Traumatic stress, active engagement and resilience in first responders and civilians in the outbreak of war

ABSTRACT

Background: The outbreak of war in Israel on 7 October and the unique events of that day have presented unprecedented challenges to first responders (FRs), who are professionally trained to engage in providing assistance in such circumstances. Moreover, while research demonstrates the long-term psychological consequences of FRs, little is known regarding how FR’s engagement in providing assistance relates to stress and resilience levels as events continue to unfold.

Objective: The current study examined the relationship between traumatic stress symptoms (TSS) and resilience levels among FRs and controls during the first weeks of the Iron Swords war, while focusing on the moderating role of active engagement in providing assistance.

Method: Data were collected during the first month of the Iron Swords war from 374 participants living in Southern Israel, of whom 77 (20.6%) were FRs. All participants filled out scales assessing TSS and resilience and provided relevant background information.

Results: High TSS levels were associated with reduced resilience in FRs and non-FRs. Moreover, both the study group and active engagement were significant moderators for the TSS-resilience link, which was insignificant among FRs who provided assistance and for civilians who did not provide assistance. However, the TSS-resilience association remained significant for FRs who did not engage in providing assistance and for civilians who did.

Conclusions: Our findings highlight the importance of examining the extent to which FRs act in line with their duties during times of adverse stress. Clinical interventions aimed towards FRs who did not engage in providing assistance are needed and should focus on the extent to which their moral values, beliefs and expectations are met, as these appear critical parameters in preserving resilience.

HIGHLIGHTS

• First responders report increased traumatic stress and reduced resilience.

• Active engagement moderated first responders’ traumatic stress–resilience link.

• Findings are discussed in the context of potentially morally injurious events.

Antecedentes: El estallido de la guerra en Israel el 7 de octubre y los acontecimientos sin parangón de ese día, han planteado retos sin precedentes a los primeros intervinientes (FRs, en sus siglas en inglés), que están capacitados profesionalmente para participar en la prestación de asistencia en tales circunstancias. Por otra parte, mientras que la investigación demuestra las consecuencias psicológicas a largo plazo de los FRs, poco se sabe acerca de cómo el compromiso de los FRs en la prestación de asistencia se relaciona con el estrés y los niveles de resiliencia a medida que los acontecimientos continúan desarrollándose.

Objetivo: El presente estudio examinó la relación entre los síntomas de estrés traumático (TSS, en sus siglas en inglés) y los niveles de resiliencia entre los FRs y los controles durante las primeras semanas de la guerra de las Espadas de Hierro, centrándose al mismo tiempo en el papel moderador del compromiso activo en la prestación de asistencia.

Método: Se recogieron datos durante el primer mes de la guerra de las Espadas de Hierro de 374 participantes que vivían en el sur de Israel, de los cuales 77 (20,6%) eran FR. Todos los participantes rellenaron escalas que evaluaban la TSS y resiliencia, y proporcionaron información de fondo relevante.

Resultados: Los altos niveles de TSS se asociaron con una menor resiliencia en FRs y no FRs. Además, tanto el grupo de estudio como el compromiso activo fueron moderadores significativos para el vínculo SST-resiliencia, que fue insignificante entre los FR que prestaron asistencia y para los civiles que no prestaron asistencia. Sin embargo, la asociación SST-resiliencia siguió siendo significativa para los FR que no participaron en la prestación de asistencia y para los civiles que sí lo hicieron.

Resultados: Los altos niveles de TSS se asociaron con una menor resiliencia en FRs y no FRs. Además, tanto el grupo de estudio como el compromiso activo fueron moderadores significativos para el vínculo SST-resiliencia, que fue insignificante entre los FR que prestaron asistencia y para los civiles que no prestaron asistencia. Sin embargo, la asociación SST-resiliencia siguió siendo significativa para los FRs que no participaron en la prestación de asistencia y para los civiles que sí lo hicieron.

Conclusiones: Nuestros hallazgos resaltan la importancia de examinar hasta qué punto los FRs actúan en consonancia con sus obligaciones durante momentos de estrés adverso. Se necesitan intervenciones clínicas dirigidas a los FRs que no prestaron asistencia, que deberían centrarse en el grado de cumplimiento de sus valores morales, creencias y expectativas, ya que parecen parámetros críticos para preservar la resiliencia.

KEYWORDS:

• Traumatic stress symptoms (TSS)
• resilience
• first-responders
• iron-swords
• acute stress disorder (ASD)

PALABRAS CLAVE:

• Síntomas de estrés traumático (TSS)
• resiliencia
• socorristas
• espadas de hierro
• trastorno por estrés agudo (TEA)

1. Introduction

On Saturday, 7 October 2023, the ongoing Gaza-Israel conflict re-erupted, as Israeli citizens woke up to massive air, sea, and ground attacks from the Gaza strip. This surprise attack resulted in the deaths of 1400 civilians, police force members, and soldiers, and 240 civilians were taken hostage (see Levi-Belz et al., 2024). Moreover, approximately 200,000 civilians who live in proximity to the Gaza strip and Israel’s northern border were displaced, thereby creating ‘an atmosphere of uncertainty and anxiety’ (Peleg & Gendelman, 2023, p. 2071).

A growing body of research has consistently demonstrated that stress reactions and symptomatology following such intense traumatic events do not collapse into a unified phenomenon; Instead, individuals tend to cluster into prototypical response patterns based on different factors such as gender, age, race/ethnicity, education, level of trauma exposure, income, social support, chronic disease, recent/past life stressors, individual/family psychiatric history and resilience (Bonanno et al., 2007; Brewin et al., 2000; deRoon-Cassini et al., 2010). Research has emphasized the interaction between these factors as having a decisive impact on the formation of stress-related pathologies such as acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). Whereas both disorders are characterized by re-experiencing the traumatic event, avoiding trauma-related stimuli, high arousal and reactivity as well as negative alterations in cognition and mood they mainly differ by the presence of dissociative symptoms and by duration. More specifically, ASD may occur in the first month following exposure to the traumatic event, and if symptoms persist, PTSD can be diagnosed (Diagnostic Statistical Manual of Mental Disorders, DSM-5; American Psychiatric Association, 2013).

One unique population that is consistently exposed to traumatic events and thus is considered at high risk for developing stress-related pathologies such as ASD and PTSD is comprised of individuals designated as first responders (FRs). Also known as Public safety personnel (PSP), these individuals received special training and are among the first to arrive and provide assistance in emergency scenes. FRs typically include law enforcement officers (i.e. police officers), paramedics, emergency medical technicians, search and rescue personnel and firefighters. In some jurisdictions, emergency department personnel (i.e. doctors and nurses) as well as military and security forces, are also required to respond to emergency scenes, designating them also as FRs. By virtue of their duty, FRs are frequently exposed to unpredictable emergency zones as well as multiple and continuous traumatic events that include personal threats (Hoell et al., 2023; Komarovskaya et al., 2011; Robinson et al., 1997). These circumstances can lead to significant physical and psychological impacts, including PTSD and depression (Baker et al., 2023; Boulos & Zamorski, 2013; Carleton et al., 2018; Hoge et al., 2004; Lade et al., 2023; Maguen et al., 2010; Maia et al., 2007).

Studies focusing on risk factors for detrimental mental health outcomes among FRs converge with those reported for the general population (Bonanno et al., 2007; Brewin et al., 2000; deRoon-Cassini et al., 2010) with specific emphasis on age, personal disaster experiences and working conditions (Saito et al., 2022). While most studies evaluated the traumatic experience of FRs and characterized this population’s susceptibility to adverse psychological consequences, fewer studies have focused on variables that may serve as protective factors. Nevertheless, research has demonstrated that both personal (e.g. resilience; distress tolerance) and contextual factors (e.g. social support; organizational debriefs) serve as important assets which positively impact FRs’ mental health (McDonald et al., 2022; Skryabina et al., 2021).

Resilience is defined as the ability to adapt, navigate and utilize one’s resources in the context of adversity and significant traumatic life events (American Psychological Association, 2014; Southwick et al., 2014; Ungar, 2006). High resilience levels have been reported as a protective factor from psychopathology (Agaibi & Wilson, 2005; Hoge et al., 2007; Horn et al., 2016). In FRs, research has shown that resilience is associated with perceived wellness (O’Neil & Kruger, 2022) and is considered protective for stress-related pathologies (Green et al., 2010; Lee et al., 2016; McCanlies et al., 2014; Oh et al., 2022; Pietrzak et al., 2009, 2010) that can explain up-to ∼30% of the variance with regard to mental health outcomes in this population (Senger et al., 2023; Streb et al., 2014). Furthermore, resilience has been shown to moderate the mediation effect between traumatic stress and PTSD symptoms via perceived stress and to buffer the impact of traumatic events on the development of PTSD (Lee et al., 2014). Findings also support that PTSD symptoms, perceived job stress and resilience interact and affect depression and/or alcohol use disorders following trauma exposure among FRs (Kim et al., 2018). Resilience also mediated the relationship between social support and PTSD symptoms in FRs (McCanlies et al., 2017). Notwithstanding, studies report low PTSD rates alongside minor functional impairments (North, Tivis, McMillen, Pfefferbaum, Cox, et al., 2002; North, Tivis, McMillen, Pfefferbaum, Spitznagel, et al., 2002) and high resiliency in FRs (Galatzer-Levy et al., 2011; Pietrzak & Cook, 2013; Saito et al., 2022).

The events of 7 October have introduced a complex situation to FRs. Some FRs fully engaged in active duty and were first-hand witnesses to the day’s acts of violence against civilians, often not knowing the fate of their immediate families and friends. Others, however, were prevented from actively participating in the emergency zones and providing assistance as dictated (and perhaps expected) due to their training. This phenomenon may pose an intriguing issue. On the one hand, there can be little doubt that providing assistance in such extremely traumatic contexts is associated, even among trained professionals, with stress symptoms and distress. On the other hand, however, not providing assistance to civilians in need, i.e. not acting in accordance with one’s perceived professional duty, may also exacerbate such negative emotions. Interestingly, no comparative literature exists regarding the traumatic load and its impact on resilience between FRs who actively engage in emergency zones and those who did not (or could not). Additionally, while most studies have evaluated the long-term consequences of traumatic events in FRs (e.g. PTSD), there is no information regarding the acute phase, i.e. the up to 1-month following the traumatic event.

Accordingly, the current study aimed at evaluating the association between traumatic stress symptoms (TSS) and resilience levels among FRs in comparison with citizens who, although living in the Southern part of Israel and experiencing the events of the day, were not trained as FRs. Moreover, we examined the potential moderating effect of active engagement (i.e. providing assistance to the civilians) on TSS-resilience link. Two hypotheses were formulated: (1) high levels of TSS will be associated with reduced resilience in both FRs and non-FRs; (2) the TSS-resilience link will be moderated by study group (FRs vs. non-FRs) and active engagement during the first weeks of the war. More specifically, we surmised that this link would be less pronounced among FRs. However, due to the lack of literature concerning the association between active engagement and stress/resilience in FRs, we could not hypothesize the direction of the interaction.

2. Method

2.1. Participants and procedure

Recruitment of participants began on 24 October 2023 (about two weeks after the beginning of the ‘Iron Swords’ war in Israel) and was completed on 7th November. We employed a computerized survey distributed to participants via social media aimed to test the study scales (see below). Participants also provided sociodemographic and background information including age, gender, relationship status and self-rated health status. In order to rule out possible confounding effects, these variables were controlled in the analyses. Data were collected through snowball sampling from 374 Jewish Israelis (see results for additional information) who live in southern Israel. Inclusion criteria were being over the age of 18, living in Southern Israel, and adequate proficiency in Hebrew.

Based on their responses, we divided the cohort into two groups: FRs (i.e. firefighters, paramedics, police force members, and those in active military service; n = 77, 20.6%), and non-FRs (n = 297, 79.4%; see Table 1 for group descriptives and differences). All participants provided informed consent for participating in the study. The study was approved by the institutional review board of the last author’s academic institution.

Table 1. Means, standard deviations, and group differences for study variables.

Variable	First responders (n = 77)		Non-first responders (n = 297)		Group differences
	M/%	SD	M/%	SD
Age	35.87	9.14	40.11	12.22	T(372) = 2.84, p < .01; Cohen’s d = .39
Gender^a (male)	76.7%	–	40.3%	–	χ^2 (N = 374) = 30.92, p < .001. Cramer’s V = .29
Relationship status^b (not in a relationship)	23.4%	–	23.9%	–	χ^2 (N = 374) = 0.01, p > .05
Self-rated health^c	4.03	0.92	4.11	0.93	T(372) = 0.74, p > .05
TSS	28.83	18.62	23.9	16.59	T(372) = −2.18, p < .05; Cohen’s d = .28
Active engagement^d (no)	39.0%	–	87.1%	–	χ^2 (N = 374) = 79.98, p < .001. Cramer’s V = .46
Resilience	28.37	6.82	26.63	7.54	T(372) = −1.62, p > .05

Note: TSS = traumatic symptom severity.

^a 0 – male, 1 – female.

^b0 – not in a relationship, 1 – in a relationship.

^cRating ranged from 1 (not good at all) to 5 (very good).

^d0 – no, 1 – yes.

2.2. Acute stress symptom severity

TSS was assessed by the PTSD checklist for DSM-5 (PCL-5; Blevins et al., 2015; Weathers et al., 2013). The PCL-5 is a 20-item self-report questionnaire measuring the 20 DSM-5 symptoms of PTSD on a scale ranging from 0 (‘not at all’) to 4 (‘extremely true’). A total symptom severity score (ranges between 0 and 80) is obtained by summing all individual scores for each of the 20 items (higher scores indicate higher symptom severity), and participants were requested to refer to the events of the war. The tool was used with regard to ‘Iron Swords’ war exposure (criterion A), in line with research which utilized this tool during a similar time frame in a previous Gaza-Israel conflict (Helpman et al., 2015). Cronbach’s alpha in the current study was .95.

2.3. Resilience

Resilience was examined by the Connor–Davidson Resilience Scale (CD-RISC; Connor & Davidson, 2003). In the current study, we used the 10-item validated version (Campbell-Sills & Stein, 2007). The 10-item CD-RISC is a self-report scale intended to measure resilience on a 0 (‘not true at all’) to 4 (‘extremely true’) Likert scale. Total scores are calculated by summing all 10 items (ranged between 0 and 40). A higher score indicates higher resilience, and Cronbach’s alpha in the current study was .91.

2.4. Data analysis

Analyses were conducted using the SPSS 24 software. Initial correlations between the study variables were calculated (see Table 2 for means, SDs, and correlation matrix for the cohort). The study hypotheses were examined by a hierarchical regression, with resilience as the outcome variable. The first step included the covariates of age, gender, relationship status, and self-rated health. The second step included the main effects of TSS, study group (FR/non-FR), and active engagement in providing assistance (‘did you provide assistance to individuals who were injured/required assistance during the first days of the Iron Swords war; no/yes). The third step included the three possible two-way interactions (TSS × study group, TSS × active engagement, study group × active engagement), in order to control for possible confounding effects of these interactions on the hypothesized three-way interaction. The fourth and final step included the three-way interaction of TSS × study group × active engagement (see Table 3 for regression coefficients). Significant interactions were probed using Model 3 of the PROCESS 3.4 macro for SPSS (Hayes, 2018).

Table 2. Means, SDs, and correlation matrix for the cohort.

	Variable	M/%	SD	Range	1	2	3	4	5	6	7
1.	Age	39.24	11.77	18–67	–
2.	Gender^a (male)	46.3%	–	–	−.14**	–
3.	Relationship status^b (not in a relationship)	23.8%	–	–	.26***	−.06	–
4.	Self-rated health	4.10	0.93	1–5	−.18**	.05	−.02	–
5.	TSS	24.95	17.14	0–79	−.14**	.26***	.02	−.16**	–
6.	First responders^c (no)	79.4%	–	0–1	−.15**	−.29***	.01	−.04	.12*	–
7.	Active engagement^c (no)	76.5%	–	0–1	−.13*	−.24***	.01	−.03	.15**	.46***	–
8.	Resilience	26.94	7.43	0–40	.03	−.03	.06	.27***	−.25***	.09	−.01

Note: n = 374; Correlation values represent Pearson coefficients except for coefficients for gender, relationship status, first responders, and active engagement, which represent point-biserial coefficients.

^a 0 = male; 1 = female.

^b0 = not in a relationship; 1 = in a relationship.

^c0 = no; 1 = yes.

*p < .05; **p < .01; ***p < .001.

Table 3. Hierarchical regression coefficients for resilience (n = 374).

	Variable	B	95% CI for B
			LL	UL	SE B	β	T	p	ΔR^2
Step 1									.080***
	Age	0.02	−0.05	0.10	0.04	.04	0.67	.502
	Gender^a	−0.53	−2.19	1.13	0.84	−.04	−0.63	.531
	Relationship status^b	1.20	−0.73	3.14	0.98	.07	1.22	.221
	Self-rated health	2.17	1.28	3.07	0.46	.27	4.77	<.001
Step 2									.060***
	TSS	−0.11	−0.16	−0.05	0.03	−.24	−4.05	<.001
	First responders^c	2.74	0.43	5.05	1.17	.14	2.33	.020
	Active engagement^c	0.14	−2.02	2.31	1.10	.01	0.13	.895
Step 3									.024*
	TSS × First responders	0.59	−1.63	2.81	1.13	.04	0.52	.600
	TSS × Active engagement	−2.21	−4.27	−0.15	1.05	−.16	−2.11	.036
	First responders × Active engagement	4.30	−0.30	8.90	2.34	.18	1.84	.067
Step 4									.029**
	TSS × First responders × Active engagement	7.03	2.68	11.41	2.22	.37	3.18	.002
Total R^2									.193

Note: CI = confidence interval; LL = lower limit; UL = upper limit.

^a 0 = male; 1 = female.

^b 0 = not in a relationship; 1 = in a relationship.

^c 0 = no; 1 = yes.

*p < .05; **p < .01; ***p < .001.

A power analysis for detecting a medium effect size (0.15) with 11 predictors required a sample size of 119, indicating sufficient power for the current sample. Additionally, potential multicollinearity was rejected, as tolerance and VIF ranges (.78–.98; 1.02–1.28, respectively) are in line with literature requirements (see O’brien, 2007).

3. Results

Data included 374 participants (age range 18–67, M = 39.24, SD = 11.77) who live in southern Israel. Half of the participants were female (n = 190, 50.8%), and most (n = 285, 76.2%) were in a relationship. Initial correlations between study variables demonstrated that higher TSS levels were associated with reduced resilience (r = −.25, p < .001), being an FR (r = .12, p < .05), and active engagement (r = .15, p < .01; see Table 2). In line with the first hypothesis, the second step of the regression analysis yielded main effects for TSS (B = −.11, SE = .03, β = −.24, p < .001), indicating that high TSS is associated with reduced resilience. While no main effect was found for active engagement, a main effect was found for FRs (B = 2.74, SE = 1.17, β = .14, p < .05; see Table 3), indicating that this group demonstrated higher resilience in comparison to non-FRs. Finally, in line with the second hypothesis, the fourth step in the regression yielded a significant three-way interaction of TSS × study group × active engagement (B = 7.03, SE = 2.22, β = .37, p < .01). Probing the interaction using PROCESS (Hayes, 2018) revealed an intriguing pattern. More specifically, the link between TSS and resilience was not significant for FRs who engaged in providing assistance (B = −.07, SE = .06, β = −.17, p > .05, 95% CI [−.20, .05]) and for non-FRs who did not engage in providing assistance (B = −.06, SE = .03, β = −.13, p > .05, 95% CI [−.12, .01]). However, the negative association between TSS and resilience remained significant for FRs who did not actively engage in providing assistance (B = −.23, SE = .09, β = −.53, p < .01, 95% CI [−.40, −.06]) and for non-FRs who engaged in providing assistance (B = −.31, SE = .06, β = −.72, p < .01, 95% CI [−.44, −.18]; see Figure 1). It should be noted that the results remained unchanged when covariates were excluded from the analyses. No autocorrelations were observed, as Durbin-Watson’s test yielded a value of 2.029. Moreover, potential heteroscedasticity was ruled out, as Levene’s test was not significant, and quartile–quartile (Q–Q) plots yielded a near-straight line, indicating normal distribution (see Field, 2013).

Figure 1. The three-way interaction between TSS, study group (FRs/non-FRs), and active engagement (no/yes) in predicting resilience.

4. Discussion

In line with the first hypothesis, higher TSS was associated with reduced resilience in both FRs and non-FRs. Moreover, in line with the second hypothesis, we found a significant moderating effect of both study group and active engagement on the TSS-resilience link. Upon probing this interaction, an intriguing pattern was found. More specifically, the negative association between TSS and resilience was not significant for FRs who engaged in providing assistance during the initial stages of the war, and for civilians who did not engage in such activities. However, the TSS-resilience association remained significant for FRs who did not engage in providing assistance and for civilians who did.

The significant negative link between TSS and resilience in the two aforementioned groups may indicate two potential trajectories. The first is manifested in civilians who actively engaged in providing assistance. This trajectory corresponds with the consequences of the known track asserting that witnessing a traumatic event impairs resilience (Tolchin et al., 2023). In this context, studies have emphasized the importance of perceived control over various aspects of traumatic events as generally adaptive (e.g. Frazier et al., 2001). However, it may be argued that the unprecedented heinousness of the war events, together with the fact that assistance was often rendered to close friends and/or family members, could have potentially contributed to a perceived lack of control (see Hancock & Bryant, 2020) and subsequently reduced resilience.

The second trajectory by which TSS and resilience are significantly associated is expressed among FRs who did not engage in providing assistance. While most studies have focused on the mental health toll experienced by FRs as part of their active duty, no information exists regarding the effects of TSS on resilience in FRs that were prevented from active engagement, or alternatively, were not able to function in accordance with their duties in active war-zone conditions. While many FRs have undoubtedly faced moral and ethical challenges in their line of duty, it may be argued that FRs’ subjective war experiences could be indicative of potentially morally injurious events (PMIEs); i.e. events in which individuals conduct, witness, or fail to prevent/assist in circumstances which transgress their moral values, beliefs and expectations (Litz et al., 2009; Litz et al., 2022). Litz et al. (2009) posited that PMIEs are potentially injurious because they can undermine foundational beliefs about the goodness and trustworthiness of oneself/others, causing psycho-social-spiritual impairments. Such events often provoke shame and guilt (whether due to acts of commission or omission active personal contribution), causing a ‘moral injury’ (Jinkerson, 2016; Lentz et al., 2021; Litz et al., 2009; Shay, 2014) which impairs resilience and thus in turn, may also contribute to significant mental difficulties.

This line of thought may be further understood in light of Terror Management Theory (TMT, Greenberg et al., 1986). According to this theory, as humans become aware of their own mortality, several defenses are activated in order to ward off this difficult knowledge and enable everyday functioning (Hirschberger, 2015). More specifically, cultural worldview validation, or the feeling that one is conducting oneself in accordance with cultural values and expectations, may reduce death awareness and subsequent distress (see review by Kosloff et al., 2019). In the current context, FRs are characterized by a strong sense of purpose in their roles, often tied to life-saving and preventing suffering. Thus, providing assistance to civilians in need following the outbreak of war may reinforce FRs’ self-esteem, and acts to validate their worldview; more specifically, the fact that they are capable and effective in their role, and are acting in accordance with their professional training, may increase the feeling that they are acting in line with social/cultural expectations. However, FR’s inability to engage in their role in war zones could challenge their sense of meaning and contribution and might lead to feelings of helplessness and a diminished sense of self-worth, which are contrary to the protective effects proposed by the theory. The inability to act according to one’s moral values, beliefs and expectations, especially in critical situations, could lead to a sense of existential dissonance, which, in turn, may be portrayed in reduced resilience levels as seen in the current study.

The results of the current study highlight the importance of taking into account not only the psychological consequences of PMIEs among FRs, but also how acting (or not acting) in line with one’s professional responsibilities as an FR may affect these outcomes. This understanding is crucial for preventing the negative impact on resilience levels in FRs, which has been associated with various negative psychological consequences (e.g. Joyce et al., 2019). More specifically, building a better understanding of the way FRs comprehend their own trauma-related symptoms, is expected to increase treatment engagement, outcomes and efficacy (Holmes et al., 2018). Given the intensely physically-mentally demanding nature of FRs’ careers, early tailored interventions for either reducing TSS or strengthening resilience levels may be beneficial for reducing long-term mental health complications and improving quality of life.

Some limitations of the current study must be acknowledged. First, as the FR group was relatively small, analyses were collapsed and thus we could not examine nuanced differences in TSS and resilience levels of service across different professions. Future research should consider the unique impacts of these measures by relating to the different professions individually, together with additional factors unique to this group (e.g. the effects of re-exposure to traumatic events). Second, the cross-sectional nature of the data prohibits discussions of causality, and therefore, we cannot rule out that resilience levels may predict subsequent stress symptoms and/or PTSD. Accordingly, it is necessary to investigate further the direction of the links between TSS and resilience, and researchers may consider assessing participants longitudinally to better understand how the presence of TSS influences resilience. Finally, the study model was not designed to examine PTSD, and additional research is warranted in order to deepen our understanding about the long-term traumatic consequences of the Gaza-Israel conflict.

The findings of the current study, based on data collected in the acute phase of ‘Iron Swords’ war, illustrate the importance of routine in preserving individual resilience as a protective factor against stress symptoms in both FRs and civilians. Clinical interventions aimed at improving the mental health of both FRs who were and were not actively engaged in assisting help to others in need should focus on how they perceive the extent to which their moral values, beliefs and expectations are met, as these appear critical parameters in preserving resilience levels in this population.

Disclosure statement

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

Data availability statement

Data are available at https://doi.org/10.17605/OSF.IO/AD27N.

Additional information

Funding

This research was supported in part by an internal research grant given to the first author from Ashkelon Academic College.