Newly freed hostages and detainees may experience a range of layered psychological impacts including anxiety, depression, disorientation, grief, post-traumatic stress and survivor’s guilt as they return home and beyond the Israel-Hamas truce, experts say.
The truce, which was slated to end Tuesday but has been extended for two days, marked the first major diplomatic breakthrough in the conflict. Over the first four days, Hamas released 69 hostages and Israel freed 150 Palestinians from prison, many of whom were detained but never charged. Under the terms of the agreement between Israel and Hamas, women and children up to the age of 18 were eligible for handover.
“You can predict that the psychological or emotional consequences will be severe — and you could also predict, from what is known in the field, that they’re going to be very different across the hostages because of differences in what they experienced when they were taken captive and their ages,” said Dr. Spencer Eth, chief of mental health at the Miami VA Healthcare System and a professor at the University of Miami.
“Many of them are not just traumatized by the terrorist attack and taken prisoner, but they’re also grieving,” Eth said, referring among others to Abigail Edan, a 4-year-old Israeli American hostage, whose parents were killed by Hamas militants during the October 7 terror attack.
Seventeen-year-old Noam and 13-year-old Alma Or were released on Saturday and learned that their mother was killed October 7, a family member told CNN. Their father is still believed to be held captive in Gaza.
Nine-year-old Emily Hand, who was released on Saturday, was told that her “second mom,” Narkis Hand — her father’s former wife and mother to Emily’s two half-siblings — was killed on October 7.
“So here we have not only the trauma but also the grief, and that compounds the psychological impact, the very pathologic impact, of those events,” Eth said.
Eth has not been involved in the hostages’ care, but he said that those who have been released may undergo medical evaluations that might include “very careful” psychological and psychiatric evaluations. Those evaluations could involve looking for signs of traumatic brain injury, post-traumatic stress disorder or other psychological conditions.
“What’s as important as that initial evaluation is, there would also be the need for ongoing monitoring and assistance over time to see how they’re doing,” Eth said.
“Some might look like they’re doing very well, like they’re resilient early on, and then develop serious symptoms later. And the serious symptoms could include depression, especially in those people who are suffering grief. Substance abuse is possible in some people, as well,” he said. “We know that there are a variety of conditions that develop in the aftermath.”
Risk of post-trauma symptoms
Recovering mentally from such a traumatic event can take years, or even a decade, depending on care. The process tends to take longer for young children and the elderly, said Ani Kalayjian, founder and president of the international humanitarian nonprofit Meaningful World, which is affiliated with the United Nations.
During post-trauma care and recovery, “I would like to also emphasize the five areas to pay attention. Physical is very important — vitamins, proper food, and exercise to build up the muscles,” Kalayjian said. “Emotional — numbness, fear, helplessness; social, in terms of irritability, being withdrawn, etc.; and spiritual, such as losing faith and meaning that they previously had.”
The fifth area is cognitive concerns, such as impaired memory or decreased concentration.
Walter Busuttil, director of research and training at Combat Stress, the UK’s leading charity for veterans’ mental health, says that every time he has worked with hostages and prisoners of war, they are initially very disoriented when they are released.
“They never knew, for example, whether or not they were going to be released, even though this might have been promised. So they initially may look really happy, and of course they will be joyful at having been released, and there’ll be huge relief, but some of them will kind of realize — the adults especially — that there are other hostages who need to be released too, so they might start feeling guilty, for example,” he told CNN’s Kim Brunhuber on Saturday
“The symptoms one would look out for are: Are they sleeping properly? Are they fearful? Are they vigilant? Are they anxious? Are they eating? What’s their appetite like? Is their mood all right? How are they adjusting?” he said. “Not everybody will develop any of these symptoms. Many will not develop symptoms at all.”
Some may experience post-traumatic growth, he said, whereas others might have post-traumatic stress.
PTSD or post-traumatic stress disorder is a mental health condition that can develop in people of any age who experience shocking, scary or dangerous events. Symptoms typically emerge within three months of the event but may begin later. People with PTSD often have co-occurring conditions, such as depression, substance use or anxiety disorders.
Signs and symptoms of PTSD in adults may include having flashbacks of the traumatic event or recurring memories, dreams or distressing thoughts; physical signs of stress; avoiding places, events or objects that are reminders of the event; being easily startled; having difficulty falling or staying asleep; feeling irritable; or having trouble remembering key features of the event.
But children can have extreme reactions to trauma that may not include some of the same symptoms as those seen in adults, according to the National Institute of Mental Health. In those younger than 6, these symptoms can include wetting the bed, forgetting how or being unable to talk, being unusually clingy with a parent or other adult or acting out the traumatic event during playtime.
“So professional well-being and mental health practitioners will need to look out for the kind of games they’re playing, if they’re aggressive or violent, or else if they’re very withdrawn,” Busuttil said.
‘Younger children are actually most fragile’
Daphna Dollberg, a clinical and developmental psychologist at the Academic College of Tel Aviv-Yaffo, said many of the Israeli hostages who have been released may show signs of PTSD, especially the children, one as young as 2.
“What we know is that the younger children are actually most fragile, and unlike what we would like to think, young children do remember traumatic events. But because their language is not well-developed and they’re less equipped to process and communicate with us what they went through, they will show their distress through bodily reactions, like maybe refusal to eat or sleep or becoming physically sick, or they may show their distress by behavioral manifestations and developmental regression and sometimes even developmental arrest,” Dollberg told CNN’s Laila Harrak on Saturday.
“They are definitely going to be very confused, very scared and on guard and fearful for a long time despite being in a safe place. They may be very hypervigilant, and the most devastating thing is their failure to trust the adults around them, even – maybe particularly – their parents because in their mind, in their childish mind, their parent did not protect them,” she said. “So I suspect we’ll see many signs of PTSD, post-trauma stress disorder, and we will need a long time to re-establish a sense of safety and protection and trust in these young children.”
Israel’s Ministry of Welfare and Social Affairs has released detailed instructions outlining how to care for freed child hostages.
Israel Defense Forces (IDF) troops have been advised on how to introduce themselves to the children — some of whom have been held in Gaza for more than seven weeks — and how to interact with them after they are released but before they are admitted to hospitals.
Get CNN Health's weekly newsletter
- Sign up here to get The Results Are In with Dr. Sanjay Gupta every Friday from the CNN Health team.
The guidelines advise that each child or family unit should be assigned a soldier and that soldiers should ask the children for permission before touching or picking up the child.
“Children will ask questions such as, ‘Where’s Mum? Where’s Daddy?’ Soldiers should not answer these questions, even if they know the answers. Any questions should be answered along the lines of, ‘Sweetheart, I’m sorry, I don’t know. My job is to bring you to Israel to a safe place, where people you know will be waiting for you and will answer all your questions,’ ” the guidelines say.
The instructions stress the importance of building routine, including rest, balanced meals and moderate physical activity outdoors, in the first week, as well as creating open spaces for dialogue about what the child has experienced.
“Avoid verbally overwhelming the child. Avoid multiple questions and detailed discourse about events that happened,” the advice says. “The use of simple words and short sentences is important. It is important to convey that we are open and able to hear and talk about difficult things.”
CNN’s Lauren Izso and Alex Stambaugh contributed to this report.