A Little History

“A science’s level of development is determined by the extent to which it is capable of a crisis in its basic concepts”
Martin Heidegger, Being and Time

Several years ago I attended a research review meeting in which we considered several particularly impressive proposals.  In the midst of the debate over the virtues of each, I heard a reviewer give one of the greatest endorsements I can recall.  He picked up one of the proposals and said,  “This is the one we want; this investigator really understands what the important questions are!”  The memory of that comment has remained with me as a cautionary tale…there are times when getting the right answer is much less important than making sure you have asked the right question.  The problem is that new questions may require not just new answers achieved in the old way, but the development of entirely new ways of thinking about “question asking” as an organizational and operational task.

One of the central organizing principles of the COE is to foster civil-military collaboration.  Often this involves partnering with other agencies and organizations in ways that encourage what we might call “collaborative questioning”, that will uncover new approaches to problem solving in humanitarian assistance.

AID WORKER CARE: EVIDENCE OF NEED

“Nature does not divide problems along the lines laid down by university faculties”
Dr. Ronald Hargreaves, World Health Organization

One example of collaborative questioning is COE’s concern with the potentially thorny issue of aid worker care among non-government organizations (NGOs).  Epidemiologic evidence is scarce, but a compelling volume of anecdotal reports indicates that many NGOs lack adequate aid worker support. Problems exist in all phases of response, from recruitment and hiring practices to on-site mission support, through post deployment follow-up.

Recent information from a World Health Organization (WHO) report illustrates the point.  In 1998, WHO published the findings of a report on more than 200 NGO aid workers serving in Rwanda, Uganda and Tanzania.  The report cited four general problem areas: the time frame of recruitment, lack of meaningful support and on-site supervision, inadequate worker preparation and lack of adequate area briefs and information on working conditions.

Details in the report underscore the problems encountered by workers.

  • 53% had no medical brief.
  • 20% had not had (or were not aware if) their vaccination status had been verified.
  • Approximately 20% were recruited by mail only, without an interview or references required.
  • Advice on food & water safety and on parasitic & infectious diseases was often lacking.

The reasons for such laxity in worker recruitment and training are unclear, but cost containment concerns are commonly thought to be a factor.  In addition, it has been suggested that NGO leadership may simply have an unrealistically high degree of confidence in prospective workers’ ability to adapt.  A less charitable view holds that workers are viewed as essentially expendable assets whose high attrition rates may be easily balanced by an ongoing supply of enthusiastic, committed humanitarians.

AID WORKER STRESS

“On the whole, I’d rather be in Philadelphia”
W.C. Fields

Once deployed, many workers are dismayed by the lack of on-site support.  As a practical matter, the financial resources of many NGOs do not permit them to provide adequate home office support and supervision for workers in the field.   Workers report that feelings of disconnection from those in charge exacerbate job related stress.   This is particularly disturbing in light of the environmental and organizational stress common to many humanitarian missions

Although sources of psychological stress for aid workers are qualitatively and quantitatively less than for the affected population, there are also some shared risks.  The nature of humanitarian assistance puts workers in contact with the local environment in ways that can erode the normal personal / professional boundaries which provide some measure of psychological protection.  In complex disasters such as those in Rwanda in 1994 or in Kosovo, aid workers may suffer intense or protracted psychological distress as they are subjected to personal trauma, losses and threats in much the same ways as the affected population.

Even in more secure situations, environmental stress can be considerable.  Separation from family, friends & home; intense physical labor; austere living conditions; different foods; limited communication; potential for injury; lack of sanitation; risk of illness and the shock of dealing with the values of a different culture represent commonly reported “ground effects” problems.

Working with other disaster response personnel can also be a source of stress; coordinating activities in the face of potentially competing professional demands can be exasperating.   Organizational stressors can create problems in concert with or independent from disaster characteristics.  These often include time pressures and work overload involving both the difficulty of the tasks and the sheer magnitude of the problems.  Especially for those in supervisory or command positions, the persistence of simultaneous multiple taskings can lead to what has been characterized as “responsibility overload.”

Without proper mental health support, workers may unwittingly add to their problems by seeking relief in stress management strategies that actually create more stress than they resolve.   The most common example may be found in excessive alcohol use or drug abuse. Not only are drug and alcohol abuse important risk factors in their own right, they also act as catalytic agents in the development of other problems.

On balance, it must be said the some NGOs make provisions for mental health support in the form of stress debriefings, mandatory periods of  “R & R”, or other social support activities.  In many cases however, requests for access to such support are met with something less than unbridled enthusiasm from the organization’s leadership.  Interestingly, many aid workers themselves actually reject the need for such services.  In part this may reflect the personality characteristics often found in aid workers; for many, this includes: optimism, the desire to demonstrate mastery,  high need for novelty, low need for harm avoidance, and high value placed on service to others.  For others workers it more likely reflects the fear of being perceived as weak or inadequate, leading to rejection by colleagues.  Even for professional responders, anger, fear, fatigue, despair and physical stress reactions are common responses to the realities of humanitarian assistance. The development of collaborative relationships between mental health assets and other relief assets is essential.  While it is true that knowledge can not buy immunity from appropriate levels of emotional distress, it is also true training and support can minimize the potential impact of such distress on worker health and efficiency.

It ain’t what we don’t know that gets us in trouble; its what we do know that just ain’t so!”
Will Rodgers

The need for adequate worker care is obvious.  One of the important questions becomes, how can we most effectively encourage and support NGOs in the development of aid worker care programs?  The honest answer is, “it depends”.  The size and financial resources of NGOs varies widely, as do their skills and missions; there is no possibility of a one-size-fits-all plan.  That said, we are able to make a few informed observations about the techniques and strategies that have demonstrated the utility in reducing worker distress and premature departure from the field.  Because of the diversity of the NGO community, it is not useful to make simplistic prescriptions, but it may be useful to examine current military policies and programs for heuristic guidance.  The outward differences in the goals and methods of NGOs and military organizations should not obscure the potentials for cross-fertilization in problem solving.

For example, the US Army’s Combat Stress Control Program is based on doctrine that has been tested and revised in the field in diverse complex environments.  In the program, written regulations and directives document the value of worker support and eliminate confusion over standards of care.  Stress control training modules contain easy to understand decision trees to help identify those in need and how to intervene effectively. Efforts focus on early intervention techniques for self-care, buddy care, and command support.  Training modules address such topics as the development of critical incident stress management teams, suicide awareness, practical stress management, and mental health resources.            Whatever else may be said of civil-military responses to humanitarian disasters, both non-government and military organizations have a shared responsibility for outcome.

SOME SPECIFICS

It isn’t what you know that counts; it’s what you can think of in time”
Dr. T.K. Schultz

Responders and supervisors can benefit from training to improve their skills in identifying signs of excessive stress, developing preventive strategies, and learning about resources available to enhance responder readiness.

Before the event

It is important to remember that meaningful mental health support is not just post-vention.  Proper planning and training mitigates the negative effects of situations we can not control; it can also enhance team cohesion and support for personal wellness in general.  It is important for NGO leadership to remember that pre-deployment training can obviate the need for much post-deployment intervention and minimize worker attrition.

It is unfortunate that the commitment to others and high standards of conduct that impel workers to enter the humanitarian aid field can also leave them vulnerable to feelings of shame or failure in the face of disturbing but normal emotional upsets.  By establishing formal (and mandatory) training, leaders can minimize the potential stigma that can often accompany the idea of mental health support.

Training should focus on heightening awareness if the need for self-care and collegial support.  Content should include typical signs and symptoms of excessive stress, methods of coping, and the need and value of formal and informal debriefing activities.  Ideally, team members who are also mental health professionals should provide part of the training; this permits mental health support to become an integrated part of the disaster response process.  As workers prepare to deploy, they should be provided with as much factual information as possible about what they will find on-site.  This provides an opportunity for workers to prepare emotionally for the job ahead.

Support in the field

Mental health services for aid workers are a process, not an event.  The operating principle is that we can all learn from each other, and part of our respective jobs is to act as a readily accessibly clearinghouse for the wisdom of our shared experiences.

Although comparatively few workers suffer from serious and persistent mental illness as a result of their experiences, many are compromised in their ability to stay on-site to operate with maximum efficiency.  Some of the more commonly reported symptoms include social withdrawal, depression, problems with attention and concentration, physical complaints, sleep disturbances, intrusive thoughts and images and profound grief.  Although these symptoms are emotionally painful, it is important to remember that they do not usually reflect mental illness, but a largely normal response to exceptionally abnormal events or environments.

One of the methods of responding to stress-related symptoms is Critical Incident Stress Management (CISM), a system of structured debriefing activities developed by Jeffery Mitchell. Critical incident stress debriefings and related activities provide an environment in which workers can discuss their experiences and the physical and emotional aspects of their efforts, without the specter of a performance critique. The success of these techniques among fire, police, and emergency response personnel are reflected in decreased rates of premature departure from the profession, and reduced risk of post-traumatic stress disorder (PTSD) or related consequences. Although more research is needed, there is an expanding body of research that supports the value of CISM and similar activities in helping workers operate at maximum efficiency on-site.  It is important to remember, however, that CISM activities are not a panacea.  Worker care involves a comprehensive program, tailored to each organization that includes pre-deployment planning, worker and supervisor training, timely and appropriate social support in the field, and post mission follow-up.

SO, WHAT ARE THE QUESTIONS?

Humanitarian assistance has been characterized as the business of caring.  At COE, it is the business of caring shaped by the realities of field experience and applied science.  As a result, COE is committed to ongoing public advocacy for improved aid worker care.  In the last two years, COE has developed training modules on worker care that have become an integrated part of both CHART and HELP courses.  During each course, participants are asked to share their thoughts about worker care, and about the “important questions” they have.

Clearly, much needs to be done to identify specific problems and optimum responses.  One of the goals of COE’s research program is to develop an epidemiologic database about aid worker health.  The data will help us shape our collaborative efforts to develop measures of effectiveness for a “best practices” model for worker care.

Author’s note: Thomas F. Ditzler, Ph.D., ABEP, is Director of Research, Department of Psychiatry at Tripler Army Medical Center and the liaison for mental health issues for the Center of Excellence in Disaster Management and Humanitarian Assistance.

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