Caring for Those Who Give Care in the Wake of the October 7th War: The Effect of Trauma Exposure on Healthcare Professionals and Coping With It on a Personal, Professional, and Systemic Level

Who Treats the Therapist? | Poem by Kama Shir

A man sits on an armchair

He sees one story after another

And he remembers

His blue eyes listening

His face reddens in confusion (when appropriate).

A man sits on an armchair

He sees one individual after another

Like a clock

And he holds worlds

And he holds a heart.

A man sits on an armchair

And at the end of the day folds his heart inside

Closes the door

And remains alone.[1]

Introduction

The current situation

Collective trauma is a response to a traumatic event that shatters the basic societal structure and has broad psychological implications not only for the individual but for the collective as a whole (Hirschberger, 2018). The event leaves a profound impact on the collective consciousness and memory, and its collective memory has a major impact on how trauma is processed and on the possibilities for rehabilitation (Gutman et al., 2024). The events of October 7, 2023 created a new reality for Israelis, one consisting of gut-wrenching experiences unlike any since the founding of the State. The shocking events — a mass terrorist infiltration, the murder of civilians and soldiers, and inhuman acts of violence against defenseless individuals — marked the start of a war for the very existence of the State of Israel and the personal security of its citizens. The ramifications of the October 7th events are evident in their impact on the mental state of Israeli residents from all parts of society. It is estimated that within the first few months following the outbreak of the war, over 30% of the Jewish population suffered post-traumatic symptoms (Shmueli et al., 2023).[2]

In addition to those who directly experienced the events and the evacuation of entire settlements, there are an increasing number of individuals who have been indirectly exposed to this trauma. Healthcare professionals who are on the front line in treating trauma victims find themselves in a shared traumatic reality and experience the disaster’s aftermath alongside its victims (Saakvitne, 2002). Professionals who are members of the affected communities experience a double impact, both as victims themselves and as therapists for the victims of October 7th or the war situation in general (Baum, 2014; Saakvitne, 2002). They must continue working while coworkers have been killed or abducted, family members or friends have been harmed, and close family members serve in regular or reserve military duty.

This situation is reminiscent of the COVID-19 pandemic, when medical teams and their families were exposed to the disease’s effects just like the general population, and to an even greater extent. In this context, it is worth noting that the pandemic’s psychological consequences on the population as a whole and the healthcare professionals in particular — which included depression, anxiety, stress, and burnout among professional teams — have not yet received the attention they deserve. This led to Israel arriving at the events of October 7th with its systems already strained, particularly its mental health system, its education system, and its welfare system (Trotzky et al., 2023).

Both witnesses and victims alike are subject to the dialectics of trauma (Harman, 1992), which swing between the desire to know and the desire not to know, between the urge to describe and the fear of not being believed. The events of October 7th turned everyone, wherever they were, into a witness: the physician in the emergency room, the social worker in the hotel taking in evacuees, the teacher in the school, the volunteer in the preschool, and other professionals and care providers of all kinds. They were (and continue to be) witnesses to horrors that are almost incomprehensible. Additionally, the difficult ethical and professional questions that professionals had to confront during their therapeutic work also left their mark. Healthcare professionals exposed to the stories of victims may also experience secondary trauma due to the nature of the burden they take on. Within this context, the ongoing state of war being experienced by the citizens of Israel is liable to further impact the resources for coping with the situation and may lead to burnout among therapists, including non-professional ones, such as volunteers, youth in their year of national service, and others.

In these circumstances, the practice of self-care by professionals is crucial in maintaining their well-being and ensuring their personal and professional resilience. As will be discussed below, organizational involvement is a necessary condition for enabling the self-care of healthcare professionals and for ensuring their safety and well-being in crisis situations such as these. However, many organizations struggle to adequately support the self-care of their staff and to maintain the provision of high-quality service to service users during crises. A prominent example is the mental health system, which is meant to provide assistance to service users and service providers in times of crisis. Unfortunately, this system itself is in distress. A new report published by the Coalition of Mental Health Organizations reports neglect of the system,  which manifests as, among other things, the low rate of public expenditure on mental health: only 5.8% of public healthcare expenditure, as compared to an average rate of 11% in OECD countries; the lack of community resources; the shortage of manpower; and unusually long waiting times, with the average wait of 12‒16 months for a first meeting with a professional (Rosenthal et al., 2023). Furthermore, in various professions within the mental health system, the number of professionals is relatively small compared to the size of the population. For example, there are only 9.9 psychiatrists per 100,000 population in Israel. There are a total of 1,420 psychiatrists, of whom only 800 work in the public sector. This amounts to approximately 11,750 residents per psychiatrist in the public sector and about 6,590 residents per psychiatrist overall. There are 8,864 psychologists in Israel, of whom 56% are specialists. Thus, there is only 1 psychologist specialist per 1,056 residents. Aggregating specialist and non-specialist psychologists, there is only one psychologist per 596 residents. In the field of social work, there are 40,657 licensed social workers, leading to a ratio of only 1 licensed social worker per 250 residents, and it is unknown how many of them have psychiatric training (Levy, 2023). This situation underscores the systemic challenges associated with addressing immediate needs following the events of October 7th. The question is raised how mental health professionals (as the prime example, although the problem exists in other fields as well) can maintain their well-being in light of these systemic shortcomings, and what organizational responses are necessary to allow them to achieve this.

The existing persistent shortage of professional workforce leads to burnout. On October 7, thousands of therapists in both the private and public sectors, volunteered to immediately treat the most severely affected victims, often under difficult conditions and in less than optimal settings, such as hospitals, hotels, and orphanages. They did all of this without an organized system taking responsibility for them and their welfare or providing them with a place to decompress and share their collective experience. Due to a shortage of therapists, many felt dutybound to step up and treat those in need whose numbers are still continuing to grow. Like the rest of the population, they also struggled to find someone to support them and their families when that was necessary. Differences of opinion between professional authorities on the one hand and administrative and governmental authorities on the other deepened the professionals’ feelings of uncertainty and made it more difficult for them to function.[3] An additional issue exacerbated after October 7th that affects the performance of professional care staff is the tension between Jews and Arabs, as evidenced in expressions of prejudice, suspicion, and fear. In certain locations, both Arab and Jewish therapists were afraid to leave their homes or go to work on their own, and Jewish workers expressed concern or discomfort about working alongside Arab staff members. Indeed, the healthcare system has identified the issue of social cohesion in the workplace as one of its most important challenges, both in the short and long term.[4]

Caring for those who give care

Therapists and other professionals are subject to the development of post-traumatic stress disorder (PTSD),[5] vicarious traumatization, and mental and cognitive impairment as a result of their work. Comprehensive research on the long-term impact of the 9/11 events on healthcare professionals and first responders, found cognitive impairments such as dementia (Clouston et al., 2016) and increased prevalence of mental disorders (Diab et al., 2020), among others. Similar impairments have been found worldwide in these professions, and it is worthwhile to devote resources to preventing them. In addition to the effects of trauma on healthcare professionals and first responders, it is also important to address the various barriers preventing them from receiving treatment. For example, first responders sometimes hesitate to seek treatment out of fear of jeopardizing their professional advancement. Others reported not being able to find the time for treatment or not knowing where to turn to receive it (Haugen et al., 2017).

Healthcare professionals who do not receive appropriate treatment may be unable to cope with their burden and may provide disconnected and unsatisfactory care to patients, thus causing harm to both parties (Menzies, 1960). On the other hand, when professionals and patients manage to process the trauma, there is the potential for growth and resilience, with opportunities for adaptation and the development of creative solutions contributing to increased self-worth and resilience (Greenwald & Lavie, 2023).

Dealing with the collective trauma of October 7th and the ongoing state of war requires the adoption of a systemic approach and an organizational culture that will strengthen the resilience of workers and service users alike and enable functional continuity of treatment over time. It is important to note that the approach to treating therapists is embedded in professions such as social work, psychology, and psychiatry, and they can teach us about methods for coping with the secondary effects of trauma.

In addition to creating mechanisms for the support of staff members during crises, it is important to nurture their resilience in periods of relative calm. By resilience, we mean the potential to overcome difficulties, to cope and even to grow as a result of adapting to change and crisis situations. Resilience is fostered through factors such as a supportive social environment, a sense of acceptance, and warm and caring interpersonal relationships (APA, 2022). There is a direct connection between fostering the resilience of therapists in normal periods and their ability to cope with crises (Joyce et al., 2018). The new circumstances provide us with an opportunity to rebuild, and we are called upon to plan the response in the short, intermediate and long term, in order not only to return to the pre-October 7th situation but also to “build back better.”

Basic concepts

Discussing the impact of trauma on professionals requires familiarity with fundamental concepts in the field. Clarifying these concepts is particularly important because the literature often uses terms interchangeably (for example, secondary trauma and vicarious trauma). Therefore, before discussing systemic change in the treatment of healthcare professionals, it is necessary to clarify the terms used in its main categories.

The risks in the exposure of healthcare professionals to trauma

1. Compassion fatigue — Fatigue and apathy that healthcare professionals manifest after working with patients suffering from emotional pain and their compassion towards them. Identifying with patients and their trauma creates stress and promotes attempts to suppress feelings about the patient and things that remind them of the patient (Figley, 1995; 2002).
2. Secondary traumatic stress (STS) — A stress phenomenon among healthcare professionals, or family members of those suffering from trauma, who are taking care of those who have been directly affected by trauma. The prolonged treatment of trauma victims leads them to experience stress and distress as well, resulting in secondary trauma (Figley, 1998).
3. Vicarious trauma — A process in which the internal experiences and perceptions of healthcare professionals are adversely affected due to empathy towards their patients who have survived trauma. Prolonged exposure to the traumatic experiences of patients during treatment can impact the beliefs, expectations, and assumptions of treatment providers about reality and about themselves. The combination of the undermining of their perception of reality and the internalization of the impressions and experiences of their patients can lead to traumatic symptoms in professionals and severe impairment in their quality of life (McCann & Pearlman, 1990).
4. Moral distress — The psychological impact of moral and ethical tension on healthcare professionals as a result of behavior contrary to their ethical code, whether that involves avoiding doing the right thing or doing something that goes against their values, or bearing witness to such an event that they failed to prevent. Even those who in spite of their best efforts failed to provide assistance or save patients can experience this failure as moral injury (Jameton, 1984; 2013).
5. Burnout — A response to long-term stress resulting from the work environment and the nature of the work, which leads to physical, emotional, or mental exhaustion, a decline in performance, and negative attitudes towards oneself or others. This phenomenon can lead to emotional withdrawal, apathy towards patients, and depersonalization (APA, 2018; Hunsaker et al., 2015).
6. Retraumatization — A re-experiencing of traumatic moments following exposure to a situation or environment that is not necessarily traumatic in itself but is reminiscent of the previous trauma and evokes emotions and reactions linked to that trauma. Retraumatization is usually triggered unintentionally. It can occur among both staff and service users, in any setting, and it is dangerous because of its potential to exacerbate the trauma symptoms of the affected individuals and to decrease responsiveness to treatment (SAMHSA, 2014a).
7. Collective occupational trauma — A situation in which professionals experience the same traumatic reality as their patients and those associated with their various support systems (such as family members). This situation blurs professional boundaries, increases emotional distress, and amplifies the risk of psychopathological impairment among professionals (Fink-Samnick, 2022).

Growth and development as a result of encountering trauma

1. Post-traumatic growth (PTG), Vicarious post-traumatic growth (VPTG) — Psychological and behavioral growth following direct trauma or exposure to secondary trauma. This growth can develop directly from the traumatic experience or as a result of indirect factors, such as self-esteem, social support, finding meaning in work, changes in self-perception, interpersonal relationships, and personal philosophy (Arnold et al., 2005).
2. Compassion satisfaction — The experience of satisfaction derived from providing assistance to those who have experienced a traumatic event. This experience helps protect against compassion fatigue and burnout and contributes to improving the quality of life of healthcare providers (Sacco et al., 2015).
3. Vicarious resilience — A positive effect of working with patients and seeing how they are able to cope with difficulty and trauma. Empathic identification with the traumatic burden of patients and their coping abilities leads to a positive change in the inner world of therapists and facilitates their ability to cope (Hernández et al., 2007).
4. Self-compassion — A positive self-attitude among care providers towards themselves which makes it possible to cope with negative experiences and feelings. Such an attitude includes self-kindness, self-acceptance without criticism, a sense of connection to others and oneself, self-compassion and compassion towards others, and retaining an aware balance regarding painful thoughts and feelings that prevents sinking into overidentification with feelings of pain and difficulty (Neff, 2003).

 Professions in which the approach to employee well-being and reducing the impact of exposure to traumatic experiences is embedded

In the professional world, there are several areas in which there is a comprehensive focus on preventing the erosion of human capital and reducing the impact of exposure to traumatic experiences among professionals. It is important to become familiar with the existing body of knowledge, the various approaches to coping, and the challenges that arise in this area.

Human resource (HR) management

Professionals engaged in human resource management in any organization are dedicated to nurturing human potential, developing employee resilience, and providing appropriate support to those experiencing difficulties. In the field of HR there are a number of methods that enable professionals to help employees cope with challenging events. The initial interaction between the organization and individuals experiencing loss or trauma usually takes place through the human resources department. Therefore, it is crucial that human resource professionals receive specialized training to provide rapid and sensitive responses to employees experiencing trauma.

At the strategic level, organizations that develop programs for increasing resilience and the mitigation of employee burnout will be healthier and better equipped to handle crises. It is vital to develop an organizational plan for coping with traumatic events and encouraging employee recovery. Special emphasis should be placed on facilitating access to mental health services and to information on relevant care providers. Since an employee experiencing trauma may not be functioning optimally and may struggle to absorb necessary information, it is important that employees understand their rights and the services available to them in times of crisis, and that the HR staff disseminates this information frequently, including during non-crisis periods. Human resource professionals are also responsible for enriching and developing human capital. Therefore, it is important to provide training for employees at all levels to foster empathy in the workplace. Ultimately, HR professionals provide support to employees in the organization starting from the hiring stage until the termination of the employer-employee relationship, and they are exposed to the difficulties that employees experience throughout this entire period. Consequently, in order to create a safe and supportive work environment that assists job candidates and new employees in coping with anxiety and concerns and alleviates employee distress at every stage, it is important to incorporate trauma-informed principles[6] tailored to the organizational needs in HR procedures. These include actions such as promoting clear and transparent communication between employees and employers, respecting employees’ personal time, creating a safe and respectful employment termination process, etc. (Lytle, 2023; Missouri Trauma Roundtable, 2017).

Care of terminal end-of-life patients

Among healthcare professionals who deal with terminal and end-of-life patients, bereavement responses are likely to occur that interfere with their functioning and quality of life. In the professions that face this challenge, various coping strategies have emerged. For example, in the field of oncology, protocols (both formal and informal) have developed that dictate professional behavior in the presence of loss and ways to cope with it. Acceptable professional behavior in response to patient loss and death includes, among other things, establishing ties with the family of the deceased and participating in mourning rituals. Coping mechanisms are diverse and include, seeking social support, engaging in hobbies or sports, spending time with family, leaning on religious or spiritual faith, compartmentalizing professional and personal lives, and maintaining a degree of emotional distance from patients (Granek et al., 2013).

Coping of emergency teams and first responders in disasters

First responders, by the nature of their duties, are exposed regularly to traumatic events, and develop various strategies for coping with them — before, during, and after their arrival on scene. Mental and functional control in emergency situations, achieved through prior self-preparation by means of internal dialogue and simulation of the anticipated challenges, make it possible to experience events as empowering and positive, despite the difficulties encountered. Maintaining emotional distance from patients and their families during the event facilitates optimal functioning without negative emotional burden. Following the event, seeking social support and engaging in dialogue with individuals who can assist in processing emotions that may overwhelm team members can aid in easing traumatic experiences and coping with difficult memories, thus reducing the risk of post-traumatic stress and depression. In addition, compensatory actions, such as attending funerals, offering condolences to the bereaved family, or visiting patients in hospital, help foster positive emotions among team members (Avraham et al., 2014).

The supervision relationship and the therapeutic relationship in healthcare professions

The therapeutic relationship between healthcare professionals and patients is influenced by the psychological profiles of both the therapist and the recipient and emerges from their interaction. The psychological interaction in the relationship affects both the patient and the therapist, and it is important to understand the significance of mutual decision-making processes and the impact of the therapeutic relationship on the therapist’s well-being. Supervision, as an integral part of training and professional development in therapy professions, establishes a powerful encounter between two professionals. In addition to the professional content delivered, meetings between the supervisor and the therapist also address the therapist’s emotional world. In the realm of psychotherapy, supervision includes therapeutic elements such as emotional support, empathy, and understanding, thus serving as a means to process the therapeutic experiences of the supervised therapist through the open discussion of their challenges and their coping strategies. The relationship and atmosphere created during supervision shape the meaning attributed by the therapist to their experiences, allowing them to unpack their emotional burden and assisting them in coping with the pressures associated with their work (Yerushalmi, 2012).

When coping with trauma is part of the job, supervision provides an important space for processing the traumatic aspects of the work and protecting against secondary trauma (Itzhaky et al., 2017). In such cases, there is a need for the development and expansion of the supervisee’s reflective ability so that they can analyze and understand their behavior and experiences and attribute meaning to them. The supervision is intended to help the therapists find words to cope with their trauma and find a measure of calm and comfort that allows for reflective observation and growth (Zeevi Sela, 2017). It is important to note that supervision should be adapted to the individual therapist, including the way in which traumatic content is discussed and revealed during the supervision. When discussing trauma in supervision, it is important not to relate traumatic details that are not directly related to the subject of the training, in order to avoid secondary traumatization.

All medical schools and nursing schools in the country provide extensive supervision in the soft parts of these professions, namely those that do not require pure knowledge or skill, but are related to understanding the therapeutic relationship, so as to improve the health of patients and the well-being of both physicians and nurses. In the medical profession, this is considered to be a new and innovative approach. In the old paradigm, the physician was the sole source of knowledge who acted paternalistically towards the patient, made decisions independently, and focused mainly on the biological mechanisms of the patient. This new and contrasting approach attaches major importance to the development of the healthcare professionals’ emotional resilience and ability to recognize the impact of their work on therapeutic practice. Therapeutic work is carried out under heavy load and stress conditions and involves making decisions under uncertainty and coping with vicarious traumatization, medical errors, or violence towards medical staff. The new approach acknowledges the need for healthcare professionals to receive adequate support for their needs at all stages of their work — before, during, and after patient encounters (Wright & Richmond, 2019).

Specialization in family medicine includes training for specialists during and after the specialization process. Family medicine is based on a continuous relationship with the patient, accompanying them through different stages of health and illness and addressing various physiological systems, ages, and life situations. Learning about the therapeutic relationship occurs under supervision, in which the trainee can learn about the significance of being in a nurturing relationship. The supervisory relationship has an educational goal that is parallel to that of the therapeutic relationship, whose goal is to improve health. Close guidance allows the supervisee to pay attention to emotional aspects of personal development during the supervision process and can help deal with complexities and difficulties encountered in training, as well as coping with symptoms that have no clear explanation and with complex relationships with patients. It is customary that within these supervisory relationships, emotional aspects of family medicine and daily professional experiences, as well as the accumulating burden, are also discussed. Examples of such training frameworks in Israel are the Department for Teachers of Family Medicine (HIMAR – the Hebrew abbreviation) within the Israel Association of Family Physicians and the Israeli society for medical education within the Israel Medical Association.

Clinical encounters with patients in family medicine have the potential to impact the physician in various and surprising ways, which go beyond the encounter itself. In the 1950s, British psychoanalyst Michael Balint developed a method for the joint safe processing of such encounters. At that time, family physicians often dealt with patients returning from World War II with complex issues that they had not been professionally trained to deal with. Balint groups regularly meet with an appropriately trained facilitator, discussing any topic of concern to participants beyond their routine clinical practice. The groups are intended to help develop an understanding of the emotional aspects of the therapeutic relationship and, as an added value, to encourage resilience and reduce burnout (Roberts, 2012). Each session includes a brief case presentation followed by extensive group discussion. Balint groups meet in Israel and around the world, but they are used primarily by family physicians and even among them are not particularly common. However, in recent years, such groups have begun to operate in Israeli hospitals. For example, a pilot Balint group began meeting at the Sourasky Medical Center in Tel Aviv ten years ago with the goal of training new group leaders. This group, which currently includes psychologists and physicians, is still in existence, and its graduates have established and led about 20 new Balint groups in the hospital departments (Krontal, 2019).

Mapping of programs and methods for reducing and coping with traumatic effects on healthcare professionals

In both Israel and worldwide, there are programs designed to provide both personal and organizational responses to the exposure of healthcare providers to traumatic content and events. This includes professionals in therapeutic fields such as mental health, medicine, and first responders, as well as various other professions in healthcare, education, and welfare, which although not necessarily defined as therapeutic per se, include a therapeutic and interpersonal component. These programs aim to develop coping skills and apply them not only in emergencies but also in day-to-day routine with the understanding that a lack of proper functioning in routine situations can make functioning in emergencies even more problematic.

These programs attempt to mitigate emotional impact, including vicarious traumatization and burnout among healthcare teams; to encourage resilience and post-traumatic growth; and to preserve human resources in the organization in the long term. However, implementing these programs involves numerous challenges. Coping with trauma poses unique challenges and requires careful consideration in order to prevent adverse effects on the staff. Treating and dealing with the trauma of others can evoke processes among healthcare professionals that change one’s worldview and can lead to secondary post-traumatic symptoms among them. Therefore, it is important to address this risk before it is realized.

When an organization fails to cope with trauma, there is a danger to both professionals and patients. When professionals and service recipients who have been exposed to trauma turn to their organization for support but do not receive it, the trauma may be exacerbated. In such cases, negative behaviors may emerge, such as service user aggression towards staff or vice versa. If the organization fails to manage its employees’ work load, work can become unbearable, and the staff may adopt methods of coping that exacerbate emotional detachment from patients.

The success of intervention programs depends on creating unity and collaboration among the various professionals in the organization, rather than establishing a hierarchy of professions between those that are considered deserving of assistance and those that are not. If an intervention program focuses only on specific professions within the organization, while other trauma-affected professions are neglected, it may lead to internal tensions within the organization or exacerbate already existing ones.

Prevention programs: A conceptual framework

Preventive measures can be implemented at various times and stages according to the situation. Primary prevention attempts to prevent or mitigate harm in advance through early planning and action, before the traumatic event or exposure occurs (National Health Council, 2023). When dealing proactively with traumatic exposure among staff members, it is important to maintain their well-being and welfare during routine periods and also to prepare them for emergencies. If the staff is already exhausted, worn down and burned out, then the cost and negative impacts when dealing with complex cases will be even greater. In a system that does not provide appropriate resources for its operations and relies on commitment and investment on the part of its employees that goes beyond the call of duty — even at the expense of their personal lives and leisure time — the staff may not be capable of dealing with a crisis situation when it arises.

Secondary prevention involves intervention after exposure to the risk factor and the traumatic event, with focus on preventing the worsening of the situation and the development of persistent post-traumatic disorders (National Health Council, 2023). An organizational culture that encourages quick identification and timely action is able to maintain the health and well-being of employees despite their exposure to trauma.

Tertiary prevention seeks to minimize damage after the appearance of the damage, that is, once the signs of secondary traumatization are already evident. This prevention is the most complex and challenging to implement.

Strategies for developing personal coping abilities

Several methods of coping have been found to be effective in developing the personal coping abilities of healthcare professionals. These methods include personal therapies such as mindfulness, cognitive-behavioral therapy, engagement in sports and maintaining a healthy lifestyle, spending time in nature, increasing self-awareness or self-dedicated time, seeking social support, setting boundaries between personal life and work, continuous learning and professional development (Barrington & Shakespeare-Finch, 2014; Melnyk et al., 2020). Beyond the variety of methods implemented, it is important to highlight the abilities that contribute significantly to personal coping:

1. The resilience of healthcare professionals — This ability facilitates recovery after a crisis. Vicarious resilience is a central component in the resilience of professionals dealing with trauma. It is important to increase awareness of the power that lies within the therapeutic process and to develop an awareness of this resource. Studying the ways in which trauma and resilience are shaped by gender identity, ethnicity, sexual orientation, status, and other social markers creates a conscious investigation process contributing to the development of new meaning in the work of caregiving staff (Hernandez-Wolfe et al., 2015). Another contribution to building the resilience of the caregiving staff is related to maintaining and developing hope in the therapeutic process. Personal growth following trauma is linked to the existence of a space that allows the healthcare professional and the patient to maintain hope during the therapeutic process — hope that is founded on the trust-based relationship formed during treatment and that provides meaning also for the therapist who has chosen this field of work (Levi, 2013). There are also targeted interventions for the development of resilience that can be offered to healthcare professionals, such as SMART (Stress Management and Resiliency Training) programs that teach a variety of self-treatment methods in a number of sessions over a period of several weeks; online training modules for developing self-reflection regarding stress, resilience, and the relaxation response; professional development workshops and educational workshops; practicing psychosocial skills; mindfulness; etc. The longer and more comprehensive the intervention and the more time allotted to each session, the greater the likelihood that it will be effective (Cleary, 2018). A central component in psychological resilience is the sense of coherence, which reflects the individual’s ability to see life as having a rational structure, as manageable and as meaningful. Individuals who develop a sense of coherence will have a positive approach that enables them to succeed in coping with complex challenges. For example, during the COVID-19 crisis, the importance of a sense of coherence in the functioning and coping of first responder team leaders was underscored (Gabay et al., 2022).
2. Self-awareness and self-regulation in therapist-patient relationships and correct empathic regulation — In the training of medical staff, there is sometimes an overemphasis on maintaining a professional distance from patients in order to preserve functionality in times of crisis; nonetheless, concern and empathy for patients must not be neglected, and it should be remembered that they, too, can assist in containing the problem (Fox, 2006). It is recommended to conduct training programs that develop the awareness of healthcare staff with respect to their opinions and feelings towards patients (Goldblatt et al., 2020). It is important to remember that adverse reactions in response to exposure to traumatic content are natural and express the emotional response to the difficult experiences undergone by the patient. For example, vicarious traumatization is a natural response to exposure to a patient’s difficult experiences, and this can be emotionally burdensome for healthcare professionals who have not been trained to cope with it. These natural reactions can be anticipated and regulated by adopting principles of empathic development: nurturing the ability to feel compassion, recognizing the limitations of assistance that professionals can offer, and understanding that the support they provide can be healing (US Department of Health and Human Services, 2020).

Strategies for developing organizational coping capacity

For organizations that supply social services to the population – from health funds through to educational institutions and the local authorities – there is great importance to developing a comprehensive system for supporting the care professionals in their organizations. It has been found that certain changes in organizational culture can make an effective contribution to coping with trauma. This includes, for example, the accessibility of management for employees, establishing peer dialogue on difficult topics as part of the organizational agenda, adopting an approach that fosters human strength and encourages professional advancement, and designing a positive work environment (Barrington & Shakespeare-Finch, 2014). In this context, several key organizational methods can be identified:

1. Trauma-informed organizations — Creating an organizational culture that is aware of the broad impact of trauma and responds to trauma at all levels, including secondary trauma among healthcare providers, with the goal of creating safe and healthy spaces for patients and preventing re-traumatization. The well-being of the professionals is also beneficial to the patients since it prevents phenomena such as compassion fatigue and secondary traumatization and improves the quality of treatment (SAMHSA, 2014).

Trauma-informed care recognizes that events which people experience throughout their lives affect their development, behavior, belief systems, relationship formation, and mental and physical health. This approach emphasizes the events that brings the individual to their current state, as opposed to narrowly focusing on their current condition. Within the principles of this approach lies an understanding that therapeutic encounters in all forms can lead to re-traumatization in patients and staff, and a trauma-informed system takes active steps to prevent this and works to create a safe environment for everyone within it. This not only involves dealing with the symptoms of trauma among the organization’s employees but also creating a safe environment with the aim of preventing or minimizing the negative effects of traumatic experiences on the staff and service recipients, both now and in the future. These principles are relevant whether dealing with organizations directly involved in treatment (such as the healthcare system) or those providing support services (such as volunteers and office workers), as well as organizations in which employees are exposed to stories of trauma (such as legal and welfare systems) (Keni-Paz, 2022).

The encounter with trauma can create defensive reactions among employees in the form of numbness or distancing from the patients, and it is the organization’s obligation to create appropriate mechanisms to deal with these reactions. It is important that the organization and its employees perceive themselves as bearers of a message and of a social role, as professionals who validate the injury that patients experience by acknowledging their trauma, and spreaders of a message of hope that treatment is an opportunity to help the patient and prevent the recurrence of similar injuries (Keni-Paz & Cohen, 2021). The events of October 7th created a personal and professional, sensory and emotional, overload of a magnitude that professionals were not accustomed to. Accordingly, it is essential to recognize their efforts from that day forward and validate them, to assess their emotional state, to give them encouragement, and to build customized work plans in case such an event happens again. It is important that the organization act to highlight moments of success and moments of meaning so that the significance of their efforts is recognized (Keni-Paz, 2022).

According to the NCTSN (National Child Traumatic Stress Network), practical professional training that provides tools to deal with the effects of trauma is the most important organizational tool for employees in trauma-informed organizations (David, 2022). The training contributes to an employee’s sense of competence, so that they feel important to the organization and helps to reinforce their sense of mission and alleviate feelings of compassion fatigue. Reflective training is an excellent tool for dealing with compassion fatigue, burnout, and secondary traumatization. It allows healthcare providers to identify feelings of helplessness and despair they may experience and to address the emotions aroused by the difficult descriptions they hear, thereby influencing their conduct towards the patients.

Promoting trauma-informed organizational leadership is an important step in empowering and protecting employees during challenging times. Many factors that are influenced by the managerial hierarchy in the workplace affect the severity of exposure to traumatic events. Therefore, it is important for leadership address the needs of staff members, provide support, and create a work environment that protects them as much as possible. Efforts should be made to create a mutual and supportive system of relationships and to also take practical steps, such as encouraging employees to take personal time for mental recharging, organizing team-building days, ensuring healthy nutrition, addressing the health and well-being of employees by, for example, monitoring stress levels, conducting two-way communication including explanations and rationalization of guidelines, and the like (Fink-Samnick, 2022). Leaders in trauma-informed organizations should know how to deal with expressions of anger or psychological difficulty among staff members and service recipients during crises, while viewing them not as weaknesses but as steps towards strengthening and improving the professionalism of both the staff members and the organization. It is important for them to adjust the work load to the employee’s situation, respect their personal time, and encourage employees to engage in leisure activities and spend time with their family in order to build resilience and alleviate the continuous burden of trauma encounters. Staff meetings are essential tools for collaboration and support, facilitating shared learning and highlighting successes. Support groups contribute to creating an additional space of familiarity and closeness that strengthens the staff. The principles of directly treating the victims of trauma, i.e., acquiring the experience of visibility and creating connection and significance, should also be applied in trauma-informed organizations to reinforce employees, convey the message that they are crucial to the success of the services provided, and emphasize their importance and that of their opinions and personal lives (Keni-Paz, 2022).

A trauma-informed approach can be implemented across various systems. In the US, for example, the Support for Patients and Communities Act, which was enacted in 2018, implements a trauma-informed approach in government policy and legislation. The law includes a commitment to support children and families experiencing trauma and negative childhood experiences, including trauma resulting from substance abuse. It includes a provision for the establishment of an inter-agency task force for trauma-informed care, with the goal of studying the impact of trauma on child development and formulating recommendations for action. The task force recommendations were published as part of a national strategy and action plan for trauma-informed care.[7] Another example is the implementation of a trauma-informed approach in the Cambridge Police Department in Massachusetts. Police officers are first responders who routinely deal with complex cases, and their performance under pressure and trauma in these events dictates the level of impact on both themselves and other parties. The Cambridge Police Department worked to formulate policies and foster an organizational culture aimed at preserving the health and well-being of its employees, preventing re-traumatization, expanding the officers’ knowledge, and developing their abilities to provide assistance to trauma survivors, as well as improving interaction with the broader public based on trauma-informed communication.[8] Another example is the transformation process of Fall Hamilton Elementary School in Nashville, Tennessee, into a trauma-informed school. The process focused on transitioning from an educational approach emphasizing obedience and compliance to one that nurtures students, supports them, and instills a sense of security.[9]

2. Occupational health and well-being, psychosocial risk management — Adoption of an international standard for psychosocial risk management at the organizational level. This entails a set of guidelines for implementing an occupational health and safety management system at the organizational level in order to identify psychosocial risk factors endangering the health and well-being of an organization’s employees. These risk factors are related to the organizational structure, the social factors at work, and aspects of the work environment, such as the equipment used by employees and the activities they engage in, which can adversely affect their physical and mental health, as well as the economic costs to the organization and society as a whole. Due to the organization’s commitment to employee health and well-being, it is expected to assess the risks inherent in the work environment and act accordingly.[10] This organizational approach, which aims to assess risks to the physical and mental health of employees and acts to mitigate them, is a powerful tool for maintaining employee well-being in routine and emergency situations. Implementation of this standard includes measures for monitoring and controlling employee well-being at the individual and departmental levels and prevention activities at various other levels. This standard is relatively new and has not yet been widely implemented in companies and organizations in Israel or worldwide. One of the companies that implemented the standard is ICTS, a British company specializing in security services.[11] In Israel, Tel Aviv-Yafo Academic College offers a training program for psychologists to accompany the implementation process of the standard in various organizations.[12]
3. Appointment of a Chief Wellness Officer (CWO) — The appointment of a senior-level official responsible for promoting employee well-being within the organization and ensuring the implementation of this approach throughout the organizational structure. The CWO is tasked with, among other things, identifying sources of anxiety among employees, utilizing the organizational infrastructure to support employees experiencing difficulties, evaluating employee well-being, and promoting systemic initiatives for improving well-being. They are solely focused on promoting employee resilience, health, and well-being within the organization and are expected to maintain direct communication with the organization’s management. This direct relationship with management contributes to a rapid organizational response during crises; it facilitates keeping management up to date in real time regarding the status of organizational support services and necessary improvements; it strengthens communication between management and employees and it enhances transparency; it facilitates the integration of support services offered by various entities within the organization; it facilitates recovery and rebuilding following a crisis; etc. (Brower et al., 2021). In 2017, Stanford Medical Center hired its first Chief Wellness Officer and developed a training course for position holders (Walia et al., 2024).[13]

 Implementation: Policy proposals and organizational changes

Implementing a trauma-informed approach in disciplines and organizations

Implementing a trauma-informed approach in organizations and various service sectors is a key tool in maintaining the health and well-being of workers in various professions. Promoting the implementation of this approach is crucial for dealing with phenomena such as vicarious traumatization, burnout, and other effects of the current crisis on the professional population. It is important to encourage organizations to examine the benefits of implementing this approach for all stakeholders in the organization (service providers and users), in all the disciplines and at all levels of involvement, even if the services offered are not necessarily related directly to the therapeutic world. Understanding the broad impacts of trauma on worker performance and the advantages of adopting a trauma-informed approach can help any organization or system meet their goals and objectives (SAMHSA, 2014b).

Implementing a trauma-informed approach in organizations and systems requires the adoption of the approach’s fundamental principles at the organizational level and the implementation of systemic changes. There is no one-size-fits-all implementation strategy, but it is possible to outline the basic assumptions and key principles that will allow each organization to independently implement an organizational trauma-informed approach (SAMHSA, 2014b).

These are the six main principles at the core of the trauma-informed approach: (1) ensuring physical and psychological safety in the work environment; (2) organizational conduct that is transparent and trust-building; (3) peer support; (4) partnership and mutuality in the work environment; (5) individual empowerment; (6) avoidance of stereotypes and cultural biases (SAMHSA, 2014b; 2023). To implement these principles, a trauma-informed system must include four fundamental characteristics: (1) awareness of the broad impact of trauma; (2) the ability to identify signs of trauma; (3) the existence of policy decisions, procedures, and work methods for response when signs of trauma are identified; (4) measures to prevent re-traumatization in the work environment.

There are many sources that describe how to implement a trauma-informed approach at the organizational and systemic level (for example, Air, 2016; CCTIC, 2009; Trauma Informed Oregon, 2018; TSI, 2019), and they share a number of themes and processes. The first stage is an organizational assessment and preliminary planning in implementing the approach. It is important to integrate organizational assessment procedures at an early stage of the process aiming to identify needs and assess preparedness with the goal of identifying openings and barriers to the process and to respond appropriately. To this end, the following actions are called for: the formation of an assessment team; the encouragement of organizational preparedness; the identification and promotion of cross-system collaboration; the selection of the appropriate assessment tools and methods of data collection and analysis; and the formulation of the assessment plan. After assessing organizational readiness and capacity to implement the approach, it is possible to move on to the implementation phase itself, which requires that measures be taken in various areas of organizational action (SAMHSA, 2023).

1. Organizational leadership. People with experience in dealing with trauma should be integrated into leadership roles; it is important to build trust between employees and management and to encourage transparency in the communication between them.
2. Workforce training and development. It is essential to identify capabilities and encourage ongoing training processes in order to impart trauma-informed skills and to prevent burnout and secondary traumatization.
3. Inter-sectoral collaboration. It is important to connect and coordinate among all services provided by organizations and service providers that affect the health and well-being of the staff and service recipients. For example, by creating a support network composed of various service providers.
4. Funding. It is important to ensure there are appropriate and sustainable funding sources for the implementation process.
5. Physical environment. The organization’s location and work environment should support the physical and mental security of the staff and service users. It is important to obtain feedback from individuals with lived-trauma experience with regard to opportunities for improving the environment.
6. Involvement and partnership of all stakeholders. The involvement of professionals and people with lived-trauma experience at all levels of the organization is crucial for the success of the implementation process.
7. Surveying, assessing, and treating trauma. A universal screening procedure to identify exposure to trauma should be offered to all employees and service users; an in-depth assessment of the impact of trauma should be conducted among those who are identified as being exposed to it; and professional, accessible, and culturally appropriate treatment services should be offered to those in need.
8. Monitoring progress and quality assurance. Implementation is an ongoing process that impacts the professional knowledge, personal attitudes, and skills of the organization’s members. Therefore, it is important to monitor indicators that reflect the process impact on the organization and to carry out quality improvement processes as needed.
9. Evaluation. It is important that the organization evaluate the implementation of the approach initially and long term, that it learn from its successes, and that it replicate them in order to ensure the sustainability of the process.
10. Organizational policy. A policy that includes integrating a trauma-informed approach within the organization’s operational processes, by-laws, and vision should be formulated. Such a policy is crucial to maintaining the process and to its sustainability, even in the event of organizational changes that may occur later on.

The adoption of the ISO standard by organizations

ISO-45003 is an international standard for the management of an organization’s psychosocial risks; its implementation requires action on several levels. At the planning level, the organization needs to develop a procedure for employees’ psychological health and well-being, in which it defines objectives for employee health and well-being, and outlines a strategy for achieving them. This procedure demonstrates the organization’s commitment to the continuous improvement of employee safety. It should consider the specific context of the organization, its capabilities, its area of activity, its employees’ needs, etc. At the identification level, the organization should act to identify risk factors using a variety of methods (observation, questionnaires, interviews, literature reviews, etc.).

At the prevention level, actions can be taken on three different sublevels in order to reduce adverse effects on employees. At the primary sublevel, organizational measures to embed work methods for reducing risk can be implemented: ensuring rest, proper work distribution, cooperative relations with management, bureaucracy reduction, the provision of appropriate equipment, the creation of a safe organizational climate, etc. At the secondary sublevel, the amount of resources allocated to employees to deal with risk factors can be increased and awareness of these risk factors can be promoted. This can be accomplished by, for example, providing information about risks and rights and conducting training to identify warning signs and teach coping methods. At the tertiary sublevel, affected employees should be identified and provided with an appropriate response and should receive support in their rehabilitation.

At the monitoring and control level, the organization should act to detect problematic areas that require organizational intervention early on and to identify affected employees. Monitoring activity should be conducted according to various indicators that can detect a problem at the level of an individual employee’s performance or at the level of team or department performance, such as a decrease in output, absences, an increase in mistakes, and negative behavioral change.[14]

Implementing the recommendations of the National Council for Post-Trauma in order to reduce distress in intervention teams

The National Council for Post-Trauma was established in 2021 by the then Director General of the Ministry of Health and includes prominent professionals and figures in the field of post-trauma treatment. Since then, the Council has been working to establish guidelines for the prevention of post-trauma and the treatment of those affected by it.[15] Following the events of October 7th, the Council published a series of recommendations to protect first responders. These recommendations include the creation of clear and accessible guidelines that can be implemented during disaster events and in situations of ongoing stress to reduce the effects of trauma exposure and allow all first responders to continue functioning.

These recommendations can be divided into two main categories. The first is health at work and the self-care of staff dealing with an overburdened workload. It is important for the staff to look after their own basic needs and to eat and sleep regularly, to whatever extent possible. Breaks and rest are important tools for self-care. It is important to rest when providing care for others and to dedicate some time to family and leisure activities like sports or hobbies. It is not advisable to deal with difficulties alone, and it is important to share and consult with peers. Other important recommendations are to maintain boundaries and avoid over-identification in the therapeutic encounter and to set appropriate boundaries on work demands. It is advisable to remind oneself of the importance of helping others, to find meaning in the work, and to identify signs of burnout and compassion fatigue in oneself and in others (Ministry of Health, 2023).

The second category of recommendations concerns the functioning of the healthcare professional teams. It is recommended that there be regular staff meetings (at least once a week) for the purpose of comparing notes and sharing experiences. In planning the staff’s work structure, it is recommended to incorporate guidance and counseling. Professionals who do not treat trauma victims directly are less exposed to the trauma and can help staff members relate to their experiences, maintain psychological distance from the events, and continue to interact with patients. It is important for staff members to look after one another, identify signs of burnout in themselves and others, provide support for each other, and engage in team-building activities. At the end of a shift, it is recommended that a brief meeting be held in order to share difficulties, as well as positive experiences. Team leaders have a significant impact on their team’s functioning, and it is important that they act to maintain the team’s cohesion, allocate work appropriately, monitor the difficulties encountered, and provide appropriate responses (Ministry of Health, 2023).

 Conclusion

The State of Israel has experienced numerous traumas since its establishment. Healthcare professionals In the medical and para-medical spaces, the emergency services, the welfare system, the education system, and others are exposed to trauma in every therapeutic interaction with individuals who have experienced it.

The events of October 7th added another layer of trauma to the experiences of healthcare professionals and all those working in these spaces, leading to encounters in which they shared the same traumatic reality as the direct victims. Both the collective trauma and the personal trauma are present in these spaces, but the role of the professional is to contain the trauma of the victim while the victims are there simply to be heard and embraced. The need to be a witness, to treat wounds and injuries while listening, and to absorb the unthinkable outcomes of human evil require personal and professional resilience. The therapeutic work environment cannot rely solely on individual personal resilience, since the strength to absorb such trauma may have its limits. At some point, the trauma may be so great that it cannot be absorbed. Thus, professionals from various fields report that their experiences, emotions, behaviors, and ways of thinking merge with those of the victims suffering from post-trauma — they are likely suffering from vicarious traumatization.

To prevent such situations, organizations employing healthcare professionals of all types need to create trauma-informed spaces that will contain the difficulties of their workers and will offer them emotional and psychological support, while encouraging the processing of encounters with trauma by means such as peer groups and group and individual guidance and support, so that workers do not feel alone in their distress. It is important for organizations to recognize the importance of supporting staff and that they make this a structured part of their work, one that takes place once a week or more in clearly defined frameworks (individual, group, etc.). This guidance and support contributes to the development and preservation of the healthcare professionals’ reflective capacity, which allows them to process the experiences, attitudes, and insights in their work and encounters with patients, clients, and peers. The management and human resource professionals in the organization must embed an organizational climate of sharing and mutual support among staff members who experience various types of challenges. Moreover, it is important for the organization to maintain hope among its staff members and service users with respect to the therapeutic process. Hope allows both patients and professionals to grow from exposure to trauma and emphasizes the strength and significance of the therapeutic process while strengthening the therapist’s sense of mission. Changing the organizational culture is important in order to reduce the risk of such phenomena as compassion fatigue, vicarious traumatization, moral distress, and burnout.

In planning systemic change, the knowledge accumulated in various fields and professions regarding the maintenance of worker health and well-being should be considered. It is important to recognize the existing knowledge in each field, to utilize existing platforms in order to avoid duplication and wasted resources, and to create a unified, common language. The involvement and commitment of management to systemic change are crucial for its success. Without continuous administrative attention, the proposed solutions will only provide a temporary response; in the long term, the health and well-being of the staff will be neglected and in the next crisis, they will again be vulnerable and exposed.

In light of the events of October 7th and their impact on the healthcare professionals, a systemic process of rebuilding and planning is needed to improve the existing infrastructure that supports therapists, with the goal of achieving an even better situation than that which existed prior to October 7th. In the short and medium term, planning needs to address the healthcare professionals’ experiences after October 7th, and in the long term, its goal should be to prevent or minimize the adverse effects on care providers both during crises and in normal times.

It is important to understand the relationship between operating during routine periods and operating during an emergency. Without addressing the issue of trauma during periods of calm, an adequate response to the needs of the healthcare professionals in an emergency cannot be ensured. To provide an appropriate response, processes for dealing with the everyday trauma experienced by them need to be put in place routinely. These processes will also serve as the basis for the response during times of emergency and crisis. Furthermore, it is important to address the structural component of a comprehensive implementation of organizational change and to deal with the system’s additional demands, including appropriate budgeting for the execution of organizational change and for ensuring standards and manpower sufficient to do the job, as well as a balanced distribution of the workload. At the same time, it is crucial to ensure that the process does not deepen the gaps in treatment and organizational capabilities that exist across fields and geographical areas. In the distribution of resources, the varying needs and capabilities of each area and each profession should be considered, to prevent investment in specific professions and areas while neglecting others. This change needs to be made from a holistic viewpoint of worker health and well-being, one that recognizes the tight connection between their health and their environment as well as the obligation to consider worker health when designing an organizational culture and work environment.

References

English

American Institutes for Research (AIR) (2016). AIR’s Framework for Building Trauma-Informed Organizations and Systems.

APA Dictionary of Psychology (2018). Burnout.

APA Dictionary of Psychology (2022). Resilience.

APA Dictionary of Psychology (2023). Posttraumatic stress disorder (PTSD).

Arnold, D., Calhoun, L., Tedeschi, R., & Cann, A. (2005). Vicarious posttraumatic growth in psychotherapists. Journal of Humanistic Psychology, 45(2), 239–263.

Avraham, N., Goldblatt, H., & Yafe, E. (2014). Paramedics’ experiences and coping strategies when encountering critical incidents. Qualitative Health Research, 24(2), 194–208.

Barrington, A. J., & Shakespeare-Finch, J. (2014).Giving voice to service providers who work with survivors of torture and trauma. Qualitative Health Research, 24(12), 1686–1699.

Baum, N. (2014). Professionals’ double exposure in the shared traumatic reality of wartime: Contributions to professional growth and stress. British Journal of Social Work, 44(8), 2113–2134.

Brower, K. J., Brazeau, C. M. L. R., Kiely, S. C., Lawrence, E. C., Farley, H., Berliner, J. I., Bird, S. B., Ripp, J., & Shanafelt, T. (2021). The evolving role of the chief wellness officer in the management of crises by health care systems: Lessons from the Covid-19 pandemic. NEJM Catalyst Innovations in Care Delivery, 2(5).

Cleary, M., Kornhaber, R., Thapa, D. K., West, S., & Visentin, D. (2018). The effectiveness of interventions to improve resilience among health professionals: A systematic review. Nurse education today, 71, 247–263.

Clouston, S. A. P, Kotov, R., Pietrzak, R. H., Luft, B. J., Gonzalez, A., Richards, M., Ruggero, C. J., Spiro, A. III, & Bromet, E. J. (2016). Cognitive impairment among World Trade Center responders: Long-term implications of re-experiencing the 9/11 terrorist attacks. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring, 4, 67–75.

Creating Cultures of Trauma-Informed Care (CCTIC) (2009). A self-assessment and planning protocol.

David, P. (2022). Teaching professionals about trauma-informed practice for children and their families: A toolkit for practitioners. International Journal on Child Maltreatment: Research, Policy and Practice. Advance online publication.

Diab, O., DePierro, J., Cancelmo, L., Schaffer, J., Schechter, C., Dasaro, C. R., Todd, A., Crane, M., Udasin, I., Harrison, D., Moline, J., Luft, B., Southwick, S. M., Feder, A., & Pietrzak, R. H. (2020). Mental healthcare needs in World Trade Center responders: Results from a large, population-based health monitoring cohort. Administration and Policy in Mental Health and Mental Health Services Research, 47(3), 427–434.

Figley, C. R. (Ed.) (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner/Mazel.

Figley, C.R. (1998). Burnout in families: The systemic costs of caring. CRC Press

Figley C. R. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self-care. Journal of Clinical Psychology, 58(11), 1433–1441.

Fink-Samnick, E. (2022). Collective occupational trauma, health care quality, and trauma-informed leadership: Intersections and implications. Professional Case Management, 27(3), 107–123.

Fox, J. (2006). “Notice how you feel:” An alternative to detached concern among hospice volunteers. Qualitative Health Research, 16(7), 944–961.

Gabay, G., Naamati-Schneider, L., & Pikkel, D. (2022). Cultivating psychological resilience of Israeli medical directors of COVID-19 Divisions: The dynamic spheres of salutogenics. Frontiers in Public Health, 10(801297).

Goldblatt, H., Freund, A., Drach-Zahavy, A., Enosh, G., Peterfreund, I., & Edlis, N. (2020). Providing health care in the shadow of violence: Does emotion regulation vary among hospital workers from different professions? Journal of Interpersonal Violence, 35(9‒10), 1908–1933.

Granek, L., Mazzotta, P., Tozer, R., & Krzyzanowska, M. K. (2013). Oncologists’ protocol and coping strategies in dealing with patient loss. Death Studies, 37(10), 937–952.

Gutman, M. A., Yavelberg, Y., Rabivo, G., Wellner, G., Van Essen, Y. E., Koren, M., Kenett, R., Rom, I., Shchory, N., Shiri, M., Tamir, G. (2024). Home: Milestones in shaping a policy for the return of residents to their homes at the end of the war. Samuel Neaman Institute for National Policy Research. (English abstract)

Haugen, P. T., McCrillis, A. M., Smid, G. E., & Nijdam, M. J. (2017). Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis. Journal of Psychiatric Research, 94, 218–229.

Herman, J. L., (1992). Trauma and recovery. Basic Books/Hachette Book Group.

Hernández, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family Process, 46(2), 229–241.‏

Hernandez-Wolfe, P., Killian, K., Engstrom, D., & Gangsei, D. (2015). Vicarious resilience, vicarious trauma, and awareness of equity in trauma work. Journal of Humanistic Psychology, 55(2), 153–172.

Hirschberger, G. (2018). Collective trauma and the social construction of meaning. Frontiers in Psychology, 9, 1441.

Hunsaker, S., Chen, H. C., Maughan, D., & Heaston, S. (2015). Factors that influence the development of compassion fatigue, burnout, and compassion satisfaction in emergency department nurses. Journal of Nursing Scholarship, 7(2), 186–194.

Jameton, A. (1984). Nursing practice: The ethical issues. Prentice Hall.

Jameton, A. (2013). A reflection on moral distress in nursing together with a current application of the concept. Journal of Bioethical Inquiry, 10(3), 297–308.

Joyce, S., Shand, F., Tighe, J., Laurent, S. J., Bryant, R. A., & Harvey, S. B. (2018). Road to resilience: A systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open, 8(6), 1–9.

Keni-Paz, C., & Cohen, E. (2021). Moral development in young children exposed to domestic violence: The case for the proactive role of the therapist. Journal of Infant, Child & Adolescent Psychotherapy, 20(4), 425–438.

Krontal, S. (2019). Balint infrastructure in a large tertiary hospital In Israel [Paper presentation]. 21st International Balint Congress, Portugal.

Levi, O. (2013). Individual therapy via the phenomenon of hope for treating chronic and complex PTSD. Psychoanalytic Social Work, 20, 150‒175.

Levy, M. (2023, 11 December). Who is treating the national trauma? How many psychologist and psychiatrists are there in Israel? Shomrim, The Center for Media and Democracy.

Lytle, T. (March 15, 2023). How to create a trauma-informed workplace: In the aftermath of a violent incident or sudden death in the workplace, HR professionals can help employees heal. SHRM.

McCann, I. L., & Pearlman, L. A. (1990).Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149.

Melnyk, B. M., Kelly, S. A., Stephens, J., Dhakal, K., McGovern, C., Tucker, S., Hoying, J., McRae, K., Ault, S., Spurlock, E., & Bird, S. B. (2020). Interventions to improve mental health, well-being, physical health, and lifestyle behaviors in physicians and nurses: A systematic review. American Journal of Health Promotion, 34(8), 929–941.

Menzies I.E.P. (1960). A case-study in the functioning of social systems as a defence against anxiety: A report on a study of the nursing service of a general hospital. Human Relations, 13(2), 95–121.

Missouri Trauma Roundtable through the Department of Mental Health (2017). Policy guidance for trauma informed human resources practices.

Neff, K. D. (2003). Self-compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and identity, 2(2), 85–101.‏

Roberts, M. (2012). Balint groups: A tool for personal and professional resilience. Canadian Family Physician, 58(3), 245–247.

Rosenblum, S. (2024, 7 January). ‘Unbelievable number of amputated organs,’ nurse haunted by October 7 horrors. Ynetnews.

Saakvitne, K. W. (2002). Shared trauma: The therapist’s increased vulnerability. Psychoanalytic Dialogues, 12(3), 443–449.

Sacco, T. L., Ciurzynski, S. M., Harvey, M. E., & Ingersoll, G. L. (2015).Compassion satisfaction and compassion fatigue among critical care nurses. Critical Care Nurse, 35(4), 32–43.

Shalita, C. (2024, 1 February). The physicians of October 7: ‘One day, we’ll all break down. Now is not the time.’ Shomrim, The Center for Media and Democracy.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2014a). Trauma-informed care in behavioral health services (Treatment Improvement Protocol (TIP), Series 57. HHS Publication No. (SMA) 13-4801).

Substance Abuse and Mental Health Services Administration (SAMHSA). (2014b). SAMHSA’s concept of trauma and guidance for a trauma-informed approach (HHS Publication No. (SMA) 14-4884).  

Substance Abuse and Mental Health Services Administration (SAMHSA). (2023).  Practical guide for implementing a trauma-informed approach (SAMHSA Publication No. PEP23-06-05-005).

Time.News (2023, 20 December). The NIS 2 billion dilemma: how to restore the mental health system after years of neglect. Times.News.

Trauma Informed Oregon (2018). Roadmap to trauma informed care.

Traumatic Stress Institute (TSI) (2019). Whole-system change model to trauma-informed care.

Trotzky, D., Aizik, U., Mosery, J., Carady, N., Tavori, G., Cohen, A., Pachys, G., Avraham, M., Levtzion-Korach, O., & Tal, O. (2023).Resilience of hospital staff facing COVID-19 pandemic: Lessons from Israel. Frontiers in public health, 11, 1050261.

U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start, National Center on Parent, Family, and Community Engagement. (2020). Understanding trauma and healing in adults: Brief 2: Caring for ourselves as we care for others.

Walia, S., Nordenholz, K. E., Krywko, D., Norvell, J. G., Hewitt, K. V., Parmele, K. T., Levin, R. M., Kennedy, J., & Manfredi, R. A. (2024).The chief wellness officer: A long overdue catalyst for systemic change in emergency medicine. The International Journal of Health Planning and Management, 39(1), 141–151.

Wright, B., & Richmond Mynett, J. (2019). Training medical students to manage difficult circumstances- a curriculum for resilience and resourcefulness? BMC Medical Education, 19, 280.

Yamin, D., Lev-Ari, S., Mofaz, M., Elias, R., Spiegel, D., Yechezkel, M., Brandeau, M., Shmueli, E. (2023). Risk and early signs of PTSD in people indirectly exposed to October 7 events. Research paper. Tel Aviv University. (Research review)

Hebrew

Doctors Only (2024, 3 January). Hospital administration has a direct link to burnout of senior physicians. DoctorsOnly.

Doctors Only (2024, 7 February). The physicians union demands recognition of psychiatry as a profession in distress. DoctorsOnly.

Efrati, I. (2024, 4 February). The children arrived directly after being pulled from underground. It was like a punch to the stomach. Haaretz.

Gil-Ad, H., & Yanko, I. (2023, 19 October). Ministry of Health demand: Induct thousands of psychologists in an emergency program. Ynet.

Greenwald, N., & Lavie, T. (2023). The significance of therapeutic work under conditions of extreme trauma. In N. Greenwald (Ed.), A guide to therapeutic intervention with children, youth, and their families in cases of complex shared and long-term trauma (pp. 5‒11). The Center for Psychological Services Sha’ar Hanegev and NATAL.

Itzhaky, H., Weiss-Dagan, S., & Ben-Porat, A. (2017). Does effective supervision help in dealing with secondary trauma among social workers working with youth and families? The Journal of Society and Welfare, 37(3), 475‒490.

Keni-Paz, S. (2022). Trauma-informed workplaces: Guidelines for creating a safe base for care providers and recipients. Meeting Place, 23, 22‒29.

Linder, R. (2024, 12 January). Mass casualty exercises stop at 80 injured which is considered an exaggeration — here there were nearly 700. TheMarker.

Ministry of Health (2023). Lessening distress among intervention staff — the National Council on Post Trauma.

National Health Council (2023). The National Post Trauma Council: Recommendations to the Council 2023. Ministry of Health.

Rosenthal, G., Tsuk, R., Hadas, H., & Tessler-Lazovik, S. (2023). The economics of mental healthcare in Israel: Status, international comparison, optimal size and composition, challenges, and recommendations. Position Paper. Coalition of Mental Health Organizations.

Vaizberg, M. (2024, 2 February). Medical staff on the edge: “It is difficult to face the sight of the wounded.” Globes.

Yanko, A. (2023, 13 December). An agreement has been reached: Grants of tens of thousands of shekels for psychologists in public service. Ynet.

Yerushalmi, H. (2012). Supervision as a space for mutual influence. Hebrew Psychology.

Zeevi Sela, H. (2017). A supervision model for dealing with vicarious trauma: from stress to personal resilience. The Journal of Society and Welfare, 37(3), 451‒474.

 * Natan Lev, Guest Researcher, Taub Center; doctoral student, School of Public Health, Ben-Gurion University of the Negev. Yifat Ben David-Dror, MSW; Director general, ISST; Co-Chair, Forum for Promoting a Trauma-Informed Health System; Director, intensive hospitalization and Ogen center for day treatment for sexual trauma victims, the medical center for mental health, Lev HaSharon. Hadass Goldblatt, Professor Emeritus and social worker, Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa.  Dr. Daphna Bardin Armon, psychiatrist; Director of “My Way” A short term inpatient ward treating Complex Trauma, Merhavim Be’er Ya’akov; Co-Chair, Forum for Promoting a Trauma-Informed Health System. Shai Krontal, family medicine specialist and psychotherapist; Chair, Israeli Balint Association, Department of Family Medicine, Faculty of Medicine and Health Sciences, Tel Aviv University. Guy Tavori, social worker; Chair, Shlomot Association, Tel Aviv University and Ichilov Hospital. Prof. Nadav Davidovitch, Principal Researcher and Chair, Taub Center Health Policy Program; Director, School of Public Health, Ben-Gurion University of the Negev.

This document is about coping with the effects of exposure to trauma among caregiving teams in general, rather than just the current situation. The current war is presented as a key case study for addressing the issue.

[1] From: Woman – Girl, Man – Woman and Other Poems, self-published, 2020, p. 86. [Hebrew]

[2] According to the PCL-5 questionnaire.

[3] The media reported many examples of such tensions which made the work of therapists more difficult. See for example, Doctors Only, January 3, 2024; Doctors Only, February 7, 2024; Eisenbruch, 2023; Gil-Ad & Yanko, 2023; Yanko, 2023.

[4] Multiple reports from therapists have appeared in the media regarding the events of October 7th. They illustrate the intensity of the horrors they were exposed to and the difficulties they dealt with. See, for example, Efrati, 2024; Linder, 2024; Rosenblum, 2024; Shalita, 2024; Vaizberg, 2024.

[5] Symptoms resulting from exposure to an event experienced as life-threatening or endangering the physical safety of oneself or others. Typical symptoms include reliving the traumatic event, avoiding actions and places reminiscent of the traumatic event, lack of interest in meaningful routine activities, avoidance of such activities, and heightened psychological arousal (APA, 2023).

[6] For further details about the trauma-informed approach, see “Implementing a trauma-informed approach in disciplines and organizations” in the section “Implementation: Policy proposals and organizational changes.”

.

[7] See the operating plan of the Substance Abuse and Mental Health Services Administration (SAMHSA): National Strategy for Trauma-Informed Care Operating Plan.

[8] As a result of this process, the Cambridge Police Department published a guide containing information about the project, its implementation, its evaluation and the lessons learned. See Guide for a Trauma-Informed Law Enforcement Initiative.

[9] See the Edutopia site, Fall Hamilton Elementary.

[10] See the site of the Israel Institute for Occupational Health and Hygiene, https://www.osh.org.il/eng/Main/

[11] See the company’s site – A Security Solution Provider Driven by Innovation, ICTS UK.

[12] See the site of the Tel Aviv Yaffo Academic College, https://www.mifrasim.mta.ac.il/new-courses/training-program [Hebrew]

[13] For details on the training of the Chief Wellness Officer, see WellPhD | Stanford Medicine.

[14] See the site of the Israel Institute for Occupational Health and Hygiene, Guide for the Management of Psychological Risk in the Workplace. [Hebrew]

[15] See the site of the Ministry of Health, First Conference of the National Council on Post Trauma in the Ministry of Health.