Psychotherapeutic Interventions for Combat Soldiers in Complex Clinical Settings

INTRODUCTION

Military service and exposure to war zones affect millions worldwide, putting soldiers and veterans at high risk of physical, emotional, and psychological responses, from resilience to stress-related psychopathologies [1,2]. Posttraumatic stress disorder (PTSD) rates are higher among veterans than in the general population, estimated at 15% of combat veterans [3]. In Israel, military service is mandatory for Jewish and Druze men and Jewish women; many other citizens voluntarily enlist to promote social integration [4].

Active service begins at age 18 for 2–3 years, followed by reserve duty until age 40 [5]. Despite widespread exposure to potentially traumatic combat events, PTSD rates among Israeli Defense Forces (IDF) personnel remain unclear. Recent studies reported a trauma exposure rate of 96% among combat veterans [6], with PTSD estimates ranging from 2% to 16.5% [7–9]. However, the current ongoing conflict has likely increased these rates [10].

Official recognition of mental injuries in Israel, similar to that in other countries, is more complex than physical harm. Providing psychological aid to traumatized soldiers involves dilemmas about the nature, timing, and recipients of interventions, as well as the personal and social consequences [11,12].

The current narrative review [13,14] examines the psychological treatment of military personnel in conflict settings, a perspective that is rarely discussed [15]. It considers the diverse landscape of mental health opportunities offered for Israeli veterans, including official services, the private sector, and non-profit organizations. It aims to contribute to the international discourse on mental health care for military personnel in complex, conflict-prone environments by illuminating considerations for clinicians and policymakers dealing with emotionally injured soldiers or veterans.

This review explores two main research questions:

• What obstacles and dilemmas do professionals face when providing veterans with therapeutic solutions?
• What lessons can be learned from the Israeli experience to help clinicians worldwide better plan therapeutic interventions for military populations?

MATERIALS AND METHODS

This paper presents a narrative review [13,14] of the literature on psychological interventions for Israeli combat veterans, supplemented by clinical case descriptions. This approach was chosen to provide a comprehensive overview of the topic while allowing for the integration of diverse perspectives and critique, and deepening the understanding of clinical insights through the inclusion of case materials.

A thorough literature search was conducted using PsycINFO and Medline (PubMed), supplemented with manual searches on Google Scholar. The search was restricted to peer-reviewed articles published in English and Hebrew between 1990 and May 2025. Additionally, clinical papers and book chapters that present the treatment of combat soldiers and veterans were also included. Non– peer–reviewed sources were intentionally sought to describe the study’s socio-political context, and they included major local and international press. Papers and unofficial media or press publications were excluded if they were not initially published in Hebrew or English. No private or social media forums were included in the current narrative review. Search terms included psychological intervention-related keywords such as Psychotherapy, Group Therapy, Public health system, Private Sector; trauma-related keywords such as Trauma, Post-traumatic stress symptoms, PTSD, Suicidality; and military-related keywords such as Veterans, Soldiers, and Israeli Defense Forces.

The narrative synthesis of the literature focused on identifying key themes and issues relevant to the psychotherapeutic treatment of Israeli combat veterans, in light of global psychotherapeutic trends. These themes were organized into four major categories:

1. Admitting the Injury: Psychological Help for Mentally Injured Israeli Soldiers

2. Intergenerational Traumatic Consequences

3. Preservation of the “Soldier Identity”

4. Making Sense among Therapeutic Opportunities

To illustrate the clinical implications of these themes, case examples were drawn from the author’s professional experience as a therapist and clinical supervisor. These case descriptions reflect patterns seen frequently in clinical practice and exemplify complex clinical situations. These composites offer a bridge between research findings and clinical practice, providing concrete examples of how theoretical concepts manifest in real-world therapeutic settings. All presented cases are composites of multiple real cases, with names and identifying details altered to protect client confidentiality.

The integration of literature review findings with clinical case descriptions allows for a rich, nuanced exploration of the psychological and psychosocial interventions that Israeli soldiers receive after developing traumatic distress during exposure to military-related trauma [14]. This approach aligns with the narrative review format, enabling a comprehensive discussion of complex clinical scenarios that may not be fully captured by more structured review methodologies. By combining a broad overview of the literature with detailed clinical examples, this study provides valuable insights for researchers and practitioners working with combat veterans, highlighting the unique challenges and opportunities in this field of psychotherapy. Since the majority of IDF combat soldiers are men, the examples presented describe treatment cases involving male soldiers only.

However, the ideas they illustrate are equally applicable to the experiences of female soldiers. Still, further research is needed to examine the unique challenges faced by female combat soldiers in coping with the emotional post-service impact on their lives, as well as how they utilize therapeutic services.

RESULTS

Admitting the Injury: Psychological Help for Mentally Injured Soldiers

Due to mandatory IDF service, Israel provides various treatment options for military-related distress [16]. IDF mental health services involve about 260 professionals, mostly psychotherapists and psychiatrists [17]. According to the press, these numbers have tripled since October 2023 due to increased demand [18]. Mental health professionals can be accessed across military units, and soldiers can seek help during or after service through their unit’s psychologist or the Unit for the Treatment of Combat-Related PTSD. Professionals offer evidence-based psychotherapies in various settings. However, many veterans complain of insufficient or inadequate treatment, according to media reports [19].

The case of Sergeant Y.S., a 26-year-old Israeli veteran who self-immolated in 2021 to protest inadequate mental health support, highlights the challenges that IDF veterans face in seeking help. Unofficial reports indicate that this incident led to increased public awareness and the implementation of the “Nefesh Achat” (One Soul) reform to improve care for traumatized veterans [20]. However, the media keeps raising the voice of many veterans who still report insufficient mental health care [19,21]. Such reports highlight the risk of suicidality and suicide attempts, which have increased among Israeli soldiers in recent years [22], raising questions about the reform’s effectiveness. According to these sources, many soldiers and veterans avoid seeking help due to stigma, fear of self-exposure, bureaucracy, or underestimation of their condition [23,24].

These barriers persist despite efforts to improve mental health services.

Intergenerational Traumatic Consequences

In Israel, most soldiers are second- or third-generation veterans, creating a unique context in which combat experience is viewed as a “civilian duty.” The country’s small size means combat often occurs near where soldiers live. Negative world views among parents can increase trauma-related stress in children through behavioral imitation and cognitive interpretation [25]. Indeed, mothers can play a crucial role in transmitting or buffering intergenerational trauma. These conditions make the effects of military service tangible for other family members and can lead to intergenerational and bidirectional traumatic stress, frequent shared traumatic reality, and secondary stress reactions in families of veterans [26]. Hence, therapists should consider the broader context of trauma, including its connections to a veteran’s personal and interpersonal world.

Exemplifying this condition is the case of Josh, 27, who sought therapy 6 years after he finished his mandatory service. Growing up in a village known for its military sacrifices, he served in the armored corps, like his father did 30 years before him. During his service, Josh experienced traumatic events that triggered anxiety, doubt, and PTSD symptoms. Despite this, he described initially feeling undeserving of support and believing physical injuries were necessary to qualify for help. Only years later, when he experienced the horrific sights and fear of the October 7th, 2023, surprising attack by Hamas in the south of the country, he realized how his life followed a reliving of his father’s traumatic experiences. As he joined his combat comrades on that day, he understood his emotional reaction was a transgenerational family burden, one he did not choose for himself. Encouraged by his girlfriend, Josh sought treatment for his military-related distress. Although emotionally clear to him, proving the connection between his current condition and past events was complicated, requiring careful navigation of bureaucracy and emotional sensitivities by both Josh and the professionals involved.

Preservation of the “Soldier Identity”

After service, soldiers face stress while readjusting to civilian life due to the stark contrast between military and civilian cultures [5]. Military service emphasizes power, aggression, obedience, and dichotomous thinking, whereas civilian life requires autonomous thinking, contextual understanding, and restraint. Transitioning between these worlds involves a challenging identity shift [27], affecting veterans in terms of personal, interpersonal, familial, and professional aspects of life. Due to their long-term reserve commitments, Israeli combat soldiers must maintain these conflicting identities for years and often never fully relinquish their military ways [28]. Combat experiences can lead to moral injury that exacerbates emotional burdens [29]. Facing longitudinal emotional stress and feeling trapped between ingrained military responses and unfamiliar, emotionally regulated approaches to problem-solving, veterans may resort to substance use [30].

David, aged 34, exemplifies these challenges. As a former infantry soldier, he struggled to adapt his combat instincts to civilian life. His aggressive responses, once valued in the military, became problematic in everyday situations. A turning point occurred when he reacted violently to his 5-year-old son’s playful behavior that triggered memories of past military operations. In therapy, David realized how automatic responses to stress that he developed during service were now maladaptive. He grappled with guilt over his current actions as a father and past experiences as a soldier. This led to anger toward the Ministry of Defense, and David questioned the lack of support for veterans transitioning to civilian life and described feeling “used” and “disposable.” This example illustrates the complex and long-term impact of military service on personal and family life.

Trauma exposure can interact with established traits among combat veterans, potentially leading to violent behavior [31]. Israeli therapists who are usually veterans may face challenges in helping other veterans process these complex situations, as they often struggle with their own identification or attempts to restore emotional balance in the face of military-related stress. This aspect often becomes a central transferential issue in treatment [32]. Helping veterans process such complicated situations and acknowledging their various emotional origins, as well as their current implications, is a challenging therapeutic task. Clinicians who deal with such conditions often find themselves either identifying with their patients or trying to help them reach a more balanced state, in which they can once again find order in their inner world. These reactions by clinicians are reflected in their hardships related to bearing witness to these violent acts [33]. Press and media reports indicate this situation is especially complicated for minority soldiers, who may face racism during service [33–35]. These individuals can experience both peer criticism and the stigma of seeking help [36]. Providing therapy in such contexts with multiple conflicts requires significant effort to build trust and emotional safety, along with a mature clinical at ude [37].

Choosing among Therapeutic Opportunities

Israeli veterans often struggle with the emotional toll of their service and rely on functional coping methods that can generate emotional avoidance and loneliness [5,38]. Like in other countries, many veterans hope time will heal their wounds or perceive their PTSD symptoms as minor, leading to underutilization of official support systems [40,41]. A recent study found 21% of Israeli combat veterans dealt with subthreshold PTSD, while 14% had clinical levels [39]. To address this increasing need, nongovernmental organizations have developed group intervention programs focusing on raising awareness, adjusting to civilian life, and enhancing emotional resilience [42,43]. These programs combine being in nature and outdoor activities, stress reduction techniques, and group processing of service-related events. They aim to enhance veterans’ emotional coping, reduce guilt, and promote social recognition in the army service’s psychological impact, helping veterans resolve unfinished business from their service in a supportive environment.

An example of these group interventions is the case of Daniel, 32, who grew up in an orthodox, traditional, low-income family. He described army service as a chance to achieve social mobility and volunteered for an elite commando unit, where he served as a sniper. After his service, he experienced emotional and physical stress, depression, and life dissatisfaction. He didn’t connect these issues to his military service until participating in a group intervention program with his unit. There, he realized his depression stemmed from his role in killing others while in the military. The program helped him process a particularly conflictual incident during which he shot a young attacker. This shared experience with comrades helped him feel legit for his distress, relieve the big parts of it which were related to social demands and expectations, and seek further future therapy.

As described, army service often provides the first opportunity for minority youth to integrate into broader Israeli society [44]. However, minority soldiers often cope with both inner stress and social criticism when facing traumatic events and their consequences. Their race and socioeconomic background can impair resilience, increasing emotional vulnerability [37]. In such conditions, acknowledging combat-related emotions in therapy requires confronting difficult feelings, leading many young soldiers and veterans to avoid emotional processing and dwell in emotional numbing [45].

Sharon’s case, a 23-year-old soldier who participated in a “friendly fire” incident where an Israeli soldier was killed, demonstrates this state of affairs. Right after this deadly incident, a group session with the unit’s psychologist was provided, but all the squad’s members remained silent throughout this whole session. In a later individual session, Sharon gave mostly rational answers to the therapist’s attempts to reach his emotions, detaching from any emotional connection. Recognizing this as a defense mechanism, the therapist acknowledged the normalcy of stress and emotional detachment in such situations. He validated the ongoing challenges of combat service and encouraged Sharon to seek support, including after service completion. This message of partnership and hope proved crucial for Sharon’s present coping and future development.

DISCUSSION

Balancing the Opposite Ends

Israeli society, like many others, often overlooks veterans’ needs, focusing primarily on major psychopathologies while missing cases of long-term subthreshold PTSD [40,42,43]. Awareness has grown in recent years that combat soldiers need time to integrate into civilian life after service, with volunteer and “third-sector” organizations supporting this transition [5]. Providing therapy in this context is challenging due to unresolved questions about optimal timing and format [46]. Even though early and tailored interventions that leverage established social cohesion are considered beneficial [47], the effectiveness of psychological aid for young, cynical soldiers or veterans remains uncertain. The multicultural nature of Israeli society makes this tough clinical situation even more complex. Although army units are cultural melting pots, veterans often return to their original communities after service [44]. Balancing soldier and civilian identities is complicated, especially for people from traditional, patriarchal backgrounds in which admitting emotional hardships and seeking help through individual therapy can be intimidating [28,48]. Social workers must recognize both general and culture-specific aspects of these situations to support the integration of veterans into civilian life effectively [38,49]. This requires addressing controversies and the unique cultural needs of diverse populations when providing beneficial psychological aid. According to the press, these challenges have become even more difficult during the past 2 years, because Israeli reservists have been required to undertake numerous extended service rotations amid an atmosphere of extreme social division in Israeli society [49].

Resilience and social support are critical resources that can help combat veterans cope with PTSD and other stress-related symptoms. Although resilience levels among veterans are generally high, their impact often depends on individual coping skills [6]. Prior research and clinical experience have suggested that interventions should encourage authentic emotional expression, strengthen social relationships, and provide stress-management strategies, thereby reducing distress following military service without compromising resilience. Social support can play a particularly important role in mitigating symptoms of depression, like social withdrawal and emotional restriction [50]. Concurrently, identity integration remains a central challenge for many veterans during the transition from military to civilian life, particularly as they reconcile traumatic experiences and navigate societal expectations [27]. These processes differ based on cultural, social, and political contexts, highlighting the need for culturally competent practice. Group-based processing with peers can facilitate the integration of traumatic experiences into veterans’ personal and social identities. Prior research [51] and clinical practice provide evidence of veterans who benefit from such interventions across a wide range of ages, depending on their emotional preparedness to utilize psychological help. Hence, practitioners must remain attentive to local cultural and familial at udes toward military service and norms around emotional expression, which shape how veterans manage post-service adjustment and distress. These issues may be even more complex when dealing with female veterans’ post-service emotional distress, which requires further study.

This study has limitations related to its narrative review methodology, which may have introduced author bias in the selection and interpretation of materials. Unlike systematic reviews, this approach does not reflect objectivity, reproducibility, or an exhaustive evidence search. However, it allows for holistic analysis, interpretation, and critique of the focal topic. This review synthesized current knowledge on treatment for Israeli veterans and highlighted knowledge gaps. It emphasizes the need for carefully considered solutions to treating traumatized veterans and encourages therapists to address their service-related emotional wounds, which may surface during therapy. Future research should explore the complex professional and relational aspects of this clinical area.

CONCLUSION

Both professionals and lay people who deal with PTSD symptoms often lack knowledge about the complexity of this condition and its effective treatments. Social workers and psychotherapists should provide traumatized veterans with comprehensive bio-psycho-social solutions. Professional coordination across sectors is crucial for optimal therapeutic outcomes, and public education is needed to help veterans recognize when and where to seek care. Although support for PTSD among veterans is a global need, recent developments in Israel and other countries demonstrate that progress in this field is achievable and should be prioritized by professionals and policymakers.

Conflicts of interest and sources of funding

The author declares no conflict of interest. No artificial intelligence automatically generated text was inserted in this manuscript, and no image was previously published in another journal or is under consideration for publication elsewhere. This research received no external funding.

Authors’ contribution

As the only author, the author is responsible for the design, data collection, reviewing, interpreting the results, and revision of the manuscript.

Ethics approval and consent to participate

Not applicable.

Patient consent for publication Not applicable.

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