By Peter Salama, Medical Coordinator, Concern Worldwide, Dublin, Ireland
What we see is a new type of war veteran, the international humanitarian worker, returning from the battlefields unable to escape the horrors there. It is obviously very important that aid organizations begin considering seriously the factors affecting their project personnel. Someone must be able to spot the danger signals at an early stage, and help exposed personnel in dealing with their situation (Smith et al, 1996).
Relief workers today are faced with situations which generate more stress than straightforward natural disasters. This happens in a context in which the usual support mechanisms of family, partner or close friends are absent. Furthermore, the culture in the humanitarian community – which may be one of bravado and competition in emergency situations – does often not allow the space for discussing issues such as psychological stress.
Despite mounting anecdotal evidence (and, recently, more substantiated findings; Markey, 1998) that stress and its consequences are key occupational health hazards, humanitarian agencies have not moved quickly enough to minimise the risks to the psychological well-being of their staff, whether they are expatriate or local.
Some Common Problems
Some of the common stress-related problems seen in relief workers include burnout, psychosomatic disorders, and risk-taking behaviour such as alcohol abuse. Unlike domestic rescue workers who are periodically exposed to short stressful events, relief workers may suffer exposure to chronic low levels of stress by, for example, residing in insecure environments for many years. It is in this setting that stress may be cumulative.
Burnout is probably the most commonly used lay term associated with cumulative stress. It is a process that is usually gradual in onset. Symptoms can be grouped into five categories (Kahill, 1988):
i. physical: fatigue, emotional and physical exhaustion, sleep difficulties, and non-specific physical symptoms such as headaches and gastro-intestinal disturbances;
ii. emotional: irritability, anxiety, depression, guilt, a sense of helplessness;
iii. behavioural: aggression, callousness, cynicism and substance abuse;
iv. work-related: tardiness, absenteeism, poor performance;
v. interpersonal: withdrawal, poor communication, distancing self from situation and beneficiaries.
Acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) are more formal psychiatric diagnoses related to exposure to severe traumatic stressors such as a direct assault or abduction (primary traumatisation) or witnessing the death or abduction of a colleague (secondary traumatisation). The phenomenon of tertiary traumatisation is also increasingly recognised (Jensen, 1999). Examples include being witness to mass violence or listening to first hand accounts of traumatised people.
ASD appears relatively quickly after exposure to a particular stressor and, by definition, resolves within a month. It includes a spectrum of emotional reactions, cognitive changes such as confusion, and symptoms of mental and physical hyperactivity. PTSD symptoms appear from one month to three months after a given event. Symptoms usually involve ‘flashbacks’ to the events and a state of being hyper-alert. Symptoms may become chronic and extremely debilitating.
In their attempt to find a new internal equilibrium, relief workers may also respond to unresolved stress with more subtle behavioural changes. One such reaction has been termed ‘enmeshment’ and is akin to survivor guilt with an over identification with the beneficiary population (Smith et al, 1996). This reaction may be more common in the younger, more idealistic relief worker. By contrast, avoidance reactions of distancing, withdrawal and denial may be more common among experienced personnel. Finally, relief workers may exhibit self-destructive behaviours such as working to the point of exhaustion, consuming excessive amounts of alcohol, or engaging in unprotected sexual encounters. Psychiatrists term this a dissociative response; the individual feels distant from his/her previous self and environment in which he/she may have acted more cautiously.
Problems Exacerbated by the Humanitarian Sector
Many of these problems may be exacerbated by factors particular to the humanitarian sector. For example, relief workers do not usually benefit from being in a well-trained, tightly knit unit with a clear command structure. In addition, training and briefing, particularly with regard to psychological issues, is generally inadequate. This is particularly pertinent for those organisations which deploy a high proportion of first assignment volunteers. Third, aid workers are often called upon to perform duties outside their realm of professional competency and experience. Finally, there is the pressure when the drive to ensure the visibility of their own organisation may over-ride questions of the appropriateness or quality of interventions.
Two other issues deserve mention because they are relatively modern sources of tension in the humanitarian sector. First is the pressure of discovering that one’s internal mandate in terms of personal ethics and preferred approach does not match the mandate of a particular organisation. Second is the changing culture of humanitarian work. Organisations are more self-critical than previously and are increasingly putting resources towards evaluating their activities. Inevitably external criticism, even if constructive, leads to a re-assessment of an individual’s perception of his/her own effectiveness. The latter is particularly true if individuals have an unrealistic expectation of what they may achieve under any given circumstance.
An individual has three levels of resources – personal, social and organisational – at his/her disposal with which to tackle demands. Organisations should seek to strengthen these resources wherever possible.
The personal level: Selection and training are key areas where organisations could better support their personnel. In the past the key qualities organisations have looked for when selecting personnel are flexibility, maturity, adaptability, ability to work in a team and past experience in emergency situations (McCall & Salama, 1999). While experience is crucial, this must be tempered by the knowledge that stress can be cumulative, especially in the setting of aid workers going directly from one emergency to the next. Individuals who have a past psychiatric history including that of alcohol abuse or those with a recent significant life event such as a relationship break up should be regarded as being at higher risk of psychological distress.
More effort needs to be made to ensure that an individual understands and is comfortable with the mandate of the organisation and has a realistic expectation of living conditions, security conditions, potential risks including to psychological health and what can be achieved in the circumstances. Some examples of best practice in this setting include being interviewed by the person directly responsible for the project by telephone or in person, and in-depth discussion of hypothetical field scenarios that illustrate some of the complex trade-offs inherent in humanitarian work.
Studies in various settings have shown that untrained, poorly briefed staff suffer most from stress-related illness (Ursano & McCarroll, 1994). Briefing and debriefing should be mandatory and in person. It should cover an individual’s personal and emotional reaction to their work environment, not merely the programmatic or administrative issues encountered. A briefing and debriefing by a psychologist or counsellor should represent the standard for all emergency assignments. Mental health professionals working in this role should themselves ideally have experience of humanitarian emergencies. Training courses should cover stress management techniques (types of stress, coping strategies, how to access help within the organisation), cross-cultural issues, team building/conflict resolution strategies, as well as the ethical frameworks and moral dilemmas of humanitarian relief. Courses should also help to prepare recruits for the task of adapting their professional skills to an environment which may demand a very different orientation.
The social level: Organisations should be more willing to accommodate couples on assignment, particularly if both have relevant skills. Unless situations pose extreme risk, couples themselves should be given the autonomy to weigh the benefits and risks of the presence of an accompanying partner. Managers should consider flexibility in breaks so as to maximise, wherever possible, couples’ time together. It is also important that those responsible for recruiting understand the team dynamic in each particular field and attempt to match new recruits to a field that will potentially suit them.
The organisational level: Formal policies on the prevention of stress in the humanitarian sector are frequently non-existent or incomplete and vary significantly from one organisation to the next (McCall & Salama, 1999). Strategies for improving briefing, training and debriefing need to take place in the context of organisations developing clear, written and comprehensive policies on the psychological health of their employees. Within the framework of institutional policies, mechanisms to support relief workers in the field need more detailed elaboration. A formal mentoring system for new personnel or the designation of a particular individual chosen by his peers in the field to act as the support person for that particular area are two examples of current practice.
Policies on the use of critical incident stress debriefing (CISD) also need to be put in place. CISD may be a useful technique particularly in acutely traumatic events such as a line-of-duty death. There is still a need, however, to document its efficacy, to clarify the timing and location of this type of debriefing, and to ensure that the staff of less well-resourced agencies have access to it if needed. Furthermore, organisations should come to a consensus on the most appropriate methods for psycho-social follow-up of employees so that they are able to determine what happens to their workers after leaving the organisation; the success with which they negotiate the difficult transition back into their former environments, as well as the proportion that suffer psychological distress. Anonymous cross sectional surveys at regular intervals are one possibility.
Finally, there must be a recognition of the effects on empathetic field managers of coping with the stress of numerous employees. In effect this is a form of tertiary traumatisation and they too must be able to recognise the symptoms of stress in themselves and call in re-enforcements if necessary. Peer support networks of regional managers often occur on an ad hoc basis but this could be made more formal and facilitated by HQ.
Unfortunately, humanitarian emergencies are becoming more common. Concurrently the humanitarian sector is becoming larger and more professional, and we are seeing a new type of professional: the career relief worker. These environments, however, are not ordinary work places; they expose individuals and organisations to new dilemmas and new challenges. Staff turnover is high and burnout is common. Perhaps the crucial element in the achievement of the humanitarian goal today is the development of a stable and experienced workforce whose energies are effectively harnessed through more enlightened organisational policies. When seen in this light, the psychological support of relief workers is simply part of the employer’s duty and responsibility. It is not an optional extra.
Peter Salama is a physician with experience both as a clinician and as a manager in humanitarian emergencies in Afghanistan, Burundi, Thailand, Sierra Leone and southern Sudan. At time of writing he was the medical coordinator for emergency programmes for Concern Worldwide. He can be contacted on: firstname.lastname@example.org
Jensen, S B (1999) Taking care of the care-takers under war conditions, who cares? European University Centre for Mental Health and Human Rights.
Kahill, S (1988) ‘Interventions for burnout in the helping professions: a review of the empirical evidence’ in Canadian Journal of Counseling Review 22 (3):310-342.
Markey, K (1998) ‘Reports on risks to health and safety identified by Concern Worldwide’s international personnel’, Concern.
McCall, M & Salama, P (1999) ‘Selection, training and support of relief workers: an occupational health issue’ in British Medical Journal 318:113-6.
Smith, B, Agger, I, Danieli, Y & Weisaeth, L (1996) ‘Health activities across populations; emotional responses of international aid workers’ in Danieli, Y et al (eds) International Responses to Traumatic Stress (Amityville, NY: Baywood Publishing).
Ursano, R J & McCarroll (1994) ‘Exposure to traumatic death: the nature of stressor in individual and community response to trauma and disaster’ in Ursano et al (eds) Cambridge University Press, Cambridge.