Birkhat Ha’Gomel: Community Response to Acute Stress Disorder

ABSTRACT

The aim of this paper is to propose
the introduction of a communal ritual
as a post trauma early intervention
technique. There are specific community oriented
methods for dealing with trauma
survivors; we believe that, in particular,
the Jewish ritual of birkhat ha’gomel (the
blessing recited when saved from danger)
is helpful for reducing chronic effects of
trauma. Similar post trauma traditions are
seen in other ethnic groups, such as the
Navajo; those will be briefly discussed as
well. It is important to note that therapies
that are currently employed as the result
of years of research have many similarities
to those rituals that have existed for
thousands of years. When providing
early intervention for a trauma survivor,
it is important to be aware of culturally
appropriate treatments as well as the most
commonly used professional methods. A
combination of these techniques may be
effective to alleviate acute stress disorder
and prevent chronic post traumatic stress
in the general public.

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Introduction

Biblical-rabbinic and modern psychological definitions of trauma
overlap, both viewing a traumatic event as an experience in
which an individual is faced with the possibility of death or serious
injury. Specifically, the DSM-IV® (Diagnostic and Statistical Manual of
Mental Disorders) defines a traumatic event as an event that is experienced
or witnessed which involves an actual or threatened death or serious injury
or a threat to the physical integrity of self or others.1
The Talmud2 sages qualify trauma as a situation of being faced with
danger to one’s life. The Talmud, completed in 200 BCE, enumerates four situations after which an individual is required to say Birkhat Ha’Gomel (the
blessing recited when saved from danger): crossing a desert; traveling by
sea; recovering from illness; being released from prison.
Interestingly, the major criterion for performing this post trauma ritual
is identical to the major criterion for PTSD—a person’s perception that
his or her life was in danger. According to many rabbinic authorities, this
blessing is recited whenever one’s life was in danger, even if the circumstances
do not exactly match the four situations defined by the Talmud.
Clinical Treatment
Survivors of traumatic incidents (including illnesses) suffer from many
psychological effects. Although some people enjoy an initial phase of excitement
and hope as the result of having been saved from death, many
other survivors begin to engage in risky behavior, such as non-compliance
with medical treatment.3 S. Blacher4 finds the development of depression
and guilt in postoperative patients who seemed to feel that they were getting
“too good a share” in life in comparison with others who did not fare
as well through a disease or surgery. Holocaust survivors, paradigmatic
examples of trauma survivors, have been found to suffer from depression,
anxiety, survivor guilt, and social withdrawal.5 Other survivor symptoms
include fear, insecurity, anxiety, and uncertainty.6
Studying the guilt that results from trauma, Lewis7 believes that guilt
is a major outcome for most people who have experienced a severe life
stress. Berger8 writes that guilt is one of the four major therapy themes
of Holocaust survivors. People suffering from survivor guilt display
a prominent self-perception of unworthiness and indifference; they are
preoccupied with those who died. They often appear dysthymic, feeling
undeserving of life and believing that others died so they could live.9
Immediately and within the first month post trauma, some survivors
develop acute stress disorder (ASD), a psychiatric diagnosis which was
introduced into the DSM as recently as 1994. The current diagnostic criteria
for ASD are similar to the criteria for PTSD. ASD criteria, though, encompasses
a greater emphasis on dissociative symptoms, and its diagnosis can be given only within the first month after a traumatic event. Statistics
of prevalence vary; studies of survivors of motor vehicle accidents have
found rates of ASD ranging from 13 percent10 to 21 percent.11 A rate of 19
percent was found in survivors of violent assault.12 A recent study of victims
of robbery and assault found that 25 percent met criteria for ASD,13
while a study of victims of a mass shooting found that 33 percent met the
criteria.14
An ASD diagnosis permits early identification of trauma survivors who
are at risk for developing chronic post traumatic stress disorder. To prevent
the onset of chronic PTSD, there are many early intervention options.
Recently, traumatologists in Israel have presented a Position Paper
to hospitals and medical centers recommending that treatment for ASD
begin in the hospital and up to three days following a traumatic event.
They posit that treatment of ASD has been shown to reduce the number
of people who will suffer later from PTSD (personal communication, June
2008, Bituah Leumi/National Insurance of Israel).
Arieh Shalev, MD, Chair of the Department of Psychiatry and founding
director of the Center for Traumatic Stress at Hadassah University Hospital
in Jerusalem stated at a recent American College of Neuropsychopharmacology
(ACNP) annual meeting:
We found that cognitive therapy and cognitive behavioral therapy
worked well on these patients, whose symptoms and duration of PTSD
were compared at the end of three months of intervention. At that time,
their symptoms were significantly less severe than in patients who were
treated with medication, placebo, or no treatment at all.15
Shalev added that although antidepressants did not work during
this early post trauma period, it is important to continue exploration of
pharmacological interventions for early treatment of PTSD. Shalev says
that other research16 suggests that both pharmacotherapy and cognitive
behavioral therapy can be partially effective for PTSD when given three
months or more after a traumatic event. He adds that it is important for
PTSD survivors to know recovery is still possible even if treatment is not
received immediately. Nevertheless, Shalev adds that his results indicate
that it is best for survivors to be treated as early as possible.
One medical method, abreaction, is the discharge of repressed emotion by way of talking about a disturbing experience. This is often done while
under hypnosis, allowing the patient to discuss the traumatic event and
discharge the emotions that cannot be released during the normal state
of consciousness. Hypnotic techniques have been reported to be effective
for symptoms often associated with PTSD such as pain,17 anxiety,18 and
repetitive nightmares.19 Most of the studies which report that hypnosis
was useful in treating post trauma disturbances lack methodological rigor,
however, and therefore strong conclusions about the efficacy of hypnosis
to treat PTSD cannot be drawn.20
Another therapeutic method of coping is psychoeducation technique,21
recommended for the prevention and treatment of PTSD and its related
symptoms, including guilt.22 This technique consists of education regarding
the symptoms and treatments available for PTSD and any other disorders
presented by the patient. Blancher’s 1978 study on depression after
heart surgery shows one example of the effectiveness of this method.23
Once the depressed patients in the study were informed of the phenomenon
of survivor guilt, almost all of them recovered quickly.
Psychological debriefing (PD) has been advocated for routine use following
traumatic events. Its purpose is to review the impressions and
reactions of survivors shortly after a traumatic incident, avoiding psychiatric
labeling and emphasizing normalization. Recent studies show,
however, that while PD is generally well received by clients, there is little
evidence that early PD prevents later PTSD. Additionally, some studies
of individual PD have raised the possibility that the intense reexposure
involved in the PD can retraumatize some individuals without allowing
adequate time for habituation, resulting in negative outcomes.24
Eye Movement Sensitization and Reprocessing (EMDR) is a post trauma
technique that has the patient imagining the trauma while making
back-and-forth eye movement, or alternating his or her attention to both
sides of the body (bilateral ‘use’ of motor cortex).25 Different variations of
this therapy have been found to be extremely effective with victims of
terror in emergency rooms.26 EMDR has been shown to be more effective
than psychodynamic, relaxation, or supportive therapies.27 Research com-
paring EMDR to cognitive-behavioral treatment (CBT), however, shows
significantly better results with CBT at the three-month follow-up. CBT
results also show greater sustainability.28
There are many other treatments utilized for early trauma intervention.
Currently, EMDR during the acute aftermath of a traumatic incident has
shown itself to be most effective in preventing subsequent PTSD.29 Bryant
and others30 have conducted the only studies that specifically assessed
and treated ASD. They have shown that a brief cognitive behavioral treatment
may not only lessen the severity of ASD, but it may also prevent the
subsequent development of PTSD. In a 1999 study, Bryant and colleagues
randomly assigned individuals with ASD to five individual, ninety minute
sessions of either a cognitive behavioral treatment or a supportive
counseling control condition. The assignment was done approximately
ten days after an individual experienced a non-sexual assault, motor vehicle
accident, or work accident. They found that fewer CBT subjects met
criteria for PTSD post-therapy six months later. They have also studied
different CBT techniques (prolonged exposure plus anxiety management,
and prolonged exposure alone) and compared them to supportive counseling
intervention. The results indicated that both CBT groups showed
significantly greater reductions in PTSD symptom severity compared to
the supportive counseling group. Research comparing EMDR to cognitive-
behavioral treatment (CBT), however, shows significantly better
results with CBT at the three-month followup. CBT results also show
greater sustainability.
Thanksgiving for Salvation
In addition to the aforementioned early intervention techniques, we
would like to propose another coping method seen in multiple cultural
groups. In Jewish culture, this method can be traced back to biblical times,
when—after escaping life-threatening situations—individuals would
bring a thanksgiving offering to the Tabernacle and later to the Temple
to express thanks to G-d. The thanksgiving sacrifice consisted of a huge
amount of food that was to be eaten in a short amount of time. The time
limitation compelled the bearer of the sacrifice to share it with a large
group of people. In addition to taking the individual out of social isolation,
the thanksgiving process probably induced the survivor to talk about
the traumatic event many times over and as such brought about a therapeutic
catharsis.
After the Temple was destroyed, the rabbis instituted Birkhat Ha’Gomel,
a short prayer of thanks, to replace the thanksgiving sacrifice. The blessing,
which must be recited aloud in a group of at least ten, states:
Blessed are You, G-d our L-rd, King of the universe, Who bestows goodness
[even] to the guilty, Who has bestowed upon me all that is good.
All those present respond:
Amen. May G-d Who has bestowed upon you all that is good, bestow upon
you all that is good, forever.
Another version of the communal response is:
G-d, blessed and exalted above all blessings and praise, has bestowed on
you His goodly favor, love, and grace. May He in His love ever guard you
henceforth and grant you all that is good.31
Survivors often make arbitrary inferences (conclusions without any
solid evidence) that since they were lucky this time, they have “used up”
all of their merit. The phraseology of both the blessing and its reply may
serve to guard the survivor against such maladaptive cognitions. The
words imply that G-d may save us even if we are unworthy and that G-d
can continue to save us repeatedly (more than “just” once).
The public recitation of this blessing creates an opportunity for the survivor
to discuss his or her experiences with those present.32 It is crucial to
note, however, that he or she is not required to do so. This fits smoothly
with Foa’s guidelines for trauma response, which emphasize that the
therapist should listen actively and supportively but not probe for details
or emotional responses.33
Reciting Birkhat Ha’Gomel may also help the survivor recover by removing
excessive guilt caused by personalizing the blame for the event to
begin with. At first glance, it might appear that the more commonly used
form of the blessing psychologically ‘harms’ the survivors by labeling
them as guilty rather than reassuring them of their innocence. However,
we have discussed above the importance of facing and experiencing one’s own guilt in order to be freed from it. Once it is acknowledged, guilt can
be worked through in the hope of eliminating it completely. Recognizing
a higher authority—in this case, G-d—as responsible for the event
may remove feelings of blame from the survivor, bringing him or her one
step closer to recovery. This is similar to the popular twelve-step recovery
method, in which an individual feels free to heal after turning responsibility
over to a higher power.34
A similar custom is seen among members of the Navajo Nation (Native
Americans), who conduct a ‘Sing’ to heal tribe members who have
returned from combat. Sings are attended by the community at large,
who come in support of the traumatized individual. The Sings reflect on
the individual’s experience, focusing on the fact that he or she is being
reintegrated into society and will soon return to a normal state. Topper35
remarks that the Sings restore the ego function and integrate the warriors
back into the social setting from which they had been separated.
Sandner36 analyzes the process further. He finds four major reasons for
the efficacy of the Sing: 1. herbal remedies are often presented that have
psychopharmacological effects; 2. the intricate psychological structure of
the chants repeatedly encourages the survivor’s expectations of healing;
3. the survivor is socially supported by the entire community; 4. the words
of the chant guide the survivor to find culturally appropriate answers to
difficult cosmological problems, such as the management of evil. Studies
by Manson and colleagues37 show that Native American war veterans
who do not experience this type of ritualized trauma treatment have significantly
higher rates of PTSD.
The Lakota Times reported on February 22, 2006 that
Navajo and Hopi veterans of northern Arizona will now receive the
counseling services and traditional ceremonies they may need to help
them re-adjust to civilian life after the traumatic stress of combat or military
service.…the Northern Arizona Veterans Administration Health Care System
officially launched its expansion of services for the Navajo and Hopi
nations with a dedication at the Chinle Community Center.38
Likewise, a comparable phenomenon was found among the Betsimisaraka
Tribe of east Madagascar, where an influx of communal ritual
activity, mainly cattle sacrifices, were used to heal the community after a
rebellion that took place in 1947. According to the Betsimisaraka tradition,
if people forget their ancestors, the ancestors will punish their descendants
until they reconnect with them. Therefore, cattle sacrifices—a ritual
directed towards the ancestors and offered after war or illness—were seen
as a purifying ritual in which the community becomes cleansed from any
evil they may have done. The performance of the sacrifice, along with
a ritual speech containing explanatory and responsive elements, helps
to remove feelings of guilt or blame accompanying the traumatic event.
Cole’s research in the Betsimisaraka community led her to conclude that
rituals have the ability to aid the reconstruction and processing of painful
memories. Archival documents, including the Betsimisaraka testimony,
suggest that Betsimisaraka were active participants in the 1947 rebellion.
However, afterward, sacrificial speeches stated that “We didn’t mean to
hurt each other; it was all the government’s fault,” thus greatly reducing
their own guilt.39
Comparison of the Jewish and Navajo Approaches
to Proximity Immediacy Expectations
Both the Jewish and Navajo cultures place significant value on the necessity
of a supportive community ritual. There is an understanding that
once a traumatic event occurs, the survivor is not expected to continue as
if nothing has happened. Instead, there is a ritualized way of coping that
is very similar to the popular PIE40 early intervention for soldiers in battle
conditions. PIE connotes Proximity Immediacy Expectations.
Proximity
The principle of proximity—to ensure attachment to the Army unit—is
met by promoting attachment to a social support group. It is important
to note that in both Navajo and Jewish rituals, there is a quorum present
when the ritual is performed.
Immediacy
Immediacy is met by rules regarding the recitation of prayers. Birkhat
Ha’Gomel is preferably recited within three days, or, if not, within thirty
days, although it can be said for a significant time after that if necessary.41 It is interesting to note that PTSD is only diagnosed if the qualifying
symptoms for the disorder last for over thirty days. If they last for a shorter
time, the diagnosis is ASD. Considering that the timing of the diagnosis
coincides with the period in which Birkhat Ha’Gomel is recited, it is possible
that the blessing might help prevent the shift to the more severe and
lasting PTSD.
Among the Navajo, the ritual is performed as soon as possible, because
they believe that the entire community is connected. Therefore, if one individual
is ‘out of balance,’ all are affected.
Expectations
A clear message that the individual will return to full functioning is
given in the text of the blessings and chants themselves, the support
of the community, and the existence of the ritual aimed at normalizing
events. We have seen many instances in which the recitation of Birkhat
Ha’Gomel normalizes the experience for survivors, probably preventing
chronic PTSD.
Conclusion
While no formal tests have been conducted, anecdotal evidence repeatedly
proves that a community response is beneficial for post-trauma
for the reasons stated above. We highly recommend that individuals perform
a ceremony within a group of friends and family as soon as possible
after a traumatic event. As we have discussed the aspects of the Birkhat
Ha’Gomel prayer in particular, it is possible that a survivor can also benefit
from recitation of a personally meaningful prayer or text.
This information is particularly relevant to us as Israeli mental health
professionals. Since the start of the Al-Aksa Intifada in Israel, we have had
extensive contact in hospital emergency rooms with victims of traumatic
events. According to a recent study of emergency room patients in Jerusalem,
the ratio of physically injured to emotionally affected individuals following
critical incidents is 1:12.42 Reactions such as those described above
are almost commonplace in Israel. While a communal ritual is helpful to
all patients, it is especially helpful to recommend Birkhat Ha’Gomel to Jewish patients as a therapeutic early intervention.
Acknowledgments
I wish to thank E. Acobis, D. Appel, and G. Mintz for their indefatigable
efforts during their tenure as research interns at the Neuropsychology
Unit of the Shaare Zedek Medical Center. I also wish to express my gratitude
to my husband, Rabbi Dr. Harris Guedalia, for a lifetime of teaching
and learning, this article being just a small example of this blessing.
Notes
1 American Psychiatric Association, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th
ed. text revision (Jaypee, 2000).
2 Talmud Brakhot 54b.
3 S.N. Broun, “Understanding ‘Post-AIDS Survivor Syndrome’: A Record of Personal Experiences,”
AIDS Patient Care and STDS, vol. 12, no. 6, (1998) pp. 481-488; M. Vamos, “The Survivor Guilt and
Chronic Illness,” The Australian and New Zealand Journal of Psychiatry, vol. 31, no. 4 (1997) pp. 592-
596.
4 R.S. Blacher, “Paradoxical Depression after Heart Surgery: A Form of Survivor Syndrome,” Psychoanalytic
Quarterly, vol. 47, no. 2 (1978) pp. 267-283; R.S. Blacher, “It Isn’t Fair: Postoperative Depression
and Other Manifestations of Survivor Guilt,” General Hospital Psychiatry, vol. 22, no. 1 (2000) pp.
43-48.
5 A. Kruse and E. Schmitt, “Erinnerungen an Traumatische Erlebnisse in der Zeit des Nationalsozialismus
bei (Ehemaligen) Judischen Emigranten und Lagerhaftlingen,” Gerontol. Geriatr., vol. 3, no.
2 (1998) pp. 138-150.
6 National Center for PTSD (2005).
7 H. Lewis, Shame and Guilt in Neurosis (New York: International Universities Press, 1980).
8 D. Berger-Reiss, “Generations after the Holocaust: Multigenerational Transmission of Trauma,” in The
Handbook of Infant, Child, and Adolescent Psychotherapy, eds. B. S. Mark and J. A. Incorvaia, vol. 2:
New Dimensions in Integrative Treatment (Northvale, NJ: Jason Aronson, 1997) pp. 209–219.
9 R.E. Opp and A.Y. Samson, “Taxonomy of Guilt for Combat Veterans,” Professional Psychology: Research
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10 A.G. Harvey and R.A. Bryant, “The Relationship between Acute Stress Disorder and Post traumatic
Stress Disorder: A Prospective Evaluation of Motor Vehicle Accident Survivors,” Journal of Consulting
and Clinical Psychology, vol. 66 (1998) pp. 507-512.
11 V. Holeva, N. Tarrier, and A. Wells, “Prevalence and Predictors of Acute Stress Disorder and PTSD
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Therapy, vol. 32 (2001) pp. 65-83.
12 C.R. Brewin, B. Andrews, S. Rose, and M. Kirk, “Acute Stress Disorder and Post traumatic Stress Disorder
in Victims of Violent Crime,” American Journal of Psychiatry, vol. 156 (1999) pp. 360-366.
13 A. Elklit, “Acute Stress Disorder in Victims of Robbery and Victims of Assault,” Journal of Interpersonal
Violence, vol. 17 (2002) pp. 872-887.
14 C. Classen, C. Koopman, R. Hales, and D. Spiegel, “Acute Stress Disorder as a Predictor of Post traumatic Stress Symptoms,” American Journal of Psychiatry, vol. 155 (1998) pp. 620-624.
15 Arieh Shalev, “Psychotherapy Useful in Treating Post-Traumatic Stress Disorder in Early Stages,”
Science Daily (9 Dec 2007). When treated within a month, survivors of a psychologically traumatic
event improved significantly with psychotherapy, according to a new study presented at the
American College of Neuropsychopharmacology annual meeting.
See also:
“Cognitive Therapy Can Reduce Post-Traumatic Stress in Survivors of Terrorist Attacks,”
British Medical Journal (13 May 2007) ScienceDaily. Retrieved 7 Jul 2008 from http:www.sciencedaily.com/
releases/2007/05/070510194055.htm
A. Bleich, M. Kotler, Ilan Kutz, and A. Shalev, A Position Paper of the (Israeli) National Council for Mental
Health: Guidelines for the Assessment of and Professional Intervention with Terror Victims in the Hospital
and in the Community (Jerusalem, Israel: 2002). EMDR is one of only three methods recommended
for treatment of terror victims.
Ilan Kutz, “Mental Health Interventions in a General Hospital following Terrorist Attacks,” The Israeli
Experience (2005) pp. 425-437. Dr. Kutz directs the psychiatric services of Meir General Hospital in
Kfar Saba.
American Psychiatric Association, Practice Guideline for the Treatment of Patients with Acute Stress Disorder
and Post traumatic Stress Disorder (Arlington, VA: American Psychiatric Association, 2004). SSRI’s,
CBT, and EMDR are recommended as first-line treatments of trauma.
E.B. Foa, T.M. Keane, and M.J. Friedman, Effective Treatments for PTSD: Practical Guidelines of the International
Society for Traumatic Stress (New York: Guildford Press, 2000). EMDR was listed as an effective
treatment for PTSD with further research needed for an “A” rating. Such research has now
been completed and the proposed revised “Practice Guidelines” (posted 2007) have given EMDR
an “A” rating for chronic adult PTSD.
16 “Cognitive Therapy Can Reduce Post-Traumatic Stress in Survivors of Terrorist Attacks,” British
Medical Journal (13 May 2007) Science Daily.
17 E. Daly and J. Wulff, “Treatment of a Post-Traumatic Headache,”Br J Med Psychol, vol. 60 (1987) (Pt
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D. Jiranek, “Use of Hypnosis in Pain Management in Post-Traumatic Stress Disorder,” Australian J
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18 Etzel Carena, “Hypnosis in the Treatment of Trauma: A Promising, but not Fully Supported, Efficacious
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2000) pp. 225-238.
19 Burr Eichelman, “Hypnotic Change in Combat Dreams of Two Veterans with Posttraumatic Stress
Disorder,” Am J Psychiatry, vol. 143, no. 1 (Jan 1985) pp. 112-114.
S.J. Kingsbury, “Brief Hypnotic Treatment of Repetitive Nightmares,” Am J Clin Hypn, vol. 35. no. 3 (Jan
1993) pp. 161-169.
20 B.O. Rothbaum et al., “Virtual Reality Exposure Therapy for Vietnam Veterans with Posttraumatic
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22 L.E. O’Connor, J.W. Berry, J. Weiss, D. Schweitzer, and M. Sevier, “Survivor Guilt, Submissive Behavior,
and Evolutionary Theory: The Down-Side of Winning in Social Comparison,” British Journal of
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23 See note 4.
24 B. Raphael, L. Meldrum, and A.C. McFarlane, “Does Debriefing after Psychological Trauma Work?” British Medical Journal, vol. 310 (1995) pp. 1479-1480.
25 F. Shapiro, Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures
(New York: Guildford Press, 2001).
F. Shapiro, ed., EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations Explore the
Paradigm Prism (Washington, DC: American Psychological Association, 2002).
F. Shapiro and M.S Forrest, EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress and Trauma
(New York: Basic Books, 2004).
F. Shapiro, Handbook of EMDR and Family Therapy Processes (Wiley, 2007).
26 J. Guedalia and F. Yoeli, Presentation at the EMDR European Conference on EMDR under Fire:
EMDR in the ER, Université des Saints-Pères, Paris (Jun 2007)
27 M.M. Scheck, J.A. Schaffer, and C. Gillette, “Brief Psychological Intervention with Traumatized
Young Women: The Efficacy of Eye Movement Desensitization and Reprocessing,” Journal of
Traumatic Stress, vol. 11 (1998) pp. 25-44.
J.G. Carlson, C.M. Chemtob, K. Rusnak, N.L. Hedlund, M.Y. and Muraoka, “Eye
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28 G.J. Devilly and S.H. Spence, “The Relative Efficacy and Treatment Distress of EMDR
and a Cognitive Behavioral Trauma Treatment Protocol in the Amelioration of Post-
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29 Y. Gidron, R. Gal, S.A. Freedman, I. Twiser, A. Lauden, Y. Snir, et al. “Translating Research Findings
to PTSD Prevention: Results of a Randomized Controlled Pilot Study” Journal of Traumatic Stress,
vol. 14, no. 4 (2001) pp. 773-780.
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Comparison of Cognitive–Behavioral Therapy and Supportive Counseling,” Journal of Consulting
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E. Echeburua, P. deCorral, B. Sarasua, and I. Zubizarreta, “Treatment of Acute Posttraumatic Stress
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CIGNA Health Care Coverage Position; subject: Eye Movement Desensitization and Reprocessing
(EMDR); coverage position number 0374; revised date 15 Jun 2008.
A June 2008 CIGNA Health Care Position Paper recommended supporting the use of EMDR for
ASD, noting that “while questions remain regarding some aspects of EMDR, such as the theoretical
basis and the role of eye movements, the literature appears to indicate that EMDR is as effective
as other established treatments for PTSD and ASD, and in the practicing behavioral health
community EMDR is an accepted treatment for PTSD and ASD.
30 Bryant et al., 1998.
R.A. Bryant, T. Sackville, S.T. Dang, M. Moulds, and R. Guthrie, “Treating Acute Stress Disorder,”
American Journal of Psychiatry, vol. 155 (1999) pp. 620-624.
31 Shulhan Arukh, Orah Hayyim, chap. 219.
32 S. Scheidlinger, “The Minyan as a Psychological Support System,” Psychoanalytic Review, vol. 84, no.
4 (1997) pp. 541-552.
33 M. Shacham and M. Lahad, “Stress Reactions and Coping Resources Mobilized by Children under
Shelling and Evacuation, ”Australasian Journal of Disaster and Trauma Studies (2004).
34 Alcoholics Anonymous, “Chapter I: Bill’s Story” (New York: Alcoholics Anonymous World Service,
Jun 2001) 1-16.
35 M.D. Topper, “The Traditional Navajo Medicine Man: Therapist, Counselor, and Community
Leader,” Journal of Psychoanalytic Anthropology, vol.10 (1987) pp. 217-249.
36 D. Sandner, Navaho Symbols of Healing (New York: Harcourt Brace Jovanovich, 1979).
37 J. Beals, S.M. Manson, J.H. Shore, et al., “The Prevelance of Posttraumatic Stress Disorder among
American Indian Vietnam Veterans: Disparities and Context,” Journal of Trauma Stress, vol. 15
(2002) pp. 89-97.
Jay H. Shore, S.M. Manson, and M. Spero, “Telepsychiatric Care of American Indian Veterans with
Post-Traumatic Stress Disorder,” Telemedicine Journal and e-Health, vol. 10 ( 2004) S-64.
38 See also: Michelle Roberts, “Medicine Man Uses Ancient Arts to Help Care for Veterans,” Associated
Press (2005), http://www.usatoday.com/news/nation/2005-12-10-medicine-man_x.htm.
39 Jennifer Cole, “Painful Memories: Ritual and Transformation of Community Trauma,” Culture, Medicine,
and Psychiatry, vol. 28, no. 1 (Mar 2004) pp. 87-105.
40 E. Jones, A. Thomas, and S. Ironside, Shell Shock: An Outcome Study of a First World War ‘PIE’ Unit:
Psychological Medicine (Cambridge University Press, 2006) doi: 10.1017/S0033291706009329.
Zahava Solomon, “Battlefield Functioning and Chronic PTSD: Associations and Perceived Efficacy
and Causal Attribution,” Personality and Individual Differences, vol. 34, no. 3 (Feb 2003) pp. 463-476.
41 According to Shulhan Arukh, Orah Hayyim, chap. 219:3 and chap. 219:6, Birkhat Ha’Gomel is preferably
recited within three days. According to Mishnah Brurah, Orah Hayyim 219:8, Tsits Eliezer, part
19, chap, 53, and Yehaveh Da’at, part 3, chap. 14, people who cannot find a minyan (quorum of ten
men) may wait up until thirty days until they have a minyan to say it.
42 See note 33.

Guedalia, JSB. Birkhat Ha’Gomel: Community Response to Acute Stress Disorder; B’Or Ha’Torah 18 (5768/2008)

Dr Judith Guedalia