Predictors of Secondary Trauma and Self-Care Behaviors Among Trauma Therapists in Sderot and the Gaza Envelope Resilience Centers: The Role of Self-Care Entitlement

Technical Summary: Predictors of Secondary Trauma and Self-Care Behaviors Among Trauma Therapists in Sderot and the Gaza Envelope Resilience Centers

Problem Statement and Context
Following the October 7, 2023 attacks and the subsequent ongoing war in Israel, trauma therapists working in resilience centers near the Gaza border face a dual burden: providing intensive, sustained trauma-focused care to communities while simultaneously navigating personal exposure to insecurity, collective threat, and loss. While secondary trauma (STS) and self-care are known to be intertwined, the specific psychological mechanisms that influence therapists' vulnerability and coping strategies in this unique context of prolonged collective trauma remain underexplored. Specifically, the role of "self-care entitlement"—the perceived legitimacy of prioritizing one's own well-being—has not been sufficiently examined as a predictor of STS symptoms or self-care engagement.

Methodology
The study employed a cross-sectional design with a sample of 120 trauma therapists (89.1% female; mean age 49.78) working in eight resilience centers in the Gaza Envelope approximately two years after the initial attacks. Participants completed an electronic questionnaire assessing:

• Secondary Trauma Symptoms: Measured via the secondary trauma subscale of the Compassion Fatigue Scale-Revised (5 items).
• Self-Care Behaviors: Measured via the Self-Care Behaviors Inventory (19 items), covering cognitive-emotional-relational, physical, and spiritual practices.
• Self-Care Entitlement: Measured via the newly developed Self-Care Entitlement Scale (10 items), distinguishing between two dimensions:
  • Active Entitlement: The belief that prioritizing well-being is justified.
  • Restricted Entitlement: Internalized beliefs that constrain or delegitimize self-care.
• Covariates: Demographics (gender, age, number of children), occupational factors (years of experience, weekly caseload), and personal exposure to war-related trauma.

Data analysis utilized Pearson correlations, independent samples t-tests, and hierarchical multiple regression analyses to identify predictors for both STS symptoms and self-care behaviors.

Key Results

1. Predictors of Secondary Trauma Symptoms:

   • Occupational and Personal Exposure: Higher weekly caseloads and personal exposure to war-related trauma were significant positive predictors of STS symptoms.
   • The Role of Entitlement: Restricted self-care entitlement was a unique, significant positive predictor of STS symptoms. Conversely, active self-care entitlement did not significantly predict STS when controlling for other variables.
   • Mediation of Self-Care: While self-care behaviors initially predicted lower STS, this relationship became non-significant in the final model once entitlement variables were introduced. This suggests that the belief in the legitimacy of self-care (specifically the absence of restrictive beliefs) may account for the protective effect of self-care behaviors.
   • Model Variance: The final regression model explained 30.3% of the variance in secondary trauma symptoms.

2. Predictors of Self-Care Behaviors:

   • Dominance of Active Entitlement: Active self-care entitlement was the strongest positive predictor of engagement in self-care behaviors, explaining a substantial portion of the variance.
   • Insignificance of Demographics/Occupational Factors: Demographic variables (gender, age, children) and occupational factors (caseload, experience) did not significantly predict self-care engagement.
   • Mediation of Trauma: Although higher STS symptoms initially correlated with lower self-care engagement, this association became non-significant after including entitlement variables, indicating that belief systems may drive both distress levels and coping behaviors.
   • Model Variance: The final model explained 42.2% of the variance in self-care behaviors.

3. Group Differences:

   • Therapists reporting personal trauma exposure during the war exhibited significantly higher STS symptoms than those without such exposure.
   • No significant gender differences were found for either STS symptoms or self-care behaviors.

Key Contributions
The paper introduces self-care entitlement as a critical psychological construct in the context of trauma therapy. It distinguishes between active entitlement (a resource for agency) and restricted entitlement (a barrier to well-being). The study demonstrates that:

• Internal beliefs regarding the legitimacy of self-care are more predictive of therapist outcomes than demographic or occupational variables alone.
• Restricted entitlement acts as a specific vulnerability factor for secondary trauma, independent of workload.
• Active entitlement is a primary driver of self-care engagement, suggesting that "permission" to care for oneself is a prerequisite for behavioral implementation.

Significance and Claims
The authors claim that their findings highlight self-care entitlement as a vital factor in therapist resilience during sustained collective threat. The study suggests that interventions and supervision should move beyond simply encouraging self-care behaviors to explicitly addressing the restrictive beliefs that delegitimize self-care. By strengthening therapists' psychological permission and agency to prioritize their own well-being, organizations may better support therapists working under conditions of prolonged adversity.

The paper modestly notes that its cross-sectional design precludes causal conclusions and that the findings are specific to the unique context of the Gaza Envelope. It calls for future longitudinal research to clarify the temporal dynamics between entitlement beliefs, trauma symptoms, and self-care behaviors.