The Psychological Health of relief Workers: Some Practical Suggestions

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 organisations 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 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.

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):

  • physical: fatigue, emotional and physical exhaustion, sleep difficulties, and non-specific physical symptoms such as headaches and gastro-intestinal disturbances;
  • emotional: irritability, anxiety, depression, guilt, a sense of helplessness;
  • behavioural: aggression, callousness, cynicism and substance abuse;
  • work-related: tardiness, absenteeism, poor performance;
  • interpersonal: withdrawal, poor communication, distancing self from situation and beneficiaries.

Acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) are more formal 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.

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.

Recommendations

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 psychotherapist 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. 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.

Conclusion

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.

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Molly and the Two Pigeons (Audiobook ver)

Molly and the Two Pigeons is a short story for upper primary and lower secondary school children to teach them about Coronavirus in a fun and light-hearted way, and records a significant period of time in history. It could also be used as a teaching tool for parents or teachers.

A loveable puppy called Molly forms a friendship with two racing pigeons, Destiny and Grace, who live in a wooden hut in the adjacent garden. Grace is kind-hearted and takes a liking to Molly, Destiny is arrogant and is known as the fastest pigeon in the South, proven by his collection of medals. Their circle of friends expands to include Marv the wise Mandarin Duck, Flash Gordon the Goose, and Merlin the Mosquito.

This strange group of friends become united through one cause, to find a cure for the Coronavirus and help the people. Their adventures take them far and wide. They travel to China and learn about the origins of Coronavirus. They explore the Yangtze River, where they learn about the legend of the mountain peaks. They head to South Korea, where they learn about “Track and Trace” to prevent the spread of the virus. They also visit Oxford, England, where they explore how a vaccine is made. Their trip to Oxford coincides with a visit from Prince William, who Molly takes a great liking to and manages to get a royal stroke from.

Proceeds will be gifted to a charity to support the NHS and all those needing additional support from the impact of Coronavirus.

Trauma and counselling interview (Flirt Radio)

Mindfulness Exercise Series: Breathing & Relaxation

More than ever, people are talking about mindfulness. But what is it and how could it help you? Mindfulness can help you manage your wellbeing and mental health. It can enable you to:

✓ feel less overwhelmed
✓ improve your sleep quality
✓ positively change the way you think and feel about your experiences (especially stressful experiences)
✓ increase your ability to manage difficult situations
✓ make wiser choices
✓ reduce levels of anxiety
✓ reduce levels of depression
✓ reduce levels of stress
✓ reduce the amount you chew things over in your mind
✓ have greater self-compassion

Mindfulness is not fluffy nonsense nor is it a passing fad, there is a great deal of research evidencing that mindfulness changes the plasticity of our brain. But, it does take effort and work to develop mindfulness skills and time to practice them.

In this, the first series of mindfulness exercises I share some simple breathing and relaxation techniques to help you unwind and take some time for yourself.

If you like this exercise then please get in touch with FD Consultants today to find out about their mindfulness and wellbeing courses.

The Role of Community in Trauma Therapy Podcast

FIONA DUNKLEY is a trauma therapist and counsellor who has helped people and communities affected by war, terrorism and sexual violence. Drawing on experiences described in her new book – Psychosocial Support for Humanitarian Aid Workers – in these podcasts she tells us about the importance of community and its values in helping people overcome trauma.

Mindfulness Exercise 6: Mountain Meditation

Meditation is the collective term for a number of techniques used to still the mind, relax the body and produce a state of inner harmony. It differs from sleep, hypnosis or other types of relaxation simply because your mind remains alert.

There are many ways to meditate. You can meditate while sitting, walking, or practising yoga, but it is easiest to learn by sitting comfortably in a quiet room for several minutes twice a day, every day. There are 2 basic steps: to focus on a single word or phrase (of your choice – perhaps “peace” or “one”, or a religious word) or simply to focus on your breath; and to ignore or disregard all other thoughts.

When we focus on a single word, thought or image, we produce a state of calm that increases mental alertness, while relaxing other body systems.

Meditating twice a day for 15-20 minutes has been shown to be the most effective. Make an effort to practice every day, even if it’s initially only for 5 minutes. You may find it’s easiest to meditate first thing in the morning and last thing at night.

One of our favourite meditations is “The Mountain Meditation” by Jon Kabat-Zinn. It encourages us to seek inner stability and peace, even in the face unpredictable change and chaos. Here is an adaptation of Kabat-Zinn’s classic guided meditation, we hope you enjoy it and find it useful.

If you like this exercise then please get in touch with FD Consultants today to find out about their mindfulness and wellbeing courses.

Mindfulness Exercise 5:Healing Light Meditation

Healing Light meditation is a popular practice. You can use it almost anywhere to lift your mood. If you’ve got a few moments free throughout the day, I highly recommend learning this practice to fill some of those extra minutes with guided white light meditation.

Many people who meditate have had unusual encounters with healing light. They find the experience perplexing. There’s no logical source for this light; so where does it originate? Individuals experience this light in different ways. One meditator might see giant glowing white balls, while another one might see tiny comet-streaked white sparkles. Experiencing a light during meditation is common, but subjective. There are many benefits to following this healing light meditation, such as enhancing overall wellbeing, boosting self-esteem and feelings of connectedness and it can be used to help “clear” any painful emotions you may be experiencing.

If you like this exercise then please get in touch with FD Consultants today to find out about their mindfulness and wellbeing courses.

Mindfulness Exercise 4: Body Scan Meditation

When you’re feeling stressed, it’s common to “carry stress in your body” in the form of tense shoulders, a stomach “in knots,” through shallow breathing, or in other ways. When people carry stress in their bodies, they’re often not even aware of it! When we’re really stressed, we may be feeling physical discomfort but not connect it with our emotions. A body scan meditation is a practice that can be performed daily or even several times a day and can help you learn to identify what you are feeling and where you’re feeling it, and learn to release the stress in your body and mind.

The body scan meditation is effective in relieving stress not only because of the mind-clearing aspects present in all forms of meditation but because of the physical component as well. Research shows that there are physical and psychological benefits to relaxing the body and relieving tension. Relieving physical tension, for example, has been shown to lead to a decrease in psychological stress, even when no psychologically-based stress relief efforts are made. Tension relieved in the body can lead to lower stress levels and lower reactivity to future stress, which can, in turn, lead to less physical tension as a result of stress.

In this way, this meditation works to break the cycle of physical and psychological tension that can feed on itself. Because of this, the body scan meditation is a very useful and effective meditation that can help you to stay relaxed mentally and physically, and return to a relaxed state when you become too tense. You can try a body scan meditation right now by following this simple video exercise.

If you like this exercise then please get in touch with FD Consultants today to find out about their mindfulness and wellbeing courses.

Mindfulness Exercise 3: Compassionate Mindfulness

This is an exercise in feeling compassion towards yourself. Self compassion often doesn’t come naturally – it is a skill you need to learn, practice and consciously engage in. Research has shown that these techniques can help improve our emotional well-being, improve our ability to cope with life’s challenges, lower levels of anxiety and depression, promote healthy habits such as diet and exercise, and lead to more satisfying personal relationships.

Cultivating self-compassion in this way can fundamentally shift how we relate to ourselves. Instead of meeting our imperfections and challenges with self-blame and criticism, we can bring a kind and mindful attention to our experiences (thoughts, emotions, and sensations) and a sense of love and care to ourselves, right in the midst of difficult situations. With practice, we can strengthen this inner quality of presence, connectedness, and kindness to improve emotional well-being and build resilience.

If you like this exercise then please get in touch with FD Consultants today to find out about their mindfulness and wellbeing courses.

Mindfulness Exercise 2: Releasing Negative Energy

On a regular basis, we encounter a wide range of energies, both positive and negative, and since the negative energies we come in contact with have the power to drain, and make us feel tired and exhausted, it is very important to remove these energies.

Negative energy can be anger, anxiety, depression, resentment, jealousy, or any negative feeling and emotions that you have been holding on to. This guided meditation will help you remove any form of psychic attack or negative energies from your life and shield you from negativity.

Before you begin, remember to first, find a quiet place where you won’t be disturbed for the next 15 minutes. Second, find a comfortable position to sit – it can be in a chair, crossed legged or on your knees, or lay down and when you’re ready, press play.

If you like this exercise then please get in touch with FD Consultants today to find out about their mindfulness and wellbeing courses.

Mindfulness Exercise Series 1: 4-Step Breathing

4-Step breathing (also called square, tactical or Box breathing) is a simple and highly effective technique that you can practice for a few minutes anytime you need to boost your creativity or concentration, break free from scattered thinking, or interrupt an intense “fight or flight” response and return to a state of healing and peace. It is also an effective breath to use at the beginning of your mindfulness practice.

This centuries old breathing technique for meditation has re-surfaced in the past few years and is being used by athletes, performers, doctors, and even navy seals, as their most effective strategy for quickly entering a calm, centered state of mind and body; especially when they are in an intense situation where they need to be fully present and directly connected to their best self/highest self. Many people report that when breathing is used as part of their meditation it has a dramatic, positive impact on their inner and outer wellbeing.

If you like this exercise then please get in touch with FD Consultants today to find out about their mindfulness and wellbeing courses.

Psychosocial Support for Humanitarian Aid Workers:
A Roadmap of Trauma and Critical Incident Care

Get your copy of Fiona’s book, Psychosocial Support for Humanitarian Aid Workers. It will appeal to all those working in the field of humanitarian aid, counsellors and psychotherapists, emergency first responders, as well as those who are looking to support themselves after surviving trauma.

Molly and the Two Pigeons

Molly and the Two Pigeons is a short story for upper primary and lower secondary school children to teach them about Coronavirus in a fun and light-hearted way, and records a significant period of time in history. It could also be used as a teaching tool for parents or teachers.

A loveable puppy called Molly forms a friendship with two racing pigeons, Destiny and Grace, who live in a wooden hut in the adjacent garden. Grace is kind-hearted and takes a liking to Molly, Destiny is arrogant and is known as the fastest pigeon in the South, proven by his collection of medals. Their circle of friends expands to include Marv the wise Mandarin Duck, Flash Gordon the Goose, and Merlin the Mosquito.

This strange group of friends become united through one cause, to find a cure for the Coronavirus and help the people. Their adventures take them far and wide. They travel to China and learn about the origins of Coronavirus. They explore the Yangtze River, where they learn about the legend of the mountain peaks. They head to South Korea, where they learn about “Track and Trace” to prevent the spread of the virus. They also visit Oxford, England, where they explore how a vaccine is made. Their trip to Oxford coincides with a visit from Prince William, who Molly takes a great liking to and manages to get a royal stroke from.

Proceeds will be gifted to a charity to support the NHS and all those needing additional support from the impact of Coronavirus.

Download the first chapter of the audiobook for free – click here