Aiding aid workers

Alcohol, excess sleep, drugs, social withdrawal and sex are some of the tools that humanitarians facing burnout use to switch off from the constant stress they face in a typical emergency response. But as research deepens into how stress affects the brain, mental health experts are hoping to build up natural resilience to maintain the mental health of field workers.



"You may be facing children dying, or people who have lost everything, and are expected to have a magic wand to return them to a place where they were pre-crisis. Plus, you're dealing with a difficult environment, you're working 20-hour days - that puts a lot of stress on everything. Some people will inevitably indulge in risky behaviour," an aid worker who had responded to disasters in Indonesia, Pakistan and Niger told IRIN. 



Humanitarian workers operate in some of the toughest imaginable circumstances. The extreme shocks - also known as high-impact stress - that they may experience or witness include wide-scale deaths, violent robberies, shootings, kidnappings and sexual violence. Aid workers are increasingly coming under direct attack.



For most, it is the less extreme daily, cumulative stress-factors that lead to burn-out: adapting to a new culture, withstanding extreme heat or cold, living in difficult conditions, working long hours, eating bad food. Add to that daily insecurity, dealing with a curfew and losing freedom of movement, and it becomes a potent mix for burnout.



"As missions become more dangerous, stress is simply an inevitability," said Donald Bosch, director of counselling at the US-based Headington Institute, which provides mental health care to humanitarian workers.



Most of the core stresses are job-related - trying to create order out of chaos, facing improbably high expectations from head office and beneficiaries, managing relationships with team-members and managers, said Kaz de Jong, a psychologist with Médecins sans Frontières in Holland, and Sian Kelly, health and safety adviser at Save the Children in the UK.



The emotional stress when staff feel let down by their agency is powerful and often overlooked - when the school they slaved over is not built; when their partners misappropriate money, when head office lets them down.



"It is very important for most aid workers to have a reason to do this [work]," said Bosch. "When that is undermined by a sense of betrayal, it is demoralizing to the very soul."



Under these circumstances, burnout is not only inevitable but healthy, said de Jong. "To think we can send people into these circumstances and not expect them to confront stress and trauma – these are expected outcomes. We should realize this and support staff before, during and after it [emergency intervention]."



Warning signs



Stress signals vary widely but Bosch said a short fuse, anxiety, depression, frequent conflict and withdrawal were signs that "your brain is getting cooked".



"People may develop a feeling that there is no room inside ... that they have no shock absorbers to deal with anything anymore - even the little things," he said. "They may not be able to think clearly, and everything and nothing may seem important."



While the majority of aid workers do not develop full blown post-traumatic stress disorder, said Bosch, staff must look out for the signs: flashbacks, intrusive thoughts, avoidance tactics, paranoia or lack of trust, memory loss.



"These are an indication that their hippocampus – essentially the brain's shock-absorber – and other brain structures are not functioning as they once did," he said. De Jong estimated that 3-4 percent of MSF workers developed severe mental illness, mainly depression or psychosis, when in the field.



Skipping ropes and family photos



Most large-scale, professional NGOs have recognized the need to maintain workers' mental health, and now provide counsellors to support staff before and after missions, links to 24-hour telephone hotlines, and routinely receive staff debriefings on the highs and lows of the mission. MSF regularly sends counsellors on "stress visits" to emergency zones to do group work with field-workers and take stock of how they are feeling.



Agencies also try to improve working and living conditions. In the Haiti earthquake response, Moustafa Osman, head of humanitarian aid at Islamic Relief, provided a television for the staff, allowed them to watch films in their down-time, and strongly urged them to participate in weekly football games to maintain physical health and social interaction.



"If we isolate ourselves, we'll all be toast," Bosch commented. Stress-relievers can be as simple as encouraging staff to contact their families by email, or bring photographs and other reminders of home with them.



One aid agency Headington works closely with handed out skipping ropes to all field-bound aid staff. The thinking behind this was based on new research that exercise can alter stress-addled brains.



The hippocampus shrinks under extreme stress, while the brain's alarm bell – the amigdala - expands, triggering trauma symptoms said Bosch. "Hence, aid workers who experienced after-shocks during the Haiti earthquake might jump every time a large truck goes by."



While the bad news is that the amigdala is trained not to forget, the good news is that exercise can cause the hippocampus to grow again. "You may not be able to jog around Port-au-Prince, but you can do calisthenics, dance, jump rope," said Bosch.



Forewarned is fore-armed



One way of reducing the likelihood of a shrinking hippocampus is to prepare staff for stress, according to mental health experts. "We have to look at the full life cycle of an aid worker – pre-deployment, on assignment, and post-deployment," said Save the Children's Kelly, who conducts personal resilience and well-being sessions pre- and post-mission.



"We discuss their work, their health status, personality traits, how they maintain connections with family and friends, the risk of isolation, boredom, overly high expectations," she told IRIN.



Intervening early can avoid burnout down the line, de Jong agreed. "In my experience, among the majority of staff, when given some initial support, their natural personal resilience will kick in. Some need an extra push, but if we do it at the initial stage, it's easy."



The Headington Institute will soon launch a 'resilience inventory', which aims to more accurately calibrate how individual staff members are likely to cope, and where their stress triggers might lie.



While high-impact events like a hostage-taking or shooting will inevitably have an effect, "high-fidelity stress exposure training", which includes running through such scenarios, can teach staff how they are likely to handle such situations.



"The best of these emphasize the psychological part," said Bosch. "Participants almost always feel more ready to cope afterwards. They tell me they knew what to watch for, and what to do about it when it happens."



aj/am/he