experts from NATAL, and in cooperation with Sderot’s municipal welfare department, a mobile clinic began to operate in the city. Six psychologists (including speakers of Amharic and Russian) travel in a special van around Sderot once a week and treat families in their homes.

This intervention is immediately associated with ethnoclass issues, for the professionals claim that it provides a response to the city’s “weaker” groups’ tendency to avoid psychotherapeutic services. In fact, the list of families scheduled for the van’s visits is based on applications of families to the municipal welfare department that its personnel, under the external experts’ guidance, perceive as having at least one member suffering from PTSD.

In operating this mobile unit the experts expand their professional repertoire to include diverse and eclectic therapeutic practices: conducting an “evaluation of the level of functioning at work and school, and in emergencies”; teaching “skills to stand against, and prepare for future stress situations and distress”; identifying family members suffering “very serious distress”; processing individuals’ traumatic memories; and teaching them how to regulate their feelings and control their bodies. Alongside a focus on specific persons in a family, all members become the object of the psychologists’ intervention and are offered a therapeutic “toolkit.” Frequently switching between individuals diagnosed for PTSD and the family as a whole, the experts also teach “parenting skills” (keeping a routine and setting rules and boundaries) and even suggest a “systematic change” in families’ lifestyles.

The therapists’ reports reveal how their new intervention is applied in practice. The PTSD reports place clients on an axis of time, spanning from past traumas to present consequences, and onto the future, thus detailing the “main problem,” “therapy plan” and “prognosis” for each family. The intervention in a family with three children is presented as follows (February 7, 2007):

Main problem: numerous Qassam hits in the home vicinity. The mother and the two daughters are treated. The son is constantly clinging to the mother, restless, and afraid to be alone even in the bathroom. Therapy plan and prognosis: work with the son to provide support, and teach skills to calm down; work with the mother on separation. Medium prognosis.

Another report presents Lea (all names are pseudonyms), a widow and mother of three:

Main problem: The woman witnessed hits of several Qassams. Two years ago she was injured in her hand, and her granddaughter was killed. Symptoms: difficulty in sleeping, tension, over-excitement, headaches with no medical finding. Therapy plan and prognosis: ventilation, ongoing therapeutic and behavioral support in coping with fear; reinforcing strengths and existing support systems. The woman is mature, the prognosis is somewhat poor, but even a partial improvement in her condition is very important.

About Miriam, a divorced mother of five children, the psychologist wrote:

Main problem: Two months ago a Qassam fell next to the house. Since then the mother suffers from anxieties and over-excitement most of the time. Once she fainted; has difficulty sleeping, and explodes at the children for no good reason. Other family members display no unusual reactions. Therapy plan and prognosis: work with the mother to give her tools for coping with fear and anxiety, like practicing self-defense and logical thinking. Reinforcing existing strengths. Good prognosis.

Underscoring clinical symptoms (like anxiety, physical clinging, overexcitement and anger), other forms of suffering like damaged property, broken glass, blasts, actual injury and loss of life due to the violent conflict between Israelis and Palestinians are downplayed or translated from the political to the medical–psychiatric arena. The mobile units mark a new form of medicalization in treating traumas. It is not only social suffering that is reconstructed as mental problems of isolated families and of isolated individuals within families (cf. Bracken 1998; Kleinman 1995; Young 1995), but also the very expansion of the clinic. Instead of clients coming to a clinic, the professionals are the ones who move around. Indeed the title chosen for the new clinic, “mobile unit,” testifies to the emphasis on portability and reflects an effort to acquire legitimacy similar to that of emergency vehicles.

Intervention at the Onset of Trauma: “Haven Rooms”

Building up haven rooms in elementary schools expresses an effort to intervene at an early stage of trauma—namely, with the emergence of anxieties, against which these rooms are meant to provide tranquility. Schools are asked to allocate a room (usually a storeroom or the educational counselor’s office), which is then redesigned according to the experts’ guidelines. Investing a few thousand dollars in each, the rooms are emptied of their contents, and filled with large colorful pillows to sit on. Games are spread over a carpet in pale hues, and dolls are placed in different corners, next to books and games that are perceived as having “emotional content,” that is, as enabling reference to feelings like fear, sorrow, anger and happiness.

Various therapeutic activities are carried out in these room: occasional talks with the school education counselor at anxious moments following a Qassam attack, series of preplanned talks, movement therapy and group discussion (corresponding to capacity) of emotional distress. The director of the project, Meir, an educational psychologist supported by the American Jewish Distribution Committee (JDC),Footnote 4 explained (interview, June 20, 2006):

The program was built in order to respond to the emotional situation, particularly among school children…when we got to the schools we understood that the situation is extremely serious: there is an increase in violence, tension, and anxiety. It is something much broader, and more damaging to everything, to everyone. So we expanded our activity, and said that we would carry out intervention with all sorts of children in whom we see and feel the effect…[this means] that the children are not referred for therapy, but the therapy is brought into the schools.

In explaining the rationale for the therapeutic action, the expansion of the pathological is evident. The therapy program is aimed at bringing the clinic to the school, to the community itself. The intervention, worked out through cooperation between ITC and JDC, treats trauma as an overall condition of social reality throughout Israel (“Haven Rooms” foundation document):

In the existing situation in Israel, many children and adolescents are exposed to traumatic events as a result of Qassam rockets and continued acts of terror. The “Haven Rooms program in the schools is intended to improve coping and competence of students, parents, and teachers in ongoing traumatic and emergency situations…. The overall goal is to create an optimal physical environment in the school…. The haven room has an added value as it is a concrete physical place that serves as an emotional “safety room” for the students.

The new room is a distinct space in the schools, permanently marked, and designed to achieve an emotional objective: tranquility. As such, it blurs the pathological symptoms on which it is founded: the numerous expressions of distress that the experts had identified in schools (“increase in violence, tension and anxiety”) led them to deduce that the Qassams “hurts everyone.” Therefore, therapy is brought into schools. The entire social body and space, and even the entire national sphere, are put under the gaze and psychiatric work of these experts. Similarly to the mobile units, here too, the new emotional semantic field echoes the “security” discourse in Israel. The “tranquility rooms” become an emotional parallel to, and draw their legitimacy from, the famous “safety rooms” built of heavy concrete and spread all over Israel. Furthermore, the medicalization of the physical and social space utilizes a rhetoric that softens the stigma of those entering the tranquility rooms. Becoming an integral part of schools, the temporary labeling of being “under treatment” is to dissipate when children return to their classrooms and their routine of studies.

Immunizing the Social Body: Resilience Workshops

The most innovative therapeutic intervention implemented in Sderot is the workshops for developing personal and community resilience. The workshops aim at preventing acute trauma prior to its onset. Their rationale was articulated by Yoni, a psychologist who led a workshop for the principal and 10 teachers at Yesodeh Hatorah school (August 10, 2005):

We are in a very complex and demanding period, with the entire nation in prolonged trauma for several years. Those at risk are our children, who don’t always understand who’s against who, and who can’t always bear the threat to their and their parents’ lives. We believe in working and strengthening the teaching staff, not because they need reinforcement, but in order to remind them a few things, to give them a tool or two so they can do some work prior to and after [attacks]. Also, the more we invest in advance, the better people will be inoculated, medically and emotionally, and the better they will hold up, and the less injured and upset they will become.

Yoni constructs the occurrences in Sderot as part of a larger scene according to which the entire nation is traumatized. Further, he identifies the most vulnerable group prone to acute trauma—children, who lack, he argues, an understanding of the situation, and are in need of better coping skills. The paradoxical rhetoric of both strength and weakness, noted earlier, is prominent here as well. The psychologist claims that teachers need minimal intervention but this will guarantee significant results. Furthermore, similar to the analogy between mobile clinics and emergency vehicles, and between tranquility rooms and safety rooms, the analogy between mental resilience and medical inoculation serves the psychologist and other professionals as an important rhetorical means to persuade people of the necessity of this new therapeutic intervention.

The booklet that guides the psychologists in their work makes it clear that the workshops are designed as a series of exercises aimed at building up resilience against potential distress. The techniques used refer to various dimensions of self control, as depicted in psychotherapeutic and mental health discourses, specifically learning about emotion, cognition and behavioral management (Gaines 1992). The goal is to “enrich our emotional vocabulary, sharpen the distinction between different emotions, and make speaking about feelings acceptable.” Special techniques are devoted to managing fear and anger. Against fear, the booklet instructs the participants to imagine a “safe place” where they feel “protected and loved.” Further, it explains that anger is not isolated from accompanying thoughts like “I was treated unfairly or unjustly,” that it is liable to be expressed in aggressive behavior and that it is an emotion that “begins with a drizzle and may become a flood.” The participants learn how to “acquire self-control, and direct anger into positive channels.” On the cognitive level, participants learn definitions of “stress,” the use of scales (numbers and colors) to express it, coping resources (organizing thoughts and collecting information), the use of religious faith to give meaning to events and the use of positive thinking and strengthening of one’s sense of optimism and capability. On the behavioral level, participants practice relaxation, guided imagery, and strengthening of social ties for the purpose of “resilience-building social support.”

These exercises are directed, as noted, to a preclinical group that does not display any PTSD pathological symptoms. The experts suggest that all residents should be inoculated by learning emotional, cognitive and behavioral skills for coping with stress and uncertainty. The aim is to develop personal and social stamina and build “resilience.”

The focus on resilience embodies a transition from risk, illness and psychopathology to adaptability, strengths and resources (Richardson 2002). In terms of the structure of PTSD (cf. Young 1995), resilience emphasizes the present and future instead of the past. In post 9/11, the U.S. followed what Young called (2007, p. 42) “PTSD of the virtual kind” in which citizens were encouraged to think of themselves as participant-observers in a traumatic event and in which the concept of “resilience” received special attention from researchers, clinicians, patients and the wider public. The emphasis on resilience marks in Sderot not only a shift in its discourse from “heroic quality” to “ordinary magic” (Young 2007, p. 41) but also to its massive popularization. By pairing trauma with resilience, each of the city’s residents becomes a vulnerable subject, regardless of whether exposed directly to Qassam rockets or suffering from any PTSD symptoms. All residents are to be taught how to prevent their own traumatization by creating a psychological posture characterized by confidence and control, as opposed to the instability, insecurity, lack of control and uncertainty that characterize the external, objective situation in the city.

Medicalization and Power: Ethnic and Geopolitical Relations

Transferring posttrauma from the private, clinical sphere into the community exposed its use to public debate. Senior psychologists belonging to NGOs that led the program portrayed their intervention as a great success. One of them, Eli, told his colleagues at their annual meeting (NATAL, September 29, 2005):

In Sderot, we gradually became the representatives of mental health. We operate twenty-one projects there. We are involved in all the schools, with a budget of 750,000 NIS [New Israeli Shekels]. Three thousand students go through the program we developed. This is our direction for the future—not direct work, but reaching large groups by means of professional work in the community.

The change in the use of posttrauma that Eli refers to (“not direct work, but reaching large groups”), as well as the complex relationships between those external experts and Sderot’s municipality and its local experts, triggered intensive discussion among all actors involved. At a meeting of the ITC board (October 16, 2005), Reuven, its CEO, noted the need to “upgrade” the involvement in Sderot:

Reuven::

The struggles with Sderot are not over. The municipal director of education does not want money for the “warm rooms” [later called “haven rooms”], but for a “resilience center.” In practice, many projects are carried out, some without formal contracts…600,000 dollars are left for the next stage of the program, and in Sderot they prefer to allocate these funds according to their own criteria

Ofer [senior psychologist, NGO in northern Israel]::

The field of direct therapy is badly neglected. 16,000 shekels is a joke, especially in the face of these endless attacks

When additional funds for operating the resilience program became available, it was discussed again (July 4, 2006):

Reuven::

Sderot won’t be able to bear the burden alone.

Ofer::

Friends, Sderot isn’t capable of containing any new knowledge or any aid. It’s a real mess in this town; there is nothing to hold onto. It’s like pouring water on sand—you could give them a million dollars!

David [senior psychiatrist, a hospital in central Israel]::

We need to respond to the question: They are investing 300,000 dollars when I know there are no patients! We have a responsibility as public officials [to call attention to this]!

The disagreements among the external experts reflect the encounter between the medical and the political spheres in operating a therapeutic intervention for PTSD (Breslau 2004, p. 120). The conversations reveal the external professionals’ efforts to control the precise relevant interventions and determine what is necessary. They also acknowledge, however, the overload of help, and the confusion created. Thus, the argument exposes the fragility of the new professional knowledge as the experts disagreed among themselves regarding the efficiency and need for aid. Whereas Eli argued in favor of the indirect work in treating trauma, Ofer complained about the neglect of “direct therapy.” Further, at times it seemed to these professionals that the city cannot absorb their expertise (“Sderot isn’t capable of containing any new knowledge or any aid”) and that at least some interventions were inappropriate (“I know that there are no patients!”).

The discussions among the external experts resonate with the debates they had with the local professionals. The latter had different priorities. For example, whereas the municipal director of education preferred a “resilience center,” the external experts wanted to build haven rooms. The external experts, psychologists and psychiatrists belonging to NGOs in central Israel, persuaded the Jewish Federations to fund their program, given their senior professional status. Still, since the local professionals hold key positions in the city, they are considered essential contacts for implementing the program, but, in fact, they tended to refuse to become passive carriers of external interventions. Despite their lower professional status (education psychologists, social workers, and education counselors), or perhaps precisely because of their unique position, they continuously wonder about the nature of the social body targeted by the new resilience program. In particular, they question—in diverse ways—its suitability for Sderot’s population. Anastasia, a psychiatrist who immigrated to Israel from the former Soviet Union, and now serving as one of the directors of the mental health clinic in Sderot, focused on the deviant body of the Sderotites (interview, June 26, 2006):

Sderot’s population is problematic and complex even without the Qassams. The Qassam sits on top of very difficult things that are specific to the place. Immigrants, without going into detail…the least successful type of immigrants, and of course unemployment, a lower cultural level, a population that is problematic behaviorally, alcoholism, drugs, children of a lesser God—these are the Sderotites…in a high percentage, I believe. If you add to this the impact of the Qassams or anything else, you get the answer…. I believe that from the start they built a sort of a ghetto of a certain kind of people here. They forgot to mix them with better material, and this is the result.

According to Anastasia, the traumas resulting from the rockets attacks is merely an addition to the population’s other “problems.” Instead of an abstract and universal language of socioeconomic indicators (such as “a very poor socioeconomic situation” or “a high level of unemployment”), she attributes to the population a series of social-ethnic labels. Moreover, perhaps in line with a biomedical discourse, the idioms the psychiatrist uses are physical: the population is of an inferior human “material,” characterized by “a lower cultural level” and a high level of deviance.

A senior psychologist in the municipal psychological services, Reut, an Israeli-born who has worked in Sderot for a long time, was also inclined to view the symptoms of trauma as an addition to a series of existing problems. However, she used different idioms of distress and different explanatory models (interview, June 11, 2006):

The community of Sderot is insufficiently strong on many levels. There are difficult groups here…new immigrants, very serious welfare cases, impoverished groups, many single-parent families, many families receiving help from the welfare department and the mental health authorities. These are people who are shattered by situations of emergency and crisis…they have no inner coping strength…now, when a mother reacts badly, automatically, her six or seven children collapse with her! It’s simple—I see this in lots of families—when the mother cries all the time, doesn’t function, is stressed, and begins screaming when they hear the siren, her children cling to her anxiously. She is unable to contain herself, and her children fall apart with her, too. How we help on this level is really a big problem. In addition, we don’t have Russian-speaking staff, and there are Ethiopians too. It is a population that isn’t used to such help, they aren’t psychologically minded, [they are not] people who know how to receive help.

Unlike Anastasia (a psychiatrist), Reut (a psychologist) refers to resilience in terms of bio-psycho-social homeostasis (Young 2007, p. 39). She describes the residents not as problematic “material,” but as subjects lacking adequate “inner” strength. As well, she argues that the residents are not reachable given the lack of therapists who can speak their languages,Footnote 5 in particular, because they have the wrong set of mind for therapeutic interventions (“they are not psychologically minded”). Further, she explains that their children breakdown together with the mothers as they follow the latter’s inadequate anxious reactions. Once again, though for different reasons, the resilience program is depicted as out of place, unfit for the local residents.

These diverse views about the appropriate remedy for the suffering population—among the external professionals, between them and local professionals and among the local personnel—are part of the politics evolving around the new interventions. In particular, the local professionals argued against the external experts that a network of interests determined the latter new applications of PTSD (on Haiti, see James 2004). For example, Sharon, born in an agriculture settlement (moshav) near Sderot and working as an educational psychologist at the local infant welfare clinic (tipat halav), said (interview, July 4, 2006):

There are all sorts of power games and contests between organizations and all sorts of things that ultimately made us feel that we were left alone in the struggle…. In the end, when there is a need, we are there and that’s it, only we are there. It is true they came with good intentions and with money—but for them alone…in no way did this [intervention] empower the caregivers here, who, unfortunately, have become the real experts in PTSD.

Shira, a Sderot-born social worker in the municipal welfare department, underscored the financial interests involved and the misfit of the program with Sderot in harsher terms (interview, July 18, 2006):

Most people who came to Sderot in the beginning came to cash in, in order to make money…lots came, many organizations. There was extraordinary disorder…it was a mess…they decide that this is needed, but this is not the true need of Sderot…. They come with their experience; the experience is excellent, but it’s not necessarily right for Sderot.

In contrast with the PTSD construct that the experts articulated in a neutral-scientific language (for example, in their founding documents), Shira points to the intervention’s political context, to issues of professional prestige and to the economic interests of the experts’ and the NGOs alike.

The reading of the new intervention in light of a capitalistic discourse was salient among the local professionals in various nuances. For instance, Nurit, a social worker living in Sderot and daughter of Moroccan immigrants who came to the city in its early years, explained why the resilience program weakened the population instead of strengthening it (interview, April 7, 2006):

They bring their people, they get a project for three to four years, accumulate knowledge and experience by working in Sderot and improve their tools, and they can present the results of their work in Sderot or any other peripheral location. Moneywise too, this money doesn’t stay here; it goes out because outsiders receive these salaries. Other organizations earn this money, and sustain themselves. And then, after three years, what a surprise, instead of being stronger, we are weaker, because the knowledge and money leave, they don’t stay here…the experts leave, the money goes…we are left depleted, and need to start anew.

The tense relationship between the external and the local experts was also expressed in meetings between them. In a workshop for educational counselors working in Sderot’s elementary schools, two external psychologists tried to explain how to prevent anger among the children following Qassams attacks. However, the local counselors objected (February 20, 2006):

Ben [psychologist]::

There are many obstacles from the outside, but take responsibility for your situation…you should believe in yourselves and that’s a matter of choice, it’s not all external forces

Oren [psychologist]::

When there is a serious emergency, when there is great distress, people think there is only one possible reaction. But in emergencies there are all sorts of options. I can influence my feelings through thoughts…influencing instead of being influenced

Sigal [local counselor]::

[But] anger, for example, is not a bad thing. It’s a sign that something needs to be changed. [Those to her left and right nod in agreement, and cry out, “Right, right.”]

Whereas the psychologists tried to teach a depoliticized, inner control of emotions and, as they later explained, refused to allow anger to influence behavior, the local counselors tried to underscore how anger expression is good, serving as a potential generator of actual change.

The status-related power relations between the external and the local professionals—at times echoing ethnic and geopolitical differences and hierarchies—are further articulated in encounters between the experts and the residents. The latter constantly challenge the resilience rationale and reject the invitation “to imagine a safe place,” the use of “emotional security shelters,” the demand to “give a positive interpretation to the experience” and the suggestion to “direct anger into positive channels.” For example, in a workshop for nursing caregivers that took place in mid-November 2006—one day after a rocket hit Sderot, killing a resident and seriously injuring a security officer (who lost his leg)—Michael, a psychologist, started talking about belief and commitment as ways to cope with the situation. The participants found it hard to listen, talking, instead, about the broader politics involved in living in this troubled peripheral city:

Michael::

It’s important to teach values: “Why do we stay here? Why don’t we move?”

Bat-Sheva [in a loud voice, agitated]::

What do you think, that everyone can get up and leave? Where to? Try selling a house in Sderot nowadays. People have no choice!

Geula::

Not everybody stays because of ideology, saying “We’ll stay and fight!”…In the south, we are the state’s forsaken children

When the psychologist suggests relying on “values” to strengthen resilience, the residents immediately reply by pointing to the economic constraints that force people to stay. In a workshop for Neveh Eshkol neighborhood—where the first fatalities from Qassam fire occurred—the psychologist, Yoseph, asked about inner- versus outer-strategies of coping (July 4, 2006). Residents replied with political protest, underscoring ethnic differences between themselves and the external experts:

Yoseph::

Who is responsible for calming us—the government or ourselves?

Salva [a Russian immigrant who arrived in Sderot a few years before the Palestinian rockets began, angrily]::

The government! Not us…the Qassams make the population [miserable]—they don’t believe in the government. I will try not to send my son and daughter to the army, I have no faith…our plan is to learn English and leave Israel…. What do they say in the center of the country?—”Ah, there are Qassams over there”—as if we are second-class citizens

Yoseph [smiling]::

There’s a lot of anger today!

Devorah [Israeli-born, long-standing resident]::

I feel that all the governments—they want…the population to be helpless…perhaps we need to set up our Sderot squads, and start firing Qassams too

Salva::

Yesterday they said, “You are Sderot, you are good.” Today they say, “You are Sderot, you are garbage.” How can I send my son to the army?…. Who will thank you if you have no son because he served in the army? Who? You will be invited to Jerusalem on Memorial Day, to stand in the background

Rivka [Ethiopian immigrant who arrived in the early 1980s]::

Everybody says about us in Sderot, “a few Moroccans, a few Ethiopians, and a few Israelis who didn’t know what they’re doing.”

Yoseph::

I planned to give you some practical tools, to help people calm down if you see they are in stress. I want to put on some soft, pleasant music and each will do what he or she wants

Rivka [sarcastically]::

This is suitable for Ashkenazim [European Jews], this music

In this dialogue, the tension between the psychological narrative of building resilience and the participants’ political narratives is clear (see Fassin and Rechtman 2009; Han 2004; Zarowsky 2004). In contrast to the professionals’ efforts to reshape the subjective reality of residents, the latter point out the difficulties of objective reality. While the nursing caregivers cited economic weakness as the reason for staying, residents expressed even stronger alienation through explicit political protest against the government, the army and other symbols of the state. Devorah suggests taking violent measures; Salva says he will try to keep his children away from the compulsive military service, and tells the group that his family’s survival depends on learning English in order to leave Israel. These oppositions are also articulated through ethnic idioms: the therapeutic tool, the calming music, is depicted as suitable for Ashkenazim, not for Sderot’s residents, most of whom are Mizrahim.Footnote 6

Concluding Remarks

PTSD has been recognized in recent years as a psychiatric disorder that is worked out through empire–peripheries power relations (Breslau 2004). External experts funded by international NGOs arrive at local sites of violence and treat individuals diagnosed for PTSD (Fassin and Rechtman 2009; James 2004), at times trying to increase consciousness for PTSD among the general public (Dwyer and Santikarma 2007). Globalized PTSD redraws the relationships between “traumas” as defined clinically and as used in popular culture. The latter refers, for example, to “national trauma” (Ettin 2003; Furedi 2004; Sederer et al. 2003; Smelser 2004)—a violent event felt to continuously effect the collective (Alexander 2004), not to a pathological syndrome.

The resilience interventions with sufferers from political violence in Sderot embody yet another turning point in the recent globalization of PTSD. First, the putative trauma victim is not an individual but rather a collectivity. Second, the human targets for psychiatric intervention are ‘pre-symptomatic’ residents (of Sderot in this case). And third, the intervention aims at enhancing resilience rather than curing or healing trauma.

Further enhancing the post 9/11’s US discourse, according to which resilience is a psychological skill that can be modified and molded (Young 2007), in this Israeli case, the experts treat not only specific individuals diagnosed with PTSD but also the preclinical majority, identified as suffering from various symptoms and “at risk.” Accordingly, the PTSD experts treat not only entire families but also anxious children in schools and residents in general. Further, efforts are made to teach ways to avoid PTSD by learning how to better manage emotions, cognitions, and behaviors. This new clinical ideology (Young 1995, p. 199) of PTSD is evident in three types of interventions—mobile units arriving at families’ homes, haven rooms in schools and workshops teaching resilience techniques to local educators and caregivers of all kinds. The experts use their creativity, improvisation skills, flexibility, and knowledge of the population to apply the posttrauma discourse to the entire community. Thus, medicalization is expressed here in rediagnosing the entire population. Clinical PTSD is realigned. Taken from its traditional place in North American and European medicine—in the clinic—it becomes a guiding principle for reorganizing the whole fabric of urban life. The new therapeutic practices implemented in Sderot mark, then, a transition from the posttraumatic to the pretraumatic, and from treatment of suffering individuals to an effort to strengthen—and immunize—the social body.

This new diffusion of PTSD is articulated “bottom up,” for it has not been worked out by a central guiding hand. The various NGOs established their projects independently of each other, with hardly any organized collaboration. For example, haven rooms and resilience workshops are worked out by separate organizations. Still, these projects are made possible through shared, yet evolving, discursive practices, and they all operate in the context of professional, geopolitical and ethnic power relations. In particular, attaching PTSD with resilience replicates cultural contestations over the ideal Jewish-Israeli national body, but is also related to ongoing struggles within it.

On the national level, in recent years the idioms of trauma and PTSD have gained currency in the discourse on suffering both in Israeli military and beyond. During and after the First Lebanon War (1982), a confluence of factors made psychological breakdown in battle further visible. The “de-glorification process” that has stained Israel’s wars since the 1970s, the heated controversy over the necessity, scope, and outcome of the war, the intensive contact with noncombatant population, and the introduction of PTSD to the third edition of the DSM (1980), contributed to a growing awareness of psychological problems in battle and their long-term aftermath. The Palestinian uprisings in the Occupied Territories—the first Intifada in 1989 and the al-Aqsa Intifada in 2000—while not escalating into full-fledged wars, have further sensitized public opinion in Israel to security-related trauma (Bilu and Witztum 2000). The new interventions of the 2000s, as explored in this article, combine an expanded version of PTSD together with its prevention, framed through the idea of “resilience” (Egeland, et al. 1993; Kobasa 1982; Paton and Johnston 2001; Richardson 2002; Young 2007). A new diagnostic and therapeutic language is offered by adding to the strictly psychiatric symptoms of PTSD signs taken from related fields of health and education, like “harsh reactions.” In response to these generalized “traumas,” various therapeutic means are formulated, like “psycho-social assistance,” “calming down,” and “strengthening personal and family resilience.” Furthermore, given the protracted military conflict, in which Israel has been involved since its inception, many Israelis routinely process military and “security” considerations as integral aspects of social reality. Hence, helping residents is formulated in terms of “reinforcing commitment to the place,” and is anchored in, and justified by, analogies to Israeli security discourse. For example, “mobile unit” and “haven rooms” resonate with emergency vehicles and safety rooms, and in Hebrew, the mental hosen (resilience) resonates with the biomedical hisun (immunization).

The combined PTSD–resilience complex resonates with current Israeli public discourse, which is constantly shifting between a sense of immense threat to national security and great pride in its strength. Whereas PTSD fits the victimization of the collective, rooted in the Holocaust of European Jewry (Kidron 2003), resilience fits the Zionist idea of the “new strong Jew,” which challenges the presumed passivity of Exilic Jews. The heroic motifs of resilience are also consistent with the popular construction of the Israeli–Arab conflict as unavoidable, and as a continuous test of national endurance (Bilu and Witztum 2000).

Looking beyond the nation as a whole, the Israeli project exemplifies once again how PTSD experts create a space in which inequality is reorganized (James 2004). Still, the power relations articulated in this Israeli case are not between the West (specifically, the United States) and trauma-stricken nation-states. Funded by Jewish charity associations from abroad, the Israeli NGOs are quite independent of government capital and bureaucracy, and do not operate on behalf of universal rights. Instead, the intervention is shaped, to begin with, in light of Jewish solidarity. Since all involved are Jews (including the sponsoring funds), introducing new interventions was easy enough. Nevertheless, despite the apparent cooperation among the various players—all belonging to the same national framework—they redefine their competing social identities through the negotiations around the new initiatives.

The PTSD experts in this case are neither all-powerful nor exclusive brokers of trauma (James 2004). Instead, this new PTSD—resilience complex is constructed by the professionals within three interconnected levels of power struggles: First, observing the program backstage reveals that the senior professionals themselves, as trauma brokers, debate the adequacy of the very therapeutic intervention they are proposing.

Second, and more importantly, the experts’ position as gatekeepers for receiving aid is constantly questioned, mediated, and negotiated by local professionals. Directors of the mental health clinics in Sderot, educational psychologists, social workers in the welfare department, and schools’ educational counselors do not readily accept the new PTSD diagnosis and the new resilience program for the residents they serve. They point to financial, professional, and political motivations of the external professionals. In addition, they defend the alternative diagnoses and interventions they have been using for years, like “a difficult population,” and “not psychologically minded,” especially underscoring the local population’s social marginality and economic difficulties. The hierarchy between the external and local professionals is related to, and worked out within geopolitical hierarchies (residents of the center versus the periphery), class differences (upper-middle versus lower-middle and even lower socioeconomic status), ethnic differences (senior professionals predominantly of Ashkenazi origin versus local professionals and residents of North African, FSU, and Ethiopia origin), and, perhaps, gender differences as well (many external professionals are men, compared with local staff, composed mainly of women).

Third, the experts need to negotiate their proposed interventions with their tough and opinionated consumers. Sderot’s residents place their suffering in the context of their peripheral position in Israeli society (cf. Han 2004). Like the Somali refugees in Ethiopia, they associate their suffering with issues of social injustice (Zarowsky 2004) and object to the individualization, psychologization and depoliticization of their problems as entailed by the new PTSD and resilience interventions. They prefer protection by means of solidarity and local assistance that emerged within the city and demand change not in their inner, mental reality alone. They prefer to politicize emotions (like anger) and to mobilize a political action that the professionals, in practice, try to prevent, avoid or downplay. Still, although the residents challenge the therapeutic interventions, their protest differs from other cases reported in the anthropological literature. In the latter, residents opposed the correlation that professionals draw between PTSD diagnosis and entitlement to relief (Dwyer and Santikarma 2007; James 2004). In Sderot, by contrast, everyone is entitled and invited to receive aid (the experts differentiate between different types of aid, not between those who are and those who are not entitled to help). Accordingly, the protest against their work is targeted at the very new expanded version of PTSD and its correlated ambitious resilience program.

In the face of the growing globalization of PTSD, it seems that some aid programs reshape the very nature of the disorder. The new forms of PTSD and resilience in the city of Sderot call for further research into situations in which extended therapeutic aid is offered to victims of violence. It would be particularly interesting to learn more about the diverse splits of the social body targeted for immunization against PTSD, and about the social negotiations among the different professionals and residents involved.