Therapists in Wartime: Holding Others' Trauma While Contending With Your Own

ABSTRACT

Objective

This study explores the experience of Israeli therapists who both worked with clients in emergency interventions during the third week following the Hamas attack on Israel on October 7, 2023, and were themselves exposed, to one extent or another, to the terrifying events.

Method

Open‐ended questionnaires were completed by 201 therapists during the third week following October 7. Using thematic analysis, therapists' reports of the themes their clients raised in therapeutic sessions were compared with their reports of the hardships they themselves experienced as individuals and professionals during the same period. Drawing on the concept of shared traumatic reality, the study considers how close the themes are, and how challenging it is to cope concurrently with a traumatic reality that is experienced both directly and indirectly.

Results

Seven main categories emerged from the responses to questions about both their clients and themselves: (1) uncertainty and worries about the near and more distant future; (2) overwhelming emotions; (3) physical sensations; (4) shattered meaning and loss of trust; (5) lack of routine; (6) self‐preservation; and (7) shared trauma.

Conclusions

The findings shed light on early reactions to a shared traumatic reality in the period closely following the trauma itself, indicating that professionals find it hard to differentiate between the personal, professional, and national levels when exposed to a large‐scale traumatic event they share with their clients.

1. Introduction

The events of Saturday, October 7, 2023 will forever be remembered in Israel, and perhaps throughout the world, as one of the most heinous terror attacks in history. On that morning, thousands of Hamas terrorists from Gaza invaded rural communities and towns on Israel's southern border, and the Nova music festival, slaughtering, brutalizing, and raping the women, men, children and babies, destroying their homes and setting them on fire, and taking hostages. At the same time, rockets were fired at nearly the whole of the country (Levi‐Belz et al. ²⁰²⁴; Ministry of Foreign Affairs, ²⁰²³). The depravity of the massacre and atrocities perpetrated during the attack, which has been compared to 9/11, brought back memories of the Holocaust for many Jews around the world, an historical event in which six million Jews found their deaths by the Nazis and has threatened the continuity of the Jewish people. All three events share the common theme of an existential threat not only on a personal level, but also on a collective‐national level, arousing death anxiety and existential terror both in those directly exposed to the threat and in their society as a whole (Oreg and Taubman–Ben‐Ari ²⁰²⁴).

But, one feature which was only occurring in the current events and not in previous ones, enourmasly empowering its effect was the availability of WhatsApp messages and the live‐filmed material from cameras situated in the places where the events took place, as well as Go‐Pro cameras that the Hamas terrorists carried on them. This made the exposure to the sights and sounds vivid and horrific, even if one tried to minimize the exposure to the media.

These events of October 7 did not end on that day. They only opened the door for a continuous dreadful reality, in which hundreds of thousands of people were evacuated from their homes which were repeatedly bombed by Hamas and Hezbollah, all of Israelis experienced heightened threats and uncertainty regarding the possibility of breakout of a greater war, and the emergency recruitment of the large draft of reserve soldiers, whose deaths in buttle added to the general shock and grieving.

Though deeply affected themselves, therapists and other health care professionals volunteered almost immediately to assist, in any way possible, the individuals, families, and communities who directly experienced the terror, including people who were still uncertain whether their loved ones had been murdered or were being held hostage in Gaza, those who were injured in the attack, those whose homes had been destroyed and were forced to relocate without any prior preparation, and young men and women who were attacked at a rave in the desert and who watched their friends being slaughtered and raped (Elyoseph et al. 2023). In addition, therapists who continued their routine work now faced the profound challenges of responding to individuals, families, and groups who were either uniquely affected by the enormity of the catastrophe or for whom the shock and horror aroused previous traumas along with their current fears. All of them had to function as professionals serving their clients while simultaneously suffering the same collective trauma.

The compounded experience of working in the midst of unfolding trauma and incalculable loss while being exposed to the impact of clients' experiences of this reality imposed a significant burden on therapists. In essence, both therapists and clients were survivors of the same event (Figley 2012). The empathic engagement with clients' traumatic material and its transforming effect on the inner experience and worldview of both parties (Pearlman and Saakvitne 1995) was only one side of the equation. At the same time, clinicians had to find a new language and conceptual framework to contain the experience of living and working under conditions of terrorism, a reality they shared with clients, as described previously in respect to large‐scale terror attacks such as 9/11 (Miller 2003).

These circumstances have been termed “shared traumatic reality” and therapists' responses to them is termed “shared trauma” (often regarded as a type of secondary trauma), and is a unique experience. It is defined as “the affective, behavioral, cognitive, spiritual, and multimodal responses that mental health professionals experience as a result of primary and secondary exposure to the same collective trauma as their clients” (Figley 2012, p. 624). While the trauma itself is considered “collective” in that many people, including clients and therapists, all experience the same event, shared trauma relates specifically to the responses of the clinician that stem from the collective trauma (Stahnke and Firestone 2024).

Previous investigations of shared trauma focus mainly on therapists' reactions to the event and contributing factors (e.g., Freedman and Tuval Mashiach ²⁰¹⁸). These studies reveal that past trauma and being more closely exposed to direct victims of the current trauma contribute to therapists' own trauma symptoms (Bauwens and Tosone 2014; Boscarino, Figley, and Adams ²⁰⁰⁴; Eidelson, D'Alessio, and Eidelson ²⁰⁰³). It has also been found that training and prior exposure can prepare therapists for future exposure (Krennerich, Haiyasoso, and Flasch ²⁰²¹). Furthermore, one study indicated that during the COVID‐19 pandemic, the rate of PTSD symptomology was similar in social workers and in the population at large (Holmes et al. 2021).

No previous studies, however, have investigated the similarity of the reactions of therapists and clients in a shared traumatic reality. The current study attempts to fill this gap by exploring the way in which Israeli therapists describe the central themes raised by their clients about 3 weeks immediately following October 7, and their own difficulties during the same period. Our intent was to compare the responses of others (clients) and self (therapist) without asking the participants to relate to this issue directly. By giving voice to the therapists' experiences as individuals in a traumatic reality and as professionals serving their clients' needs, we sought to gain new insights that would lead to a deeper understanding of shared trauma, both clinically and empirically.

2. The Current Study

The study is based on responses to an open‐ended questionnaire constructed specifically for the purpose of this investigation. The questionnaire was completed during the second and third weeks following the surprise terrorist attack on Israel on October 7, 2023. Thematic analysis was performed on the data in an effort to explain the parallel experiences of therapists and their clients in response to the trauma.

3. Method

3.1. Participants and Procedure

Approval for the study was granted by the Bar Ilan University School of Social Work Review Board. The sample consisted of Israeli mental health professionals who were recruited by means of a request posted on social media groups and forums for therapists (social workers, psychologists, psychiatrists, psychoanalysts, and art therapists) asking them to participate in the study, and including an electronic link to the questionnaire. Those who responded were asked to distribute the questionnaire to their colleagues as well. The final sample consisted of 201 therapists. Of these, 175 (87%) were women and 26 (13%) were men. Age ranged from 24 to 80, and years of professional experience from 5 to 54 (M = 19.39, SD = 11.05). In terms of family status, 8% were single, 82.6% were married or in a stable couple relationship, and the rest were divorced or widowed, and 83% had children, with the youngest being 12.6 years of age on average (SD = 9.2), and the oldest being 18.6 years of age on average (SD = 10.4). In regard to profession, 49.3% were social workers, 14.4% art therapists, 12.4% psychologists, 11.4% psychotherapists, 10.4% psychoanalysts, and 2% psychiatrists. Nineteen participants (9.5%) reported having been directly exposed to the events of October 7; of these, 4 (2%) were injured. Fifty‐three (26%) stated that one or more of their relatives was injured, murdered, or abducted. Forty‐eight of the respondents (24%) were maintaining their regular work schedule, 33 (16%) were devoting all their time to volunteering for emergency interventions, 99 (50%) were both continuing their routine work and volunteering, and 4 (2%) were not working at all during this period.

3.2. Instrument

The questionnaire consisted of several sociodemographic items followed by five open‐ended questions, two of which were analyzed for the purposes of the study:

• 1.Since October 7, what has been most difficult for you?
• 2.What were the main themes raised by clients in the emergency interventions you conducted?

3.3. Data Analysis

Thematic analysis was performed on the two open‐ended questions to identify, analyze, and report patterns (themes) in the data, using a “bottom up” approach while linking identified themes to the data (Braun and Clarke 2006). The analysis was performed by all authors (two psychologists and a psychoanalyst). Following Braun and Clarke (2006), the three researchers first became familiar with the data, reading and rereading the text of each response separately, and noting down preliminary ideas. They then independently generated initial codes and coded features of the data in a systematic fashion for each question, collating data relevant to each code. In the third phase of the analysis, the codes were collated into potential themes, and the researchers reviewed the themes and generated a thematic “map” of the data. Next, the themes were defined and named, refining the specifics so that they tell a clear story. Finally, the researchers formulated a comprehensive framework for all the themes that led to the definition of the core categories to better understand the similarities and differences between the therapists' experiences and those of their clients. The process of researcher reflectivity is an essential element of qualitative inquiry, and it is highly valuable to acknowledge potential biases (Creswell 2013). Thus, we identify ourselves as Israeli Jewish women researchers: a clinical psychologist, a psychoanalyst, and a research psychologist. In light of this, the researchers met regularly to discuss their coding and themes; discrepancies were resolved through discussion and refinement of the coding frame, which entailed developing new codes and clarifying existing ones for the final definition of the themes. Thus, agreement was reached between the researchers with regard to all coding and themes. As the similarity between the themes that emerged for the two questions became clear, it was decided to present them side by side under the same categories and themes.

Note: (1) We report how we determined our sample size (N/A), all data exclusions (N/A), all manipulations (N/A), and all measures in the study. (2) Data Availability: The datasets generated during the current study are available from the corresponding author upon reasonable request.

4. Results

The thematic analysis revealed that the same six main categories emerged from the therapists' descriptions of their own experience and their reports of their clients' concerns. In some cases, the participants related directly to the traumatic reality they share with their clients and the way it influences their professional conduct, producing a seventh category that appeared only in the list of their own difficulties. Most of the therapists, however, simply reported their feelings, thoughts, and perceptions, without conscious reference to the similarities between themselves and their clients.

4.1. Category 1: Uncertainty and Worries About the Near and More Distant Future

If the unthinkable happened, anything can happen.

This category contains a variety of comments relating to the uncertainty of the current situation and the multiple worries about the future, whether the rest of the day, the coming few days, or the more distant future, on both the personal and national levels. These issues were raised by clients in therapeutic sessions, as well as reported in response to the question of the therapists' own difficulties at the moment. The category contained six sub‐themes.

4.1.1. Uncertainty and a Sense of Ambiguity

Clients referred to their difficulty comprehending the inconceivable attack and its large scale. They spoke of the world as we know it having been shaken, the upsetting of their reality, and the inability to plan ahead.

Uncertainty. When will it end? How long will it take? What will we do? What's going to happen?

Yearning for the familiar and stability.

Fear of rocket attacks, uncertainty about the future, returning to their home in the South.

What if this is the end? Is this how I'm going to live out the rest of my life?

The therapists described their own difficulties in similar terms.

If the unthinkable happened, anything can happen.

Lack of stability and clarity; a sense of innumerable changes and helplessness.

The unknown. The difficulty of planning for the long‐term.

It's very hard for me that it's going to take a long time, that everything is uncertain, and mainly that I don't have any way to guarantee my children “never again,” because they hit us hard.

The similarity of the descriptions indicates how closely the experiences of the therapists and their clients resembled each other, representing the shared traumatic reality with which they were both coping.

4.1.2. Concern for Family Members

Another issue raised by clients was their concern for family members, whether because of the frightening situation and the sense of being unsafe in general, or because their partners, children, or relatives were soldiers at the front.

Fear for the mental health of their children.

The difficulties of parents to be a holding environment for their children at this time.

Children's unwillingness to be apart from their parents (such as sleeping in their own room); parents' apprehensions about leaving the house for work or errands.

The worsening of existing difficulties in the couple relationship, parenting, or being alone.

Here again, the therapists described their own difficulties in a similar way.

Concern for the fate of my family and myself.

Fear for my own children and the need to protect them as opposed to the need to be there for other people.

The fact that my children are experiencing such terrible feelings and secondary trauma from helping others or the ongoing war.

The hardest thing for me is the fear for my husband and nephew who are at the front. I'm pregnant with my first child and I feel alone and filled with anxiety that something terrible will happen to my husband.

4.1.3. Financial Worries

Clients also related to financial concerns created by the war. They were worried about not being able to meet their obligations and support themselves because of the loss of a steady income.

Existential fears and anxieties about basic needs, such as clothes, food, and medicines.

Financial difficulties because they weren't working and weren't getting a salary; debts they wouldn't be able to pay.

The need for practical help with clothes, food, etc.

This, too, was echoed in the therapists' descriptions of their own difficulties.

Loss of income.

Fear of an all‐out war that would lead to danger to life, loss of family, and financial losses.

I'm earning less and have less financial security.

4.1.4. Concerns About Life in Israel in General and on the Gaza Border in Particular

The therapists reported that their clients were worried about future life in Israel, and particularly near the border with Gaza, due to the feeling that nothing would ever be the same, that the war was going to be a long one, and that the country had changed since the horrific event and the collective trauma. The terror they had experienced during the attack and the difficulty of contending with the losses, the hostages, and the missing, along with not knowing if and when they would return to their homes and what their future and that of the country would be made it hard for them to adjust to their existence as refugees evacuated to hotels.

Losing their way of life; questions about the possibility of returning to the homes they had left.

Basic questions about continuing to live in Israel.

Being uprooted, refugees, with no home and an unknown future.

Fear of missile fire, uncertainty about the future and their homes near Gaza.

Similar difficulties were reported by the therapists.

The fear that something will happen to us at home. Helplessness and anxiety about the future as the war goes on.

The realization that we're just at the beginning of the war and we're going to need a lot more fortitude, resolve, and endurance to get through this period.

The thoughts going through my head about what's happening to the hostages. Fear of the war and what will happen next.

4.1.5. Apprehension for the Fate of the State and the Jewish People

The enormity of the event was reflected in clients' existential anxieties concerning the State of Israel and the fate of the Jewish people.

Loss of faith in the ability to rebuild our life.

Existential concerns for the life of the people and the fate of the country.

Fear of what will come (after the war).

The therapists' described their own apprehensions in similar terms.

The sense that we may not have a future.

The fear the nation will fall apart.

Gnawing thoughts about the future and our ability as a society to pull ourselves up out of the disaster.

The sense of our end as a society.

The sense that it is a grim fate to be part of the Jewish people, but you can never escape it.

4.1.6. Global Anxiety

The terrifying experience of October 7 and the days that followed aroused in many clients global anxiety.

Deep anxiety over what happened and what may happen next.

Fear of the future.

It's hard to see anything good in life going on.

Deep anxiety about the future and the effect of the event on life after the war.

The same anxiety emerged from the therapists' descriptions of their own difficulties.

Apprehensions about the future.

A painful sense of loss of trust in the future.

The sense that life has stopped and it isn't clear how it will go on.

The fear that more people will die.

Fear of the future and the ability to overcome the disaster.

4.2. Category 2: Overwhelming Emotions

Horror and devastation from the encounter with evil and terror.

This category contains the whole range of negative emotions, including dread, a sense of devastation, sadness, rage, helplessness, anger, pain, and more. It would seem that in the attempt to describe these emotions, words fail to capture the intensity of the event. Seven themes were identified in the therapists' reports of their clients, as well as in their comments on themselves.

4.2.1. Helplessness and Loss of Control

The sense of losing control, of losing one's grasp on the events and on one's own life, was mentioned repeatedly by the clients, along with a sense of helplessness, withdrawal, and a circumscribed life.

Helplessness. It all comes down to luck. Russian roulette.

A sense of loss of control, loss of trust in others and in reality.

Difficulty coping with what they underwent. Seeing death in front of you. Feeling overwhelmed.

Helplessness that leads to closing yourself off and avoidance, particularly staying at home.

Total absence of hope.

The therapists were flooded with similar feelings.

Helplessness and fear of what will happen as the war goes on.

Frustration and helplessness.

Helplessness in the face of the large number of casualties.

Insane helplessness, contending with the pure evil that attacked us.

The fact that it could have been prevented causes enormous frustration.

4.2.2. Fear, Dread, and Horror

Additional emotions related to the horror and anxiety clients felt in the wake of the event.

A sense of horror at what happened and is still happening.

Fear of terrorists invading our home.

Emotional overload, undermining of the existing order, tension and stress against the background of the home front versus the battlefield, paralyzing fear.

Fear of leaving the house, of taking a shower, of working around the house away from the safe room.

Fear of breaking down.

Great dread, especially about the things that are unknown, like how the terrorists invaded us.

Dread and fear of the war, the sirens, and the unknown.

The therapists' reports of their own feelings echoed those of their clients.

Dread, living alone.

The sense of an existential threat and the loss of innocence.

I'm afraid of being alone in the house.

Fears as a Jewish woman.

4.2.3. Sadness, Grief, and Pain

Another aspect of the overwhelming emotions described by the clients was their deep sorrow and pain over what happened and the loss of close friends and family members.

The loss of faith in the ability to get over it. I want to die.

Pain and grief.

Deep sadness over what happened.

The huge pain of bereavement.

Pain and grief over the heavy losses.

Profound sadness.

The therapists reported similar feelings.

Deep pain for the residents of the Gaza border communities, for the hostages, the slaughtered, and the physically wounded. Mainly, for the mental wounds that will stay with us for many years to come.

It's hard for me to deal with a kind of grief I never knew before. It's not depression, but a deep sadness that is present day and night.

Grief and pain that are getting worse and worse.

4.2.4. Anger, Rage, and a Desire for Vengeance

Clients also expressed their rage at the situation, at the government, and at the terrorists. In some cases, their rage was manifested in a desire for revenge.

Huge anger.

Rage at the country and the army.

Discourse about finishing Gaza off.

A desire to kill, to take revenge.

The therapists also reported anger, aimed mainly at the establishment that had failed the citizens.

Anger at the establishment and the prime minister.

Huge rage at the government for one failure after another caused by not properly handling all levels of civil society.

4.2.5. Shock at the Enormity and Extent of the Brutality

Another emotion referred to by the clients was their shock in the face of the atrocities, the evil, and the horrible consequences of the terror attack.

Shock and pain from the event, especially where they were and what they did.

I saw terrible things that stay with me and don't leave me alone.

Incomprehensible evil.

Repulsion and shock at what happened.

Devastation from the encounter with evil and terror.

Here again, the therapists reported a similar reaction, which they interpreted as a sign of being overwhelmed by the stories, videos, and evidence of the survivors.

The encounter with the cruelty inflicted on the people in the border communities and at the rave. Slaughter and torture. The loss of so many lives.

The appalling stories of the victims that are published every day, the pain of the families, the loneliness of the orphans, the concern for the hostages.

Taking in the extent of the losses and the cruelty.

Thoughts about the suffering of others. It's very hard for me to hear the survivors' descriptions of the sadistic torture they suffered at the hands of the terrorists.

The terrible stories, the thoughts, and identifying with those who underwent the atrocities.

The idea that children have been taken hostage, the rapes and the slaughter.

Thoughts of the hostages, especially the children. Concern for the victims and the change in their personal lives and their plans. In general, it's hard for me to listen to the stories about the atrocities.

4.2.6. Loneliness

In addition, clients also spoke of their sense of feeling all alone in the situation.

Increasing difficulties, in the marriage, as a parent, in being alone.

Loneliness.

Withdrawal.

Disconnect.

Loss of loved ones and the emptiness of the home.

Feeling alone.

This response, too, was echoed in the therapists' descriptions of their own difficulties.

I feel alone and full of dread that something will happen to my husband.

Being alone. I'm alone with the children and supposed to function properly.

4.2.7. Guilt and Survivor Guilt

Another emotion mentioned by the clients was a sense of guilt in general, and survivor guilt in particular.

Guilt. A lot of people feel very guilty about their behavior. Like “I was responsible for them and they died,” or “I might have been able to save them but I didn't.”

Guilt over the decisions they made [not to evacuate their homes].

Survivor guilt, feeling uncomfortable that they're going on with their lives.

Guilt for having survived.

Therapists also reported feeling guilty.

I feel a lot of guilt for not displaying more empathy and connection to the nation and the pain of people on the border.

The sense that I can't do more to help. Guilt for being concerned with little things in the face of what happened.

Knowing that among the people I know there are many without a home, babies without parents, parents without children. There are hostages and there are survivors with no home. And I live in a fancy high‐rise apartment.

Feeling that I'm OK or that's it's hard for me, but what right do I have compared to the people who were attacked.

4.3. Category 3: Physical Responses

Trauma symptoms: arousal, despair, insomnia, withdrawal.

The third category relates to physical reactions to the trauma, such as loss of appetite, difficulty breathing and thinking clearly, fatigue, and insomnia. Like in the other categories, these responses were referred to by clients in therapy sessions and interventions, as well as appearing in the therapists' descriptions of their own difficulties.

Clients:

Arousal, intrusive thoughts, nightmares, loss of appetite, anhedonia.

Sleep disorders.

Panic attacks.

Trauma symptoms: arousal, despair, insomnia, withdrawal.

Strong physical reactions, such as nausea, dizziness.

Therapists:

It's not a specific difficulty. It's a general feeling of being down.

Difficulty breathing.

Fatigue.

Difficulty concentrating.

Lack of sleep. Difficulty falling asleep.

Difficulty focusing.

Exhaustion and heaviness.

4.4. Category 4: Shattered Meaning and Loss of Trust

The sense that the worst thing possible happened in the safest place.

This category contains three themes relating to the collapse of the world as we know it, the shattering of its conventional meaning and cherished values, and the lack of the security and affiliation that had been taken for granted before the traumatic event. All of them led to a loss of trust and the need to reassess accepted values and truths in view of the new reality imposed on the meaningful world by the terror attack.

4.4.1. Violation of the Home: Invasion, Uprooting, Lack of Belonging

The cracks in the basic sense of belonging to one's home, community, society, or nation were intensified by the feeling that the home was violated and invaded by evil, forcing people to evacuate. This aroused feelings of loss, being uprooted, and becoming a refugee.

The sense that the worst thing possible happened in the safest place.

Loss of home and community. There's nothing to go back to.

Loss of physical home and the routine of life.

The house fell apart.

Fear. Our home was invaded. There's no safe place.

Being uprooted, being a refugee, there's no home and no known future.

Again, the therapists' reported having similar feelings.

Being uprooted from my home and a change in work routine.

A sense of not being safe at home. Our house has no safe room and no shelter. I'm worried about the people I love.

Contending with the idea that the home may not be a safe place. Shattering of the illusion of security.

Some therapists even spoke of being evacuated from their homes although they themselves had not come under direct attack.

[The possibility of] being evacuated from my own home and having to cope with the whole situation.

Becoming an evacuee, lack of belongingness.

4.4.2. Being Abandoned, Lack of Faith and Trust

Clients shared their distrust with the therapists, feeling that they had been left to cope on their own, without the protection of the government and the army, in whom they had placed their faith. They described appealing for help for many hours, but their calls went unanswered, leading them to believe they had been abandoned. This generated a loss of trust and the feeling that they had been forgotten by the “responsible adults” meant to care for the citizens and the nation (the state, the army, God).

There were no “parents.” No one came to save us. A breakdown of trust.

We were deserted.

Loss of the basic sense of being protected.

Sense of having being abandoned by the country.

A basic loss of faith in national institutions.

A cry for help in the hour of need and no one came. A sense of betrayal.

Lack of trust in the establishment and the country, a general suspicion and wariness.

Loss of faith in God.

Undermining of the whole system of trust.

The therapists reported coping with the same difficulties.

I feel like I've been orphaned, like there's no bigger person in the country for me to lean on.

The sense that there's no one in the country you can trust.

The difficulty taking in what happened to us as a country and the loss of faith in our government, leaders, and security.

Lack of leadership, loss of trust, loss of our “safe place.”

The sense that there are no leaders who are protecting us as a country.

Lack of faith in the leadership.

4.4.3. Insecurity

This theme refers to clients' realization that after the unfathomable happened, nobody can protect them. This left them without a basic, and vital, sense of security. It may be assumed that the feeling of being abandoned in the previous theme is linked to the experience of insecurity described here.

Loss of personal security.

The rug was pulled out from under my feet.

Feeling unprotected.

Similar feelings were reported by the therapists.

Lack of personal security in my own country.

Loss of faith and security in our leadership. I don't trust the people making crucial decisions.

I feel that power lies in the hands of sick people who are endangering our life in our country.

The sense that there are no leaders protecting us as a country.

Among the therapists, the sense of insecurity extended beyond physical protection, and was also expressed in questions about their own professional abilities and identity, such as: Am I capable of treating this kind of trauma? Do I have the necessary tools? Do I have the relevant skills and experience? Am I doing enough?

I have reservations about whether I can contribute in a proper supportive way. Some of the lectures stressed the importance of support now, and gave us tools for supporting people with acute trauma. Therapists with experience of acute trauma claimed that the intervention of a therapist without that specific experience can be damaging.

I felt relieved after I decided not to volunteer because I might not have the right skills. On the other hand, I feel guilty for not pitching in and doing more to help people in extreme distress in this emergency situation.

Wavering between the desire to help and the feeling that I'm not an expert in the field and I don't want to do damage, so I'm not doing enough and I feel guilty.

4.5. Category 5: Lack of Routine

The need to continue some sort of routine when nothing is clear, when I don't always have the strength to get up for work.

The themes in this category relate to the collapse of routine, the need for routine, and the simultaneous fear of returning to routine life. The traumatic event was so incomprehensible that it changed everything, and nothing was the same anymore. This was accompanied by the understanding that life had changed for good, and therefore nothing they were used to and took for granted was the same, including their perceptions of the world. Consequently, many clients expressed ambivalence regarding the need for routine versus anxiety about living a routine life after the tragedy.

Creating a routine where there is no routine in the life of a refugee.

Disruption of normal life.

A desire for things to go back to the way they were.

Fear of returning to their routine life.

Lack of routine.

Therapists were also troubled by the disruption of their routine, both personal and professional.

Changes in my prearranged schedule. Not knowing if or when I'll work.

The disruption of routine is hard.

The COVID pandemic was finally over and we started rebuilding a routine and then not more then a year went by and everything is upside down again. All my daily habits have become restricted again.

Not having a work routine.

The need to continue some sort of routine when nothing is clear, when I don't always have the strength to get up for work.

Moreover, whereas the routine life of most citizens was interrupted when schools and workplaces shut down in the wake of the attack, therapists were called upon to work even harder than usual to provide care to the survivors, as well as to their own patients. This led to an effort to create a routine that struck a balance between home and work and between their desire to help and the need to keep themselves and their families safe.

Juggling work and home.

Navigating between home, children, work, and my partner in the army.

Finding a balance between the needs of my patients and the needs of my family.

The constant transition between different roles: the clinic, welfare work which has additional demands today, belonging to a community and the desire to contribute to it, and of course motherhood. In a certain sense I wish I was “mobilized” so I could cut myself off from everything else and just be there.

Combining work with the need to be there for my children.

Another aspect of the difficult balance the therapists sought to achieve was that their desire to do as much as possible for others and the overwhelming demand it placed on them left them with little time to process the event themselves, particularly as they were directly exposed to the atrocities and evil in their interventions with survivors.

I feel overwhelmed. It's hard to work. It's also hard not to work, because it gives me a sense that I'm doing something and helping. I sometimes feel the need to detach myself. But it's also very hard to detach yourself from the events and the general atmosphere.

As a result of all the work I did and all the volunteer efforts I took part in the first week because I felt the establishment couldn't provide a response, at the end of the week I had a physical breakdown. My back and muscles were strained.

What's hardest for me is also what helps me—it's my duty and my job to be there for the clients. I feel a need to take a break and unwind, but it isn't possible.

Feeling overwhelmed by the large number of requests from the volunteer groups I joined. The need to be strong for everyone when I'm also scared and worried about my loved ones.

4.6. Category 6: Self‐Preservation

To look out for myself.

This category focuses on the need of both clients and therapists to think about themselves, to take care of themselves, and to prioritize their well‐being, which was severely compromised by the situation. This was reflected in the list of issues raised by the clients.

[Limiting the] amount of news consumption.

The need to protect themselves and find a mental balance.

Pulling themselves together to function and not dwelling too deeply on emotions.

Protecting themselves from content that can hurt them. Exposure to the details.

A sense of persecution.

A desire to reorganize themselves.

Shutting out the terrible stories.

Therapists noted having the same difficulties.

To stop working so many hours and take time for myself to prevent burnout.

The fact that I'm unusual in that I want quiet. [I want] to carry the anxiety and sadness in silence, not do something.

To keep to a routine, to look out for myself and not volunteer for too many things.

4.7. Shared Trauma

The wall falls away.

Direct references to aspects of shared trauma were also found in the responses. By nature, these appeared only in the therapists' reports of their own difficulties, where they referred to concerns about their ability to handle therapeutic sessions and interventions while experiencing the trauma themselves. The difficulties they described relate to their inability to hold themselves, not to mention their clients, in this period, their impaired ability to contain the survivors' stories, and their heightened identification with these clients.

The wall falls away. My criticism of the country meets similar criticism from the other side and doesn't always enable me to listen with a neutral, even if subjective ear, to my clients.

It's hard for me to pull myself together and be strong for the clients.

My most basic difficulty in these hard times is that the situation in the country also affects every aspect of my own life. I find myself in the same place as the clients. Moreover, because it's also hard and painful for me and I also have to look out for my loved ones during this period, I sometimes need to set clearer boundaries and give myself time for my own personal space.

I start breathing heavily in front of my clients.

Identification with the clients as a result of the personal and national crisis that causes me to overreact (in body language as well).

Uncertainty about how long it will take before we can resume a normal life. Unlike the past military operations, this time we know it will be longer, and I wonder how I'll have the mental strength to deal with it over time. I feel like my whole inner world is functioning in emergency mode, not with the connections and richness I'm used to.

To contain the clients and contain myself at the same time.

Uncertainty and anxiety that is shared by so many people have a direct and indirect effect.

The sense that I'm part of a traumatized population. Sometimes it's hard for me to deal with these intense feelings.

In one of the calls to the hotline, a mother was looking for her son and she was very emotional. I couldn't find him on the list of people admitted to the hospital, and it stayed with me. A week later, unfortunately I saw his name on the list of casualties. It was very intense, very sad.

Endless pain.

5. Discussion

The current study sought to compare the major issues raised by clients in emergency interventions and therapeutic sessions about 3 weeks after the traumatic events of October 7 in Israel with the therapists' own difficulties in the same period. The existential threat and extent of the atrocities, coupled with the shattering of basic national worldviews, such as security and trust in the leadership, intensified the reactions to the event, and left no one, neither clients nor therapists, immune to trauma.

Therapists who are both professionals and members of the same community as their clients share and interdependently affect the range of responses of their patients in the face of collective adversity (Ali et al. 2023). On the one hand, they are exposed to the same large‐scale stressor as other individuals in their community or country, attempting to cope with and process the collective trauma, but on the other hand, they are expected to provide care and assistance to others in coping with and overcoming the tragedy (Nuttman‐Shwartz ²⁰¹⁵; Saakvitne ²⁰⁰²; Sampson ²⁰¹⁶), as well as to instill meaning into the events for their clients.

Prior studies conducted in the wake of natural disasters and large‐scale human‐made events, such as the COVID‐19 pandemic or 9/11, have noted how the collective mental health of a society may be affected by a traumatic event of this kind, along with the intense rise in mental health problems during and following the event (e.g., Ali et al. ²⁰²³; Galea, Merchant, and Lurie ²⁰²⁰; Saul ²⁰¹³).

The current study focuses on the response to the unprecedented Hamas attack on Israel on October 7, which clearly triggered shared trauma. We performed thematic analysis (Braun and Clarke 2006) that relied on both the content of the therapists’ reports and existing literature. The analysis generated seven main theoretical categories: (1) Uncertainty and worries about the near and more distant future; (2) Overwhelming emotions; (3) Physical sensations; (4) Shattered meaning and loss of trust; (5) Lack of routine; (6) Self‐preservation; and (7) Shared trauma. All of them, save for the last, were found among therapists and their clients alike.

The first category, the deep sense of ambiguity and uncertainty about what comes next, is theoretically linked to time, which is a feature of the bedrock of the early experience of “going on being,” to use Winnicott, (1945) term, which is the feeling that emerges at the beginning of an infant's life, and affords a promise of continuity in their caregiver's care. It later develops into part of their self and their trust in the world by establishing a sense of time, and with it the ability to anticipate and plan for the future with a degree of confidence and the belief that “I can deal with it.”

However, the mass trauma experienced in Israel shattered that sense of “going on being,” at least temporarily, and sparked worries about the immediate future, as well as more existential anxiety concerning the survival of the country and the Jewish people. Both clients and therapists expressed apprehensions about the next stages of the war, the continuation of missile attacks on civilians, the safety of family members whether at home or in the army, economic concerns, and the ability of Israeli society to cope with the crisis and recover.

The second category, overwhelming emotions, is typical of the aftermath of traumatic events. The literature suggests that people cannot process the trauma at the time of its occurrence. Due to sensory and emotional flooding and the conflicts the trauma arouses, they are unable to fully recognize what happened to them and tell their story. This presents especially in the early stages, as impressions of the event rarely undergo integration with other experiences, remaining detached fragments of sensory and motor experiences (Bromberg 1998; Ehlers, Hackmann, and Michael ²⁰⁰⁴; Herman ¹⁹⁹²). Indeed, the therapists in the current study report, both in their clients and in themselves, feelings of helplessness and loss of control in view of the shocking event and the resulting sense that no one is safe anymore and that someone is playing Russian roulette with their lives, reflecting their feelings of vulnerability and powerlessness. This led them to be overwhelmed by emotions, including anxiety, fear, terror, dread, worry, distress, a sense of catastrophe, fear of death, and fear of collapsing, as well as grief, sorrow, and pain. Some suffered physical symptoms, such as hypertension and panic attacks as a result of this emotional overload. Along with the more internal emotions, there were also numerous references to anger, rage, and the desire to take revenge and retaliate, as well as anger at the country's institutions that had failed to protect the citizens. In addition, there were many expressions of shock and devastation over the extent of the evil and inconceivable atrocities. The inability to grasp the enormity of the event and the incomprehensible inhumanity and cruelty escalated as more details were revealed, becoming completely overwhelming. All this paved the way for feelings of frustration and despair among clients and therapists alike.

Other emotions referred to were loneliness and isolation, as well as guilt in general and survivor guilt in particular. Clients felt guilty for their decision to live in a place that turned out to be so dangerous, choosing to go to the rave held in the area and asking friends to join them, or staying alive when so many friends and relatives were either dead or abducted to Gaza. Therapists' guilt also related to their inability to do more to assist others, being well when others were not, and having the privilege to live in a relatively safe place while the victims were attacked in their homes (Saakvitne 2002; Tosone, Nuttman‐Shwartz, and Stephens ²⁰¹²).

The third category pertained to the physical responses to the traumatic event, including heaviness and fatigue, insomnia, loss of appetite, and difficulties concentrating, thinking clearly, or focusing. Here, the therapists' descriptions of themselves and their clients were highly similar.

Category Four centered around the shattering of the world as we know it, along with the sense that trust in the military and the government to protect the citizens, which had been taken for granted before the event, was no longer justified. Both clients and therapists felt that the invasion of their home and their country and the threat to their lives destroyed their fundamental sense of security and protection, leaving them feeling homeless, abandoned, and adrift. In a sense, they were estranged from everything that symbolized home, everything familiar, and everything that made them feel they belonged. Some of the therapists, like their clients, lost friends and family members and were literally evacuated from their homes, becoming refugees in their own country. Others, even though they were not direct victims of the events, felt symbolically as if the terror attack stripped them of everything they knew and threatened their sense of belonging.

It is important to note that the literature on trauma stresses the collapse of the victims' world, a moment when everything they knew about the world becomes irrelevant. They no longer recognize themselves or others, and their trust in others collapses. Although the collapse begins in external reality, it affects the inner world and continues to exert its influence on the life and worldviews of the victims (e.g., Améry ¹⁹⁸⁰). This response is reflected in the current study as well.

The fifth category concerned the sharp break in routine, an issue expressed repeatedly by both clients and therapists, leading to a yearning for normalcy and a structured daily life, which were unattainable at the time. This led in turn to heightened fears about creating a new routine and having to adjust to it, along with the understanding that things had changed for good and would never be the same again, and that everyone exposed to the trauma would carry it with them forever. Among therapists, the lack of routine was also manifested in the difficulty of balancing between the many demands of the situation, both between professional and personal‐familial demands, such as caring for clients and for one's own children, and between the need to work and volunteer and the need to allow oneself space to process the event and reserve strength for later on.

In this context, the therapists also reported concerns about their ability to handle the needs of traumatized individuals, raising a sense of guilt along with additional questions about whether they were doing enough in the circumstances. They spoke of the conflict between the will to do more and awareness of their limited ability, and between the expectation that they be strong for others and their own feelings of vulnerability and fragility because of their anxiety over their loved ones who were waiting for them at home or had been mobilized.

Category Six, self‐preservation, focuses on the need of both therapists and clients to prioritize and listen to one's own needs, to allow oneself time to process the event, to balance and regulate the continuous news broadcasts and the feelings they aroused, and to find a way to reorganize oneself and adapt to the new reality. These concerns share features with the concept of self‐compassion (Neff 2003), conceptualized as the experience of supporting oneself during difficult times through self‐kindness, a sense of common humanity, and mindful awareness of one's emotions. Here, the need to care for oneself in a state of overwhelming reality is regarded as a crucial response to the situation.

The final category related to shared trauma, even though we did not ask directly about this subject. The fallen wall (Gampel 2020) between therapists and their clients, that is, the shared reality that exposed both sides to the atrocities and trauma, appeared prominently in therapists' descriptions of their difficulties, manifested in the trouble they had listening to and containing clients' stories while at the same time being flooded with their own emotions and fears. Indeed, therapists' ability to cope is crucial to their capacity to help clients understand and digest the trauma. Therapists may experience double stress because of their commitment to clients, that is, the necessity to listen and contain their stories, and the extent and repetitiveness of the testimonies to which they are exposed (Baum 2014).

However, in the current study, it can be observed that the professionals that react to the shared trauma, are overwhelmed and shaken by it in an existential way, and at the same time, report attempts to preserve themselves and a sense of meaning that stems from their actions. The self‐preservation is sometimes linked to the meaning making they do for their clients, but at the same time for themselves in this dialectical space between them and their clients (Bromberg 2001). In this sense, therapists have the strength of their professionalism to lean on in these difficult times.

The ability of both therapists and clients to take a moment to observe the situation as it occurs and recognize their need to balance and regulate the range of negative emotions, which requires attention to their inner voice, is encouraging. Many scholars describe trauma as an unimaginable experience, evoking violent feelings that may exceed the ego's ability to regulate them (Amir 2012; Auerhahn and Laub ¹⁹⁸⁷). It damages the fundamental psychological and cultural order (Felman and Laub 1992) and paralyzes the individual (Amir 2012). Indeed, the therapists also described this experience as robbing them of the ability to bear witness and relate what happened to them (Amir 2012). Our study suggests that alternating between being the ones who suffered the traumatic event and the ones who can bear witness to it for others allows them to observe in a safer and healthier way, even in the early days, what they themselves need and what will help them to overcome the trauma and help their clients to overcome it. It might also be helpful to introduce here the concept of marked mirroring (Fonagy, Gergely, and Jurist ²⁰⁰²), which allows the therapist not only to reflect the emotional state of the client, but also maintain a separate position and introduce a difference of perspectives, as a key factor in effective interventions (Greenberg 2014). Thus, through a relationship with an attuned, responsive, mirroring therapist, the client can develop their emotion regulation of the overwhelming emotions and emotional pain. It seems that even in these tremendously tenuous reality, the therapists offered not only accurate mirroring of the emotional states of the client, but could also introduce new perspectives, both for the client and themselves.

Certain limitations of the study should be noted. First, it was conducted in the first 3 weeks after the traumatic event. The reactions reported here are likely to change over time, and therefore longitudinal studies are needed to fully capture the response to the collective trauma. In addition, we asked therapists to answer different questions about their clients and about themselves, which may limit the ability to compare the replies to the two questions. However, the similarity in responses to the seemingly different questions would appear to strengthen the findings regarding shared trauma rather than weakening them, as the same categories and themes emerged from the analysis among both clients and therapists. Finally, therapists and clients alike were exposed to the events on multiple levels, which were not accounted for in this study. Future studies might obtain information about the participants' exposure in greater detail and examine the effects of the different levels on the responses.

Notwithstanding these limitations, the current study has important theoretical and practical implications. Theoretically, it offers significant insights into reactions to a traumatic reality shared by clients and therapists. Not only does it expand existing knowledge of this phenomenon, but it also provides intriguing new evidence of therapists' responses, which are more than likely to affect their professional work.

On the practical level, the findings underline the attention that should be paid to professionals' mental health during such intense times. Although they may be better equipped to interpret and process the trauma than people in other professions, they are more overburdened and have less time and space to do so, as they are called upon to assist the direct victims and survivors of the event.

Ethics Statement

All procedures performed in the study were in accordance with the ethical standards of the Institutional Review Board.

Consent

Consent was obtained from all participants in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.