This article was first published in the Oct/Nov 2017 print and e-edition of Global Geneva magazine.

DESPITE ITS UBIQUITOUS PRESENCE, whether in crisis zones such as Syria, Yemen or the Congo, or day-to-day existence in both the developing and industrialized worlds, trauma often remains largely unrecognized and untreated. It is the same in the humanitarian sector. As a psychologist working for 30 years in the aid and humanitarian sectors, I have observed my own vulnerability – and that of others. (See Global Geneva article on Ed Gorman’s Death of a Translator on PTSD among journalists).

Stress, of course, is an entirely normal daily experience. It can motivate us to develop new strengths and skills. I am reminded of the Peace Corps refrain: “This is the toughest job you will ever love.”

For humanitarians, ‘common stressors’ includes a wide array of conditions such as hazardous living environments, relationship or communication issues, family problems back home, lack of privacy, and frequent transitions. Other typical stress factors are lack of leisure activities, boredom, uncertainty about work contracts, or having to deal with health problems. Humanitarian operations and organizations, large or small, all encounter such stressors.

ICRC medic dealing with child at war casualty hospital in Peshawar, Pakistan, during the 1980s. (PHOTO: ICRC)

CUMULATIVE STRESS

One of the most debilitating and often unrecognized types of stress in humanitarian work is ‘cumulative stress. It results from the prolonged exposure to work and non-work stressors, and it is intensified when one feels unable to help.

In disasters and armed conflict, it can escalate quickly, exhausting your normal coping mechanisms. The physical symptoms can be overtiredness, diarrhea, constipation and headaches. Some emotional results are anxiety, frustration, guilt, and depression. Cognitive impacts can affect your job performance: forgetfulness or poor concentration. The results in personal relations may be feeling isolated, resentful or intolerant of others. One common result of incapacitating, cumulative stress is ‘burnout.’

Unhealthy behavioral changes include increased intakes of alcohol, caffeine, drugs, tobacco and addictions, as I have frequently observed. Some aid workers, for example, may drink coffee throughout the day and follow this with an extended “happy hour” into the night. This is typically “socially-acceptable” yet it is a warning of unacknowledged and mismanaged cumulative stress.

Less discussed but deeply impactful are feeling challenges to one’s spirituality or core beliefs about God, humans, and life.

MSF aid workers dealing with victims of war. (Photo: MSF)

TRAUMATIC STRESS: FROM WAR ZONES TO NUCLEAR CATASTROPHES

‘Traumatic stress’ is caused by events that are shocking and emotionally overwhelming: the constant sniping targeting civilians in Sarajevo during the Bosnian war, the deliberate shelling of crowded market places in Somalia by rival combatants, managing nuclear catastrophe in Fukushima, or dealing with trapped earthquake victims in Haiti or Mexico. These stressors can and often do lead to more serious psychological difficulties. Some of these emerge relatively promptly; but delayed expression can also appear years later.

For some, their responses to major stressors can be mild and manageable, as was the case of a team I helped debrief who were held captive for weeks by a terrorist group. For others the impact can be extremely strong, even disabling. In one incident, Médecins sans Frontières in West Africa had to pull out an entire team because of severe psychological stress brought about by dealing non-stop with brutally savaged victims of violence, including women who had been repeatedly raped.

PTSD

‘Post-Traumatic Stress Disorder’ (PTSD) can occur after exposure to extreme stressors (including ongoing or intermittent exposure) where there is the threat to oneself or others of death, serious injury or violence. It is accompanied by intense fear and feelings of helplessness, with distressing recollections, dreams or flashbacks along with hyper-vigilance and avoidance of anything that reminds one of the stressor. These symptoms usually occur within one month of experiencing the traumatic event, although ‘delayed expression’ of symptoms can also occur. These can include depression, anxiety, grief, and substance abuse.

WHAT TO DO? RECOGNIZING VULNERABILITIES AND RESOURCES

1. Share the responsibility. Managing stress and trauma are not just personal responsibilities. Humanitarian organizations must also accept some major responsibilities, not the least of which are recognizing and treating stress and trauma, ensuring healthy organizational practices, and integrating stress management throughout all phases of humanitarian involvement.

2. Model health. In some humanitarian settings, the worst stressors have to do with the culture of the organization and management style rather than security risks or lifestyle demands. Hence field leaders and managers can support their teams through more effective leadership styles, management practices, and their own behaviour.

3. Defuse stigma. Humanitarian workers can be reluctant to seek help. Both during deployments or even long afterwards, there may be a realistic fear that they will be seen as weak and inadequate for redeployment or promotion. Consequently they can often disconnect from their feelings and help perpetuate the “be-tough culture” that permeates the humanitarian sector.

4. Cultivate your resilience in five areas: character strengths such as perseverance and integrity; coping skills for stress management, self-care, work-life balance, and interpersonal relationships; mutual support for colleagues, friends and family; staff support and wellbeing resources in one’s organization; and a transcendent sense of purpose, meaning, and hope.

5. Stay aware, get help, and grow. Humanitarians are not unbreakable. So don’t overestimate your immunity; but don’t underestimate your resilience. Stay in touch with the stressors in your life and their cumulative and possible delayed impacts. If you get stuck from stress or trauma, get help. There are effective treatments for trauma, including exposure, cognitive behavioral, and EMDR (eye movement desensitization and reprocessing) therapies. Find safe places, people and ways to help you grow through the challenges of humanitarian life—and beyond.

This article is adapted from Module One by the author, in Confronting Stress and Trauma: A Resource Kit for Personnel Dealing with Violent Conflicts and Natural Disasters (2017), University of Worcester in association with UNITAR, Geneva (http://www.gist-t.org/). Used by permission. The descriptions of the different types of stressors is largely based on Managing Stress in the Field (IFRC, 2009).The opening quote is one of the over 60 humanitarian, peacekeeper, and journalist “Voices” included in Yael Danieli’s edited book, Sharing the Front Line and the Back Hills (2002, pp. 115-120).

Kelly O’Donnell is a consulting psychologist based in Geneva and the CEO of Member Care Associates. His professional emphases include staff well-being, global mental health, and integrity/anti-corruption. He is a representative to the United Nations in Geneva and New York for the World Federation for Mental Health.

MCAresources@gmail.com http://membercare.org/

Further Resources

17 COMMENTS

  1. So glad to see this important topic being brought into the light. Too often we feel it is too ugly to talk about and is best kept in the interior corridors. I especially appreciated hearing how organizations can help. Great piece!

  2. Dear dr. Kelly ODonnell,

    I read your article with great interest. You touch fundamental aspects of health workers in severe stress situations. It is indeed important as you said not to overstretch/overestimate health workers immunity. Prolonged stress can impact severely on the mental health of health workers. With your experience and your knowledge I am sure that more should be done inside humanitarian organizations to train, to inform, to sensitize. As Fracarita International, an NGO working in the field of mental health we are also confronted with this immense challenge of our health workers to remain mentally in balance. The Theme of This Years WHO Mental Health Day talks about mental well-being at the work place. This applies also to humanitarian health workers. I will certainly use this article inside our organization to see for possibilities of collaboration. Thanking you once again to highlight this very important topic of trauma, stress, PTSD. Count us in to join this awareness and reality check ‘wake up’-call. Prakash Goossens, International Advocate Fracarita International

  3. Sharing the responsibility with organizations… love this point! Organizations can do so much with simple day to day changes. It doesn’t have to take a large budget to become trauma-informed. Circulating information like this among staff, as Goossens Prakash mentioned, will really help set an understanding and compassionate tone among staff and serves as a great model as well. We all have personal responsibility, but it’s nice to hear “your are not alone.” That is what stress/trauma-informed care means to me.

  4. Very interesting Kelly, and it’s good to point out that those working to promote the good mental health of the people they are helping are not forgotten, that their own mental health is just as important, and that in fact they will be able to be in a better position to help if they themselves are feeling ‘mentally healthy’. We need to move away from the false notion that those working in mental health are somehow resilient enough to deal with everything that comes their way, and they should stop feeling they should be able to carry the weight of the world and all it’s trauma’s on their shoulders. With the rise in conflict situations and humanitarian disasters around the world it is time to take action.

  5. Thank you for sharing these insights and challenging us to do ‘better’. My favorite ‘read’ was this…. “…. the worst stressors have to do with the culture of the organization and management style…. ” I appreciate you confronting this and helping us to recognize our surrounding.

  6. “Less discussed but deeply impactful are feeling challenges to one’s spirituality or core beliefs about God, humans, and life” – I think this is really important, as these are central to orienting ourselves in the world.

  7. I hope the following event in Geneva will further the discussion of issues mentioned in this GG article:

    GCSP (Geneva Centre for Security Policy) event: Nov 1, 17.30-19.00
    DUTY OF CARE: Is your organisation ready? Link: http://www.gcsp.ch/Events/Duty-of-Care

    Duty of Care with respect to mental health and well-being is a critical issue cutting across “staff’s health, safety and security at the workplace.” This event will hopefully be a timely follow-up and application to this year’s World Mental Health Day (WFMH, Oct 10) focus: “Mental Health in the Workplace”. Link: https://www.wfmh.global/wmhd-2017/
    Michèle Lewis O’Donnell, Consulting Psychologist, WFMH Representative to the UN, Geneva

  8. A timely article as natural disasters hammer North America and the Caribbean. Awful things happen here too, with no less strain on humanitarians and first responders.

    Keep up the good work.

  9. An excellent article. It is also an important reminder that humanitarian stress and trauma has an impact on quality and accountability and the reason why people management is an integral part of the Core Humanitarian Standard (CHS) on Quality and Accountability – how can humanitarian organisations be accountable to communities and people affected by disaster or crisis if there is no accountability to staff, many of whom come from communities affected by disaster or crisis.
    http://www.chsalliance.org/what-we-do/chs

  10. This article brings a out a clear message that needs to be heard. The ability to understand and recognize the major forms of trauma related stress vulnerabilities cannot be understated. The lack of adequate preparation for aid workers and the accompanying care both during and after service is in itself creating additional traumatic crises. The unprepared aid worker is often accompanied by disillusionment and debilitating fatigue on multiple levels of a person’s being. So shocking is this reality that it seems as though uniformed aid organizations brush it aside. The ongoing cultivation of resilience across a holistic framework as seems to fit the five points of O’Donnell’s article is possibly a key to a balanced approached toward life as an aid worker.

  11. Thank you for this interesting and so needed contribution. As a previous aid worked, I have been exposed to traumatic stress many times. And yes, they are very helpful techniques such as EMDR that can help us to deal with what we witness. It has helped me so much along the way. And being able to stand with all the stories and tackling this issue of challenging core beliefs about transcendence, humans, and life gave me a sense of deeper humanity today. An adequate psychological and psychosocial support is so needed in the humanitarian culture. Thank you for bringing that message forward.

  12. Great article, Kelly! Thanks. As you say, I think providers are too often overlooked, and overlook themselves in terms of their reaction to dealing with trauma. This seems to me to be part and parcel of the difficulty. The strong feelings that are stimulated by trauma, or by secondary traumatization, provoke anxiety along with the wish to avoid, deny, suppress, and numb the feelings, leaving us vulnerable to cutoff, burnout, and self-destructive behavior.

  13. Great article, Kelly. Very helpful approach and overview of the importance of recognizing and addressing the impacts of stress (in a variety of contexts) in humanitarian work. Thanks for sharing.

  14. I am glad that Global Geneva has been able to contribute toward this very necessary discussion. It is also an excellent companion to piece to the article on Death of a Translator and the problem of PTSD among journalists also published in the Oct/Nov 2017 edition. We will seek to provide consistent insight coverage of this and other related issues in later issues.

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