Good Grief

Geoffrey Melada | JNS

Almost two years after the Hamas-led massacre in Israel on Oct. 7, 2023, the Jewish state is still “a grieving country,” said Dr. Natalie Gar, a clinical and educational psychologist at Hebrew University’s Institute for Traumatic Stress and Recovery.

Since that day, 10 residents of Gar’s roughly 2,500-member community in Elazar, part of Gush Etzion, a cluster of Israeli settlements in the Judean Mountains south of Jerusalem, have been killed, she said, including one victim of the deadly attack on the Nova music festival and nine soldiers in Israel’s ensuing war with Hamas in the Gaza Strip.

Osnat Goori Mussel, a clinical psychologist at Hadassah Medical Center, compared Oct. 7 in Israel to 9/11 in the United States, describing it as a singularly tragic event in Israel’s history. “All of Israel is different now due to the scope of death and the scope of military activity,” she said. In a country the size of New Jersey, “everyone knows someone who was murdered or called up from the reserves.”

As trauma clinicians experienced in treating post-traumatic stress symptoms, Mussel and Gar acknowledged that they found themselves unprepared to respond to the tidal wave of grief that washed over the country after Oct. 7, especially among children.

According to Dr. Julie Kaplow, a national expert in childhood trauma and bereavement, and the executive director of the Trauma and Grief Center at the Texas-based Meadows Mental Health Policy Institute, grief and trauma are often thought of as one and the same. They are, however, two very different experiences.

A trauma — or a traumatic event — is a real or perceived threat to one’s life, or the life of a loved one, that causes terror, horror, helplessness and/or fear, often resulting in post-traumatic stress. Bereavement is the experience of deprivation or loss by death; grief is the psychological or behavioral response that arises from bereavement.

“Post-traumatic stress and grief can co-occur, especially in the case of deaths that are terrifying, such as homicide, but there are unique interventions needed to adequately address each experience,” Kaplow said.

Trauma treatments are mainly focused on addressing the circumstances of the death that were frightening and the symptoms of post-traumatic stress that can result. However, these treatments rarely address painful grief reactions, such as separation distress or existential distress, or healthy, adaptive grief reactions, such as making meaning of the death or carrying on the deceased person’s legacy.

Treating bereaved children in the wake of Oct. 7 has been “the hardest psychotherapy I have done in the past 15 years,” Mussel said. “I have so much to learn about grief.”

She’s not alone.

‘What Works for Most People’

Dr. Yaara Sadeh, a faculty member at the University of Haifa School of Social Work and the head of research in the social-work division at Sheba Medical Center, recalled her initial efforts to treat a 3-year-old boy from the village of Sharon in north-central Israel whose father, an IDF soldier, died in Gaza after Oct. 7.

Believing that his father had been killed in a fatal stone-throwing incident, the child began obsessively collecting the rocks strewn about his kindergarten playground, fearing that they would be used to injure him or his mother. His classmates found that behavior strange and avoided playing with him. Feeling socially rejected, the child began hitting other kids, prompting the teachers to isolate him as punishment, which in turn only heightened his anxiety, Sadeh explained.

Although Sadeh and the child worked on the traumatic event in therapy, the trauma-focused techniques in which she was trained failed to alleviate the child’s fear of abandonment or anger issues, and could not address his existential questions about where his father is now. “We know so much about trauma in Israel, but so little about grieving and traumatic loss,” Sadeh said. “I did not have that specific knowledge, which is unique.”

In search of a more targeted intervention for grieving children, Gar, Mussel, Sadeh and two more of their colleagues from Israel recently traveled to Houston for a two-day training session with Kaplow in Multidimensional Grief Therapy (MGT). MGT was co-developed by Kaplow and a team of scholars from UCLA, California State University-Long Beach and Nova Southeastern University.

The product of decades of fieldwork, said Kaplow, MGT is an assessment-based intervention designed to carry out a range of therapeutic tasks with bereaved children and adolescents. These include reducing unhelpful grief reactions (grief that keeps kids “stuck” and unable to adjust); promoting helpful grief reactions (grief that helps kids to feel and cope better after a death); reducing symptoms of psychological distress; and helping bereaved children to lead healthy, happy, productive lives.

MGT was designed specifically for children and adolescents, said Kaplow, because empirical evidence shows that children often grieve in different ways than adults. It is grounded in the latest research on how children cope with loss, including traumatic loss, and what adults can do to support them — a major draw for the Israeli clinicians. “We take evidence-based solutions for granted in medicine, but they are not always a given in psychotherapy. We should know what works for most people,” Gar said.

The training, led by Kaplow and a team of clinicians from the Houston-based Trauma and Grief Center, was made possible through two grants from the Herman H. Fleishman Foundation and the Jewish Federation of Greater Houston, which Kaplow obtained in partnership with Hebrew University psychology professor Jonathan Huppert. Kaplow said the grants will enable the five Israeli clinicians to become official MGT trainers, allowing for widespread dissemination of the treatment in Israel. The grants are also paying for the translation of all printed materials into Hebrew and the adaptation of the intervention to ensure it is culturally appropriate.

‘It Hit Too Close to Home’

Rather than framing grief as a problem to be fixed, Kaplow’s work focuses on helping young people harness their natural strengths to cope with loss in a healthy, adaptive way. “Our goal is not to rid children of their grief, but to provide them with the coping skills needed to better handle their grief reactions over time,” she said.

During the training, the attendees, who included the five Israelis and more than 100 other clinicians from across Texas, received grief psychoeducation, starting with how to separate grief-related myths from facts. A common sentiment from bereaved families is that they feel external pressure to “get over” the death of their loved one within a certain period.

However, Kaplow emphasized that grief does not have a set timeline, and said that for most individuals, waves of grief will ebb and flow over the course of their lives. With the use of illustrated scenarios, the attendees also learned how to distinguish between positive and negative grief reactions in children, and how to help children gain more control over grief-related thoughts by recognizing them as they are happening.

Although children may feel burdened with thoughts about how the person died, especially if the cause of death was violent or tragic, Kaplow said that they can find ways of transforming the circumstances of the death into something to prevent other people from suffering in the same way. For example, they can raise money for a relevant cause by participating in a suicide walk or pursue a career that directly addresses the circumstances of the death, such as an ER doctor or a firefighter.

Although the training was geared toward mental health professionals, Kaplow stressed that parents and caregivers have an important role to play as “grief facilitators,” meaning that they can model for children what healthy grief looks like and can provide guidance to help their children cope with the loss. Kaplow’s research has shown that the three most important things that parents can do to help their children after a death are to validate their feelings, listen when they are ready to talk and provide structure so that children can maintain a sense of stability when other parts of their lives may feel chaotic.

For Kaplow, who is Jewish, training her Israeli colleagues was less a professional courtesy than a calling. “We’ve been called into other disasters before: Hurricane Harvey, the Uvalde school shooting, and before that, the Santa Fe school shooting. But Oct. 7 felt very personal,” she said. “As I was watching what was happening on the news that day, not only did I feel called to action, but I also felt I couldn’t not do something. It was just so distressing to me to watch. It hit too close to home. Israel may be far away, but these are my people.”

‘Trauma- and Grief-Informed Care’

As the news broke of the deadly Hamas attack, Kaplow started making phone calls to Israeli clinicians, not knowing at first what their needs were or how she could help. “When I started to describe what MGT is designed to treat, which is missing the person, longing for the person and not feeling certain of who you are anymore without the person, they were like ‘that’s what we need. That’s what we’re seeing.’”

With the aid of the five Israeli clinicians who traveled to Houston, Kaplow is hoping that MGT can be implemented in Israeli school systems, youth movements and resilience centers once the materials are translated into Hebrew and adapted for an Israeli audience.

Dr. Tamar Silberg, a pediatric psychologist and assistant professor of psychology at Bar-Ilan University who attended the Houston training, said the Israeli MGT team has spent the past six months preparing to do just that. She and the other four Israeli clinicians who traveled to Houston to be trained in MGT plan to co-lead their own virtual training session with Kaplow and her team for an additional 60 Israeli clinicians.

Silberg envisions eventually establishing a TAG Center in Israel, modeled after the original TAG Center in Houston and its three pillars: a clinical hub where families can receive direct treatment; an education and training arm to disseminate skills and knowledge nationwide; and a research branch to evaluate outcomes, refine interventions and advance the global science of both trauma and grief.

“Advancing this vision represents more than a response to the current crisis; it constitutes a long-term investment in public mental health and the well-being of children, while positioning Israel as a leader in the development and dissemination of culturally adapted trauma- and grief-informed care,” Silberg said.

“We stand up after every tragedy in Jewish history for the last 2,000 years. We survive and thrive,” said Gar of Hebrew University. “This project with Dr. Kaplow and the TAG Center is another example of that post-traumatic growth. We take something evil and transform it into something good.”

In that sense, added Gar, “we’re following in a long line of Jewish tradition.”