Guidelines for handling released captives before transfer to medical facilities in Israel

ABSTRACT

Once the International Committee of the Red Cross hands over released hostages to Israeli hands, the first persons they meet – before they transfer to hospitals and meet their families – are military mental and medical professionals. This encounter is a challenge to both the returnees and the professionals meeting them. Over the initial handover process, the returnees feel exposed and vulnerable in the intermediate situation between captivity and return to their previous reality. Their reactions at that interim time are likely to be varied, ranging from joy and euphoria to sadness, a sense of alienation, anxiety, and disconnection. The initial reception time could prove an opportunity to offer interventions that might lead to effective adaptive responses upon returning to Israel. The present article describes the preparations made urgently to receive released hostages and the protocol developed to provide the best response to their needs on their arrival. The protocol described in this article, formulated at the IDF Combat Stress Reaction Unit, takes into account the needs of the released hostages and the responses required to meet these needs. The main protocol principles include a warm welcome to instill a sense of security and adjust the human touch to the complex situation and trust-building methods based on mirroring subjects’ emotions and leading them gently in the desired directions. Based on strict professional principles, the protocol covers an initial mental assessment, availability of personal, family, and community resources, and establishing contact with medical teams for follow-up treatment in medical facilities.

What is the public significance of this article?— Once the International Committee of the Red Cross hands over released hostages to Israeli hands, the first persons they meet are military mental and medical health professionals. This encounter is a challenge to both the returnees and the receiving professionals. The initial reception time could prove an opportunity to offer early intervention, especially psycho-educational, which can be an initial basis for calming and normalizing reactions and behaviors, creating an initial connection, and motivating the returnees to seek treatment if necessary. Psycho-educational interventions aim to help the former captive regain a sense of independence, control, and self-efficacy.

Introduction

On October 7th, 2023, Palestinian Hamas terrorists launched a surprise attack on civilian and military targets in southern Israel. The attack began with a barrage of rockets while around 3,000 terrorists breached the Gaza – Israel border fence and attacked Israeli communities and military bases in the area. For many hours, civilians of all ages, from babies to very old persons, were massacred and burned in their communities, many inside their homes, especially in the kibbutzim near the border. Simultaneously, hundreds of young people celebrating at a large open-air nature party by Kibbutz Re’im were murdered en masse, their bodies mutilated so brutally it took weeks to identify them before they could be buried. In this vicious attack, 1,139 Israelis and 39 Thai citizens employed as farmhands in the region’s kibbutzim lost their lives, of them 766 civilians and 373 members of the security forces. According to official data, 253 individuals were abducted from Israeli territory and taken to the Gaza Strip: 155 civilians and guest workers from the kibbutzim, 45 civilians from the nature party, and 23 soldiers. At the time of writing, 50 people remain captive, 20 of them believed to be alive.

In November 2023, a first humanitarian deal was struck between Israel and Hamas, which would see the release of hostages. The Head of the Israel Defense Forces (IDF) Medical Corps assigned the Combat Stress Reaction Unit (CSRU) to receive and accompany the returnees, mostly women and children, released between November 24th and December 1st, 2023, and again over a year later, when another group of hostages was released between January 19th and February 27th, 2025. Of note, while the specific characteristics of both groups of returnees were different in age, gender, duration of captivity, and military status, the same basic protocol applied, with adaptations.

The CSRU was set up following the First Lebanon War (1982) to treat ex-soldiers with posttraumatic stress disorder (PTSD) or other combat-related disorders resulting from military operations, beginning with a diagnostic intake process. Intake begins with completing administrative self-report questionnaires, followed by three PTSD assessment meetings consisting of a Clinician-Administered PTSD Scale for DSM-5 (CAPS), a clinical interview, and psychological diagnostic tests (for cases indicating a psychotic state or high risk). CSRU treatments comprise trauma-focused group interventions, prolonged exposure, eye movement desensitization and reprocessing (EMDR), and cognitive-behavioral therapy (CBT). The CSRU also instructs and advises mental health professionals across the IDF (Shelef et al., 2024).

Over the years, the CSRU has also treated former Israeli prisoners of war (POWs) (Levi et al., 2018). Receiving released captives is professionally challenging, combining medical, psychological, and organizational elements (Neria et al., 2000; Solomon et al., 2012; Stein et al., 2015), given that the long-term consequences of captivity may persist for many years after the return. In light of Israel’s ongoing circumstances, the Medical Corps has gained rich experience over the years in all aspects of receiving prisoners of war (Bachem et al., 2019; Solomon et al., 2012). Therefore, the CSRU is staffed by skilled professionals who specialize in PTSD. Most are former military personnel experienced in handling acute situations from life-threatening events, combat, and captivity. One of the key assignments upon initial reception is to carry out a quick clinical assessment in order to provide the appropriate response and to urgently convey to the designated receiving hospital any pertinent information to allow them to prepare for special situations, e.g., certain injuries or special needs (de la Fontaine et al., 2024).

Much knowledge has accumulated, particularly from Israeli soldiers taken as POW’s during the Yom Kippur War (1973) and later released (Solomon & Dekel, 2005; Solomon et al., 2015). Typically, these were young, healthy men, who had also undergone captivity preparation as part of their military training (e.g., Zerach, 2018).

Although most studies date from the 1980s and 1990s, the information they offer is still useful. Of particular value is a long-term follow-up study by Solomon et al. (2015) of released Israeli military POWs (mostly from 1973 war), comparing them with a control group of combatants who participated in the fighting but were not captured (Solomon et al., 2015). This carries particular weight due to the long-term consequences of captivity (Levi et al., 2018; Zerach, 2018).

Generally speaking, the findings of longitudinal studies indicate that captivity often leads to profound, long-term psychological, physical, and functional vulnerabilities (Solomon & Dekel, 2007; Solomon et al., 2012; Zerach, 2018). The most prominent psychiatric disorder, posttraumatic stress disorder (Neria et al., 2000), results from the life threat, terror, body and mind injury, and loss of control that characterize life in captivity (Dekel et al., 2008). In addition, the Israeli POWs captured in 1973 had negative experiences both during captivity as well as upon their return, when they felt accused of having been taken captive, giving rise to a sense of failure and betrayal (Stein et al., 2015). Within the understanding that this negative experience adversely impacted their adaptation, we wished to provide a different experience of return, one that was accepting, supporting, non-accusatory, and conducive to rehabilitation. Hence, one of the guideline cornerstones in building the return protocol was to receive the returnees in a manner that would facilitate optimal care and support. As it was clear that the hostages had been torn from their normal life, we felt that one primary purpose of the initial reception was helping them regain this path. In light of the testimonies of returned POWs from the 1973 war, we understood that this initial encounter had decisive implications for their readjustment and their future life.

Following indications in late 2023 that a hostage deal was imminent, the CSRU team rushed to organize and formulate working procedures based on previous testimonies of returned Israeli POWs, mainly from captivity in Syria and Egypt (Solomon & Dekel, 2005). The knowledge gained enabled the team to practice receiving released hostages with the medical teams of the Sheba Medical Center using a medical simulator (de la Fontaine et al., 2024).

In the first humanitarian deal of November 2023, 34 children and civilian teenagers were released (all those abducted except two small children who were murdered in captivity), as well as 15 single and young women, 16 women over 65, and 9 mothers (aged 34–49) who had been kidnapped with their children.

Of note, the reception of children, some as young as 3 years old, was particularly challenging, as many of them, on top of the hardships of captivity, would learn upon return of the loss of a close relative, sometimes a parent, and their home and community. This required advance preparation along with medical and psychological staff to best prepare the children for reuniting with surviving family and admittance to the hospitals for treatment, and constant learning and adaptation during the week-long receiving and integration process.

Also released at that time were 24 of the abducted migrant workers – 23 Thai nationals and one Filipino – which required separate culturally sensitive preparation.

The studies of the Israeli POWs served us in building the infrastructure of the protocol. However, we lacked knowledge about civilian captives, especially adult women, young women, and mothers of children taken into captivity with or without their children. In modern world history, cases of captive older women and young mothers are rare, explaining the scarcity of related studies. One study that addressed women provided insights from 96 female POWs from Israel’s War of Independence (1948), analyzing their experiences and perception of captivity from the moment of their surrender, throughout their time in captivity, and up until their return home (Rosenberg-Friedman, 2018). However, the available knowledge about handling such a large and diverse group of individuals was scarce (see Shelef & Spector-Mersel, 2025). The pending release, therefore, faced the CSRU team with an immense challenge, highlighting the need for a different and more efficient organizational approach. Moreover, despite the vast knowledge of Israeli POWs, the CSRU prepared a different reception protocol for the hostages abducted on October 7th, due to the unusually large number abducted, the wide age difference, and the fact that the majority were civilians. We present in this paper the protocol formulated for receiving the returnees, adjusted to their unique characteristics, and a list of preliminary preparations made for their return. During the preparation phase, we took proactive measures to anticipate the captives’ return by meticulously outlining the salient characteristics of their captivity to reconstruct various scenarios that could occur during and upon the return. We also attempted to characterize emotions the returnees might present concerning the ongoing war and the ideology crisis gripping Israel, including anger, guilt, blame, a sense of abandonment, lawlessness, and failure. Our comprehensive and thorough training intended to minimize any uncertainty, in circumstances that were uncertain by nature. These were formulated into scenarios of cases and responses, which were tested in simulations. This approach allowed us to rapidly address issues of regaining trust, a sense of security, control, organization, and connection to reality anticipated to emerge.

Additionally, we joined the Medical Corps and the medical civilian hospital staff in simulating the situation in the field to rehearse the encounter in the conditions and location it would occur, all with the aim of ensuring the initial encounter was as accurate as possible. This thorough preparation has boosted our confidence about our ability to manage the encounter with the returnees with utmost care and empathy.

In the present article, we depict the preparations made for receiving the returnees, more than 50 days after the attack on Israel and in mid-war. We describe the stages that led to formulating a reception protocol to best respond to their needs in the first few hours after their release.

The preparation stages

Stage 1

Already at the beginning of the war, we received a document from the American army¹ regarding the reception of POWs, which provided us with a framework for understanding what to address in the initial moments and hours of return. Additionally, we conducted a comprehensive literature review of POWs and prisoners taken captive by ideologically motivated terror groups (Giebels et al., 2005).

Based on this, we prepared questions about the handling of military POWs and abducted civilians. These questions were immediately relevant to the situation following October 7th, 2023, when in addition to military personnel, 239 Israeli civilians suddenly became captives, severed from their autonomous life in a sharp and brutal transition. The civilian captives of the present war include a wide range, including old and young men and women, teenagers, children, and toddlers. The previous knowledge about handling such a large diversified group is scant. A few studies focus on young unmarried women, such as those by Cere (2008) and Kizilhan (2018), or on teenage girls taken hostage. For example, Amone P’Olak (2005) studied 123 adolescent girls who had been abducted in Northern Uganda. In 2014, 276 Nigerian schoolgirls were kidnapped by the extremist group Boko Haram and sold into slavery (Ajayi, 2020; James, 2020). Additional studies address Yazidi women abducted by the Islamic State of Iraq and Syria for sexual enslavement (Hoffman et al., 2018; Taha et al., 2021). However, there is limited knowledge about older women and young mothers who were abducted during terrorist attacks, particularly those taken along with their children. To understand what issues must be addressed during the readaptation and psychological intervention process, we attempted to outline the unique characteristics of captivity, the needs damaged, and the answers required.

In captivity, abductees are often deprived of basic needs such as food, sleep, and proper sanitary conditions. They experience isolation, humiliation, and physical, sexual, and psychological abuse. They are subjected to mental manipulations, such as false and misleading information. All of these abuse characteristics have one purpose: to break the captive’s spirit (King et al., 2011).

Another prominent feature of captivity is the coercive captor-captive relationship, which is asymmetrical, non-reciprocal, and would never have occurred otherwise. Such relations include conflicting reward and punishment behaviors, where death is a likely punishment for the most minor matters. Such circumstances impair the captives’ ability to imagine their release, undermining their perceived internal identity. The captors benefit from such relations of terror and intimidation while minimally meeting the captives’ needs, as this creates dependence and increases their control (Solomon & Dekel, 2008).

In the absence of any power to change their situation, many captives revert to dissociation as a central coping mechanism. They may feel disconnected from themselves or from certain identity factors such as feelings, thoughts, the whole body, or part of it (American Psychiatric Association & Apa, 2013; Ataria & Neria, 2013). If the disconnection mechanism takes over the individual’s life entirely, this may result in ineffective coping that affects their personal well-being and those around them as well (Zerach, Greene, et al., 2014). Disconnection is typically viewed as a maladaptive strategy that undermines resilience (Verhage et al., 2021) and can even increase the risk of PTSD (Dickstein et al., 2012). If trauma processing does not occur, the disconnection mechanism may manifest in distancing and detachment from the spouse, children, and life, including difficulty in experiencing positive emotions and joy (Solomon et al., 2008).

If the threat to one’s life in captivity is consistently ongoing, the defense mechanisms required to cope with this hinder the captive’s ability to remain in control (Ataria & Neria, 2013). Once released, captives who fail to restore the resources depleted in captivity during the supported process of adaptation will have difficulty restoring their sense of security, competence, and trust in other people, possibly giving rise to complex trauma. In such cases, one might feel constantly exposed to traumatic events or anticipate their recurrence and remain in a survival mode, similar to that experienced in captivity (Herman, 1992).

To conclude, Stage 1 integrated all studies on receiving and treating captives in both the short and long term, the knowledge of the salient characteristics of captivity, including the deprivation of basic needs and various forms of abuse, and the diverse age, gender and familial characteristics of the captives in question. In light of these, we anticipated a wide range of emotions and questions from the captives upon their return. The initial encounter must address this unique complexity of a diverse group that experienced extreme, multi-dimensional trauma.

Stage 2

We deepened and expanded our review of studies of military POWs from other forces (e.g., Jones & Wessely, 2010; Ursano & Benedek, 2003), which show that former POWs’ health was consistently worse than that of their age groups (Hunt et al., 2008; Kang et al., 2006), with higher chronic pain tendencies and lower life expectancy (Amris & Williams, 2015; Ursano & Benedek, 2003) even decades after captivity (Tsur et al., 2019), particularly those subjected to torture or poor sanitary conditions. Therefore, we needed to plan a medical reception protocol to address both immediate and long-term health consequences.

Stage 3

We gathered as much information as possible about civilian captives from the war in Croatia (1991–1995) (Jukić et al., 2019). The few publications that mentioned female captives (Kizilhan et al., 2020; Walser et al., 2012) showed a morbid tendency for PTSD, in most cases accompanied by depression (Kizilhan et al., 2020). Several publications on sexual abuse of women, especially Yazidi women kidnapped by ISIS (Bitar, 2015; Fisher-Smith et al., 2024; Vale, 2020), were of significant help.

The combined findings of all three stages, particularly those concerning the reintegration of Israeli soldiers, taught us the noticeable value of an optimized reintegration process. They indicated that this affects the returnees’ capacity to successfully readapt to life later on (Solomon et al., 2012) despite having experienced submission, loss of autonomy and control, uncertainty, mistrust, and helplessness in captivity (King et al., 2011; Stein et al., 2015).

The initial reception process, although brief, is highly significant to the returnees, who are exposed and vulnerable on arrival. Therefore, the reception includes a reimprinting component, which involves shaping a new response to a situation, and which requires a compassionate and adaptive professional approach. With this in mind, we based the planning and construction of the protocol on theories related to restoring trust, a sense of security, control, organization, and connection to reality (“grounding”). Our purpose was to characterize issues the returnees may bring up, such as anger, guilt, shame, and feelings of abandonment and failure. We expected the returnees to likely present a variety of psychiatric and cognitive symptoms, primarily posttraumatic stress symptoms (Dekel et al., 2008; Neria et al., 2000). Having formulated these considerations, we created a protocol and tested it in relevant simulated scenarios.

Principles of early intervention

A preliminary requirement before any intervention is that the involved therapist be unpretentious, humane, and respectful, presuming that the previous captor-captive relations may have undermined the returnees’ ability to maintain a stable internal identity. Contrary to the terror-based relationship with their captors, returnees should receive from the very beginning a clear signal that from that moment on, they could feel confident about the reciprocity of the relations (Solomon & Dekel, 2008). This principle is crucial, since after experiencing distorted relationships in captivity, returnees might keep reliving the traumatic events or remain vigilant to their possible recurrence, assuming a constant survival mode in every interpersonal relationship (Herman, 1992). This understanding led to the decision to appoint a designated CSRU Mental Health Officer, with knowledge and experience in combat trauma care, to personally and continuously accompany each returnee from the moment of the Red Cross handover at the front line, on the way to meet the family, in the hospital, and communicate any relevant information to the hospital medical staff. Such an early interpersonal relationship might establish a sense of security and trust and contribute to future care (de la Fontaine et al., 2024).

The formulated intervention principles, which became the foundations for shaping the protocol, relied, as mentioned, on the clinical and research findings elicited from POWs and treating adults or adolescents who presented PTSD following trauma (Roberts & Nixon, 2023; Whitworth, 2016). So, we were prepared to receive people with acute reactions, including dissociation, a phenomenon that Ataria and Neria (2013) wrote about extensively based on their experiences with POWs.

For example, we adopted evidence-based principals used by clinicians working with PTSD patients, including the CSRU military clinicians working with post-combat PTSD, and integrated these into the reception protocol. We based our intervention on practical models effective for addressing acute stress disorders. One such model is the SIX Cs model, a neuropsychological framework for psychological first aid that focuses on addressing acute stress responses that can lead to functional impairment and increase the risk of PTSD (Farchi et al., 2024). Another example is the YaHaLOM model, developed in the IDF to help soldiers manage acute stress in a combat zone (Adler & Gutierrez, 2022). These models emphasize several key components: (a) Cognitive Communication – this aspect helps individuals manage emotional overwhelm and enhances cognitive functioning, promoting active engagement; (b) Control – this component assists individuals in regulating their cognitive responses in extreme situations; (c) Commitment – the aim is to alleviate feelings of loneliness; (d) Continuity – this ensures that individuals’ experiences maintain a coherent narrative.

Another insight adopted was that the interventions’ ability to support returnees and help them regain balance was often as significant as full-scale psychotherapy (Roberts & Nixon, 2023). Therefore, it is crucial to intervene immediately to address any significant problem in real-time to enable the reception process to move forward. For example, a returnee with a chronic illness worried about lack of medication will be seen by a doctor on hand to asses if anything is needed urgently, and then will be reassured that they will later receive full and specialized medical care. Such precise and sensitive intervention addresses the specific issue relevant to that specific moment while simultaneously enabling assistance in organizing and moving forward.

Based on theories concerning the treatment of POWs and civilians returning from captivity, as well as established principles for addressing immediate stress reactions among both military and civilian individuals who have experienced trauma, we developed a protocol for welcoming civilians returning from captivity. The protocol is outlined as follows:

A simple and focused intervention

Offer a warm welcome to instill a sense of security and adjust the human touch to the complex situation. At the meeting point, make sure to validate and bolster the returnees’ internal survival resources and heighten their sense of competence that was most likely impaired in captivity. This intervention is essential in the adaptation process, helping regain a sense of security, competence, and trust in other people (Herman, 1992). Resilience and attachment style are significant personal resources for managing stress. Research on Israeli POWs revealed that both can prevent developing mental symptoms (Zakin et al., 2003).

For example: “Welcome back to Israel – we’ve been waiting for you. My name is [X], and I’m a social worker, from the IDF medical corps. I’ll be accompanying you until you’re reunited with your family.”

Explain the next steps to provide a basic orientation

A straightforward explanation of the next steps is vital, ensuring that the returnees receive much-needed information to reconnect to reality.

For example: “Right now, we’re near [insert location if relevant], and in a few minutes we’ll drive from here to the next stop. There, you’ll have a chance to freshen up, and on the way, there will be an opportunity to share a bit more if you feel ready. Is there anything you need right now?”

Pacing and leading

Pacing and leading are trust-building methods based on mirroring subjects’ emotions before gradually leading them gently toward the desired direction.

For example: “Where would you feel comfortable standing so I can continue giving you information?”

Joining

A subtle adjustment of the therapist’s behavior, thoughts, or feelings to match the patient’s current experience. The significance of joining is in creating a platform for conversation that might generate a change by restoring the patient’s sense of control and choice without flooding the conversation with many questions.

For example: “I’ll answer all of your questions gradually. For now, let’s focus on the most urgent updates.”

Satisfying basic needs

Offering food, rest, and time to freshen up (Hobfoll, 1989).

For example: “We have some water and a light snack here – something we know will be gentle on your system after a period without eating.”

Physical contact

Do not initiate physical contact without the returnee’s explicit consent. This point is crucial for regaining a sense of control after the agonizing experiences many of the returnees have undergone.

For example: If someone reaches out for a hand or a hug, you can of course respond warmly. If you sense they may need support, you can gently ask:

“Would you like me to hold your hand?”

Initial mental assessment

Monitoring significant psychopathology and extreme mental states, particularly acute dissociation, extreme anxiety, agitation, and a psychotic state.

Psycho-educational training

Training the receiving therapists in legitimating and validating the returnees’ expected natural reactions and helping them hold their defenses. For example, initial reactions can include disbelief, shock, disorientation, out-of-body experiences, time warps, stress and fear, helplessness, survival relief, and guilt. Psycho-educational guidance should help the returnees connect to their existing resources and emphasize that recovering from traumatic experiences is possible. To achieve this, the therapists must establish a supportive relationship with the returnees under their care as early as possible after the traumatic event (Whitworth, 2016). Psycho-educational training techniques should enable this as part of the relationship built with the returnees and a more comprehensive intervention aimed at helping them organize.

For example: “I see that you’re trembling – it might be from the cold, or perhaps from the emotion of returning to the country. Trembling is a common response after everything you’ve been through, and also now, as you cope with the challenges of coming back home.”

Contact the returnee’s family/support system

Contact the returnees’ family and community gradually and according to the returnee’s needs. The accompanying Mental Health Officer (MHO) contacts the family through the designated casualty officer assigned to the family after October 7th. Although the intervention focuses on the returnee, it must also include the family, which should ideally become an active and full partner in the adaptation and rehabilitation process. During the initial contact at the forward reception point, the MHO should suggest that the returnee contact a family member to meet him or her at the hospital. The initial contact of the returnees and their families with the mental health personnel may encourage them to seek treatment later.

Contact with the medical staff

Communication with the medical staff and debriefing with them ahead of and also upon arrival at the hospital is essential to their initial interaction with the released captives. The advance contact informs both the MHO as to anything particular that should be done in the field, as well as the medical staff as to what to expect, and makes for an optimal hand-off upon arrival to the hospital. At this point, it is crucial that the receiving MHO immediately convey to the medical team any information received from their initial impression during the return or provided by the returnee himself. Released captives should not be left alone until they meet with a family member. Before leaving, make sure to say goodbye to the returnee you accompanied. Do not disappear upon arrival at the hospital. The returnees should be told that once they arrive at the hospital, the MHO will leave after sharing every information received with the medical staff to allow them to take over the treatment.

For example: “I will update the medical team with the information you have shared so that you receive appropriate care when you arrive at the hospital.”

Summary

Feelings of terror, helplessness, and constant danger to one’s life that overwhelm abducted captives often develop into mind-sets that enable survival and adaptation to captivity conditions. Typically, asymmetrical and distorted relationships that develop involuntarily in captivity can have long-term consequences for future relationships and readapting to normal life. An extra-sensitive and well-adapted professional approach is of the highest importance, particularly since many of the returnees lost family members and friends before and during their abduction or while in captivity. The first few hours after the release are crucial, as in some cases returnees are unaware of the fate of their loved ones.

The present protocol proposes short and uncomplicated interventions to establish contact, restore trust, and create a basis for regaining a sense of control and competence. Physical and mental assessments should be performed already at the meeting point. Generally speaking, the returnees’ physical and mental health before their abduction is the best predictor of recovery after their release (Norris et al., 2005). There is evidence that individuals with a previous history of mental disorders are at a higher risk of developing PTSD, and physical injury increases this risk (Neria et al., 2000). Furthermore, a study of released Israeli POWs found that the most severely traumatized POWs were those whose personal resources were deficient before the trauma. Captives whose personal resources had been undermined due to significant physical and mental abuse or inadequate adaptation were more at risk of trauma (Neria et al., 2000). These findings indicate the importance of a psychiatric evaluation and treatment plan immediately upon return from captivity.

Early intervention, especially psycho-educational, can be an initial basis for calming and normalizing reactions and behaviors, creating an initial connection, and motivating the returnees to seek treatment if necessary. Psycho-education is central in PTSD treatment approaches, and experience shows that it has particular relevance in POW treatment. Psycho-educational interventions aim to help the released captive regain a sense of independence, control, and self-efficacy. They also help their families understand what they should expect to contend with and assume a suitable attitude. It is essential to recognize that contrary to the popular belief that “time heals,” in captivity trauma and its long-term mental effects on various areas of life, the time elapsed since captivity often worsens the former captives’ mental state (Zerach, Levi-Belz, et al., 2014).

Several longitudinal studies of Israeli POWs over prolonged periods have generally recommended that initial intervention and treatment be followed by long-term therapeutic interventions to support the POWs later in their lives. Long-term treatment is particularly required for captives who experienced loss of emotional control during captivity or were held in particularly severe conditions (Solomon & Dekel, 2005). The treatment of POWs from previous wars has demonstrated that extended multi-professional follow-up treatment is imperative since difficulties may develop or emerge over time.

The protocol has several limitations. First, at the beginning, the protocol was developed to focus on females and mothers kidnapped with their children; hence, our sample was selective, consisting only of female abductees. Second, we did not validate the protocol. Third, the components of our protocol are typically implemented over a limited time, which does not allow for in-depth examination. However, the protocol’s strength lies in its modularity. At the time of writing, we have also utilized it to receive abductees who returned after 500 days (civilian men and women, as well as female soldiers), employing a broad application of the protocol and making necessary adjustments.

Clinical Implications

The long-term psychological effects of captivity (Bechor et al., 2023) highlight the importance of our protocol components in the rehabilitation process of individuals who have been held captive. Captivity is one of the most severe traumas a person can experience. Those returning from such situations require immediate and ongoing support, which is crucial due to the profound consequences that can negatively impact their mental and physical well-being and various aspects of their lives after release. The CSRU has guiding principles for receiving and treatment of soldiers released from captivity, which were implemented in January 2024 with the release of five female soldiers from Hamas captivity. Among others, these principles drew on the U.S. document mentioned earlier (“Reintegration theory for DoD personnel”) to facilitate their continued treatment by the IDF after release from the hospital, whereas civilian returnees are treated in the community after hospitalization. In both cases, however, the families are accompanied by designated MHOs from the CSRU. Given the evidence published about the physical, psychological, and sexual harm inflicted by Hamas on the hostages, our protocol principles are based on literature regarding the treatment of freed captives. This includes treatment approaches for potential complex posttraumatic stress disorder (CPTSD), which should be taken into account following prolonged captivity alongside PTSD symptoms. CPTSD is characterized by difficulties in emotional regulation, altered consciousness, changes in self-perception, modified perceptions of the abuser, disrupted relationships with others, and shifts in meaning-making systems – all of which have life-long consequences and must be addressed in long-term treatment approaches.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Institutional clearance

The IDF Medical Corps Institutional approved the publication.