An exploration of the psychological effects that aid work ...



An exploration of the psychological effects that aid work puts on delegates, with an ensuing discussion of recent strategies to reduce these stressors.“An organisation needs to practice what it preaches...[An agency] that espouses sustainable human development on a global level will also organise and manage its workplaces according to sustainable human development principles. [It must] foster a working environment compatible with its goals and objectives” The Canadian Council for International Co-operationCourse: Diploma in Tropical Nursing (March 2004 cohort)Candidate Number:Word Count: 2329 including referencesList of ContentsPage number3 - 12… An exploration of the psychological effects that aid work puts on delegates with an ensuing discussion of recent strategies to reduce these stressors.13 – 16…Reference List 17…Bibliography 18…Appendix A - Cross-cultural adjustment processes 19…Appendix B - Code of Conduct for The International Red Cross and Red Crescent Movement and NGOs in Disaster Relief. 20…Appendix C - People in Aid Code of Good Practice21…Appendix D - Sphere Humanitarian Charter and Minimum Standards in Disaster ResponseSince the late 1970’s, the incidence and magnitude of complex humanitarian emergencies has been increasing (Eriksson et al, 2001). The International Federation of Red Cross and Red Crescent Societies (IFRC, 2003) estimate that at the present time, excluding those caught up in war, two hundred and fifty to three hundred million people a year are affected by natural disasters. They predict that this figure will increase by 10 million people per year, in the absence of war.The increasing complexity of humanitarian situations presents a very real challenge to the psychological well being of relief workers (McCall and Salama, 1999; Eisenman et al, 2000). This assignment will investigate the reasons why humanitarian workers might experience adverse psychological effects when undertaking aid work and will touch upon what the risk factors are for these. An exploration of the manifestations of these adverse effects will ensue and following this, recent strategies to address both stressors and affect will be discussed.Stress is a normal physiological phenomenon. It motivates individuals to focus their attention and mobilise energies in order to prepare for a given task [in this instance a humanitarian mission], where basic stress levels may function at a greater intensity than is one’s norm (Center for Humanitarian Psychology (CHP), 2002). In fact, People in Aid (2000) and UNHCR (2000) cite stress and tension in various forms as integral to all relief operations.The hazards and potentially detrimental effects of humanitarian missions appear to be well documented in all populations (Collins and Long, 2003). Shepherd and Hodgkinson (1990) suggest three sources of extreme stress to humanitarian workers: close proximity to death, sharing the anguish of those they are helping and role related difficulties. Davidson (2000) reports that violence and threats to the personal security of members of the humanitarian community are becoming more common. Though perhaps surprisingly, these threats coupled with organisational issues, were reported by delegates as being the main sources of stress to them. People in Aid (2000) add that a lack of social support may also act as an important stressor to the delegate. UNHCR (2000) stress that despite these conditions delegates must remain effective for long hours in often uncertain or dangerous situations, make decisions with limited information and resources and function as a member of a multi-lingual, multi-functional and perhaps unfamiliar teamStewart and Leggat (1998) add an interesting dimension to this discussion in their suggestion that cross-cultural adjustment is an additional stressor to a humanitarian mission and has the potential to be harmful. Bochner (2003) however, argues that a negative transition is by no means inevitable or as widespread as is often suggested, but concurs that cross-cultural interactions are inherently stressful.One’s culture is acquired innately in childhood and then re-enforced via a complex network of both formal and informal social education. Our resulting cultural identity then provides a framework for interpersonal and social interactions and shapes how we see, our interpretation, our actions and reactions (Stewart and Leggat, 1998; Sussman, 2002). Following on from this Bochner (2003) asserts that when contact occurs between the culturally diverse [and in an environment alien to the delegate] the potential then arises for ‘culture shock’ to occur. Ward et al (2001) caution against taking the term ‘culture shock’ too literally, suggesting that the word ‘shock’ places too much emphasis on the threats of an unfamiliar situation. It is asserted that cross-cultural interaction also has potentially beneficial consequences to the participants.Bochner (2003) highlights that cross-cultural transition is a reciprocal relationship, i.e. those individuals that we as humanitarian delegates are working with, are likely to be experiencing some of the transitional anxieties that we are, for example, uncertainties regarding belief systems and illness, the sick role, medical practices and gender role (Stewart and Leggat, 1998). Argyle (1994) purports that delegates who lack culturally relevant social skills and knowledge, will have difficulty initiating and maintaining harmonious relationships with those whom their mission requires them to interact. Furthermore, it is demonstrated that culturally unskilled persons are less likely to meet their personal and professional goals. Interestingly, it has been suggested that successful cross-cultural transition in the host country may enhance ‘culture shock’ upon repatriation to one’s country of origin at the end of mission (Sussman, 2002). McCreesh (2003) terms this phenomenon re-entry syndrome or reverse culture shock and highlights feelings of disorientation, bereavement and isolation. It is further stressed that the returning delegate’s experiences will have an impact upon family and friends also. Sussman (2002) believes that with effective end of mission de-briefing and preparation, the distress of culture shock, should it occur upon repatriation can be expected to dissipate within twelve to fifteen months of re-entry. An avenue of debate is however left open here for the implications of re-adjustment to delegates undertaking humanitarian missions with only a short duration between each. Holtz et al (2002) actually recommend shorter periods of deployment to unstable situations in order to reduce psychiatric morbidity. Stewart and Leggat (1998) demonstrate conflicting data, asserting that the cross-cultural adjustment process can take up to twelve months which has further important implications for workers on shorter term missions. Collins and Long’s (2003) data suggests that this time line may need to be reconsidered and further lengthened (see Appendix A), while Sussman (2002) and Shepherd and Hodgkinson (1990) emphasize the cyclical nature of cross-cultural adjustment. Stewart and Leggat (1998) raise the important point that as with any psychological process, it is possible to remain fixed in part of the process and not progress to the final stage of adaptation. In order to minimise the potential downfalls of cross-cultural transition Bochner, 2003 advocates for an active, adaptive process of dealing with change. Ideally this would incorporate techniques that aim to reduce anxiety, increase self-efficacy and emotional resilience and facilitate the development of effective coping strategies. At the same time, the validity of the unfamiliar culture and the advantages of cultural diversity would be enforced.The prevalence of psychiatric morbidity in international humanitarian workers as a result of occupational exposure to extreme stressors is unknown (Eriksson et al, 2001). A literature search undertaken by the author presented studies that predominantly focus on the experience of the affected local population or military personnel. The affected population make no choice to participate and military personnel will generally have a very different agenda to humanitarian delegates, rendering the research not readily generalisable to the international humanitarian community.Shepherd and Hodgkinson (1990) identify six areas of psychological response to disaster exposure: emotional, cognitive, behavioural, socio-cultural, somatic effects and motivational changes. These appear to correlate with the manifestations of being ill-prepared for cross-cultural adjustment, which can be understood in physiological (disturbances in appetite, sleep and concentration), psychological (anxiety, depression, sadness, anger, confusion in role, expectations, values and self-identity) and socio-cultural responses (inappropriate thinking or behaving) (Ward et al, 2001; Stewart and Leggat, 1998).Individual but cumulative and unsupported effects can result in far more serious manifestations and Collins and Long (2003) highlight further terms used in the literature to describe these negative effects of working with trauma: Post traumatic stress disorder, vicarious traumatisation, compassion fatigue, which may be an important risk factor or precursor to burnout, and secondary traumatic stress disorder (exposure to traumatic material through a professional relationship with the primary victim, Holtz et al, 2002). Collins and Long (2003) stress the importance of not becoming over-involved in the terminology of these adverse psychological effects but instead, focusing upon the recognition of stressors, acknowledgement of symptoms of stress and the utilisation of effective coping mechanisms.Lauterbach and Vrana (2001) claim that in examining risk factors of post traumatic stress disorder (PTSD) researchers have focused too readily on trauma intensity and have not given enough consideration to alternative variables. However, various literature contradicts this claim: Risk taking behaviour has been shown to increase the likelihood of an individual developing PTSD, though Davidson (2000) asserts that people are individuals and so will be affected differently by the same situation. In the same vein we are reminded that groups of people can react differently to circumstances. For example, age and gender may influence risk-taking behaviour, as may geographic location or cultural isolation (Davidson, 2000; Shepherd and Hodgkinson, 1990; WHO, 2000). Shepherd and Hodgkinson (1990) offer that prior experience and effectiveness of coping strategies are potentially confounding variables in individuals with an increased risk of psychiatric morbidity. As long ago as 1950 occupational health was defined as “…the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations by preventing departures from health, controlling risks and the adaptation of work to people, and people to their jobs” International Labour Organisation and World Health Organisation (ILO & WHO, 1950). Davidson (2000) asserts that there is considerable variation in the way that the relief sector prepares its staff to work in the world’s most hazardous regions. The frequency and quality of information given is also questioned. Davidson (2000) also feels strongly that humanitarian organisations should not separate their agenda on human rights and global development in the international community and in their employees. These factors must raise concerns in several areas: with the agencies themselves, and importantly, the networks and donors that are funding, developing and promoting these organisations. ILO (2000) highlights that current legal guidance regarding the liability of employers towards relief workers is highly deficient and calls for legislation to rectify this. WHO (2000) recommend that donor agencies make their funding conditional on measurable accountability both to the staff of the receiving organisation and the funding agencies.In recent years three main guidance documents have been formulated by the humanitarian community and have now been adopted by many international non-governmental organisations (NGOs). These are the Code of Conduct for The International Red Cross and Red Crescent Movement and NGOs in Disaster Relief (IFRC, 1994)(Appendix B), People in Aid Code of Good Practice (People in Aid, 2003) (Appendix C) and Sphere Humanitarian Charter and Minimum Standards in Disaster Response (The Sphere Project, 2004)(Appendix D). Ditzler (2001) highlights the diversity in size, financial resources, skill mix and mission statement of NGOs and argues the case against a generic solution. Davidson (2000) stresses that the importance lies not with which law, code, convention or charter is signed by an agency, but with what is actually done, how much commitment is offered and in the auditing of practice.People in Aid (2000) purport that briefing, de-briefing and counselling of staff is an essential component of health promotion and protection. However there are few, if any, clear directives on when and how to brief and de-brief staff. Sussman (2002) further advocates for effective briefing and de-briefing in order to facilitate the delegate’s journey through the cultural transition cycle. There is an ongoing debate regarding the efficacy and indeed safety, of Critical Incident Stress Debriefing (CISD) in the prevention of post-traumatic stress symptoms/disorder (please see Bibliography for further reading). This literature does however, have one common factor in that the focus is on a single incidence of CISD, whereas it is intended to be integral to an entire critical incident stress management programme (Mitchell et al, 2003) and needs to be offered more than just once (Salston and Figley, 2003). UNHCR (2000) advocate for a stress management process to be integral to all humanitarian missions where team leaders act as role models to facilitate and empower their team to manage stress effectively. Davidson (2000) states that good management and support cost money but poor management and support have further reaching costs. Poor preparation and lack of information are cited by People in Aid (2000) as serious contributors to the erosion of work efficiency and capacity. If team members leave a programme before the end of a contract there is increased pressure on the rest of the team until a replacement is found in addition to the financial costs of repatriation, re-advertising a vacancy, and the transportation of new staff (Hartl, 1998). There will also be the additional costs to the agency’s reputation both as an employer and as a user of donor funds and also costs to the credibility of any international codes, charters and conventions supported by the agency (Davidson, 2000).People in Aid (2003) report that at the least, adequate briefing and preparation can mitigate the implicit deprivations and discomforts that come hand-in-hand with relief work. Insufficient preparation and lack of support in the field is likely to lead to feelings of powerlessness which in-turn may lead to apathy and failure (Davidson, 2000). This has been shown to have significant negative consequences in terms of effectiveness and retention, the promotion of established policy and identification with the mission (UNHCR, 2000). The costs of poor management are far-reaching and encompass the individual, their family and socio-cultural network, their host organisation and the wider humanitarian community (Salston and Figley, 2003).This assignment has highlighted the multi-factorial stressors that may challenge the psychological well being of a humanitarian delegate. Recent strategies to minimise and manage these stressors have been discussed and the diverse implications of the poor management of occupational mental health have been explored.The findings of this discussion highlight the need for further and urgent research into the quality management of the psychological well being of humanitarian delegates. Studies need to be of a longitudinal nature, measuring both qualitative and quantitative data, be methodologically sound and generalisable to the humanitarian community; factors all seriously lacking in the current literature.The work of a number of humanitarian organisations in creating standards documents that encompass guidance on the preparation and support of delegates, demonstrates some commitment towards the importance of the mental health of their work force. It has been pointed out however, that the emphasis must be on what is done, the commitment with which it is done and the audit of these efforts. The CHP (2002) encourage individuals to be pro-active in maintaining their psychological health. Davidson (2000) re-enforces the importance of self-responsibility, but stresses that it should not be the sole responsibility of an individual or group to ensure their own security, health and well being. With this in mind, perhaps the time has come for us, the delegates, to accept our vulnerabilities, and advocate for our occupational health rights as members of the humanitarian community. ReferencesArgyle, M (1994) The Psychology of Interpersonal Behaviour (5th edition). London: Penguin.Bochner, S. (2003) Culture shock due to contact with unfamiliar cultures. In Lonner, W.J. Dinnel, D.L. Hayes, S.A. and Satther, D.N. (Eds) Online Readings in Psychology and Culture (Unit 8, chapter 7). Available: Canadian Council for International Co-operation cited by Davidson, S. (2000) Consultative Meeting on Management and Support of Relief Workers, Section 2 Keynote presentation. Available: Accessed 22/05/04Center for Humanitarian Psychology (2002) Stress in Field Life. Available: Accessed 16/04/04.Collins, S. and Long, A. (2003) Too tired to care? The psychological effects of working with trauma. Journal of Psychiatric and Mental Health Nursing 10, 17-27.Davidson, S. (2000) Consultative Meeting on Management and Support of Relief Workers. Available: Accessed 22/05/04Ditzler, T. (2001) Mental Health and Aid Workers: The Case for Collaborative Questioning. The Journal of Humanitarian Assistance. Available: Accessed 04/05/04Eisenman, D.P. Bergner, S. and Cohen, I. (2000) An ideal victim: Idealizing trauma victims causes traumatic stress in human rights workers. Human Rights Review, 1, 106-114.Eriksson, C.B. Vande Kemp H. Gorsuch, R. Hoke, S. and Foy, D.W. (2001) Trauma Exposure and PTSD Symptoms in International Relief and Development Personnel. Journal of Traumatic Stress 14 (1) 205-212.Hartl, G. (1998) Preparation of Emergency Aid Workers Inadequate, says WHO study. Press Release WHO/51. Available: Accessed 22/05/04Holtz, T.H. Salama, P. Lopes Cardozo, B. and Gotway, C.A. (2002) Mental Health of Human Rights Workers, Kosovo, June 2000. Journal of Traumatic Stress 15 (5) 389-395.ILO & WHO (1950) cited by Davidson, S. (2000) Consultative Meeting on Management and Support of Relief Workers. Available: Accessed 22/05/04ILO (2000) Consultative Meeting on Management and Support of Relief Workers, Section 3, conduct of the meeting (employer responsibility). Available: Accessed 22/05/04International Federation of the Red Cross and Red Crescent Societies (1994) Code of Conduct. Available: Accessed 21/05/04International Federation of the Red Cross and Red Crescent Societies (2003) Code of Conduct. Available: Accessed 21/05/04Lauterbach, D. and Vrana, S. (2001) The Relationship Among Personality Variables, Exposure to Traumatic Events, and Severity of Posttraumatic Stress Symptoms. Journal of Traumatic Stress 14 (1) 29-45.McCall, M. and Salama, P. (1999) Selection, training, and support of relief workers: an occupational health issue. BMJ 318, 113-116.McCreesh, M. (2003) Re-entry Syndrome. Available: …whole address? Accessed 21/05/04Mitchell, A.M. Sakraida, T.J. and Kameg, K. (2003) Critical Incidnt Stress Debriefing: Implications for Best Practice. Disaster Management and Response 1 (2) 46-51.People in Aid (2000) Consultative Meeting on Management and Support of Relief Workers, Section 3, conduct of the meeting. Available: Accessed 22/05/04People in Aid (2003) Code of Good Practice. Available: Accessed 23/05/04Salston, M. and Figley, C.R. (2003) Secondary Traumatic Stress Effects of Working With Survivors of Criminal Victimization. Journal of Traumatic Stress 16 (2) 167-174.Shepherd, M. and Hodginson, P.E. (1990) The hidden victims of disaster: Helper stress. Stress Medicine 6, 29-35.Stewart, L. and Leggat, P.A. (1998) Culture Shock and Travellers. Journal of Travel Medicine 5, 84-88.Sussman, N.M. (2002) Sojourners to another country: The psychological roller-coaster of cultural transitions. In Lonner, W.J. Dinnel, D.L. Hayes, S.A. and Satther, D.N. (Eds) Online Readings in Psychology and Culture (Unit 8, Chapter 1). Available: Accessed 21/05/04The Sphere Project (2004) The Humanitarian Charter. Available: Accessed 23/05/04UNHCR (2000) Managing the Stress of Humanitarian Emergencies. Staff Welfare Unit, UNHCR:Geneva.Ward, C. Bochner, S. and Furnham, A. (2001) The Psychology of Culture Shock (2nd edition). Hove: Routledge.BibliographyArmstrong, K. O’Callahan, W. and Marmar, C.R. (1991) Debriefing Red Cross Disaster Personnel: The Multiple Stressor Debriefing Model. Journal of Traumatic Stress 4 (4) 581-593.Bisson, J.I. Jenkins, P.L. Alexander, J. and Bannister, C. (1997) Randomised controlled trial of psychological debriefing for victims of acute burn trauma. British Journal of Psychiatry 171, 78-81.Campfield, K.M. and Hills, A.M.(2001) Effect of Timing of Critical Incident Stress Debriefing (CISD) on Posttraumatic Symptoms. Journal of Traumatic Stress 14 (2) 327-340.Deahl, M.P. Srinivasan, M. Jones, N. Neblett, C. and Jolly, A. (2001) Evaluating Psychological Debriefing: Are We Measuring the Right Outcomes? Journal of Traumatic Stress 14 (3) 527-529.Hobbs, M. Mayou, R. Harrison, B. and Warlock, P. (1996) A randomised controlled trial of psychological debriefing for victims of road traffic accidents. BMJ 313, 1438-1439.Raphael, B. Meldrum, L. McFarlane, A.C. (1995) Does debriefing after psychological trauma work? BMJ 310, 1479-1480.Townsend, C.J. and Loughlin, J.M. (1998) Critical Incident Stress Debriefing in International Aid Workers. Journal of Travel Medicine 5, 226-227.Appendix APatterns of adjustment to new culturesStewart and Leggat (1998) and Collins and Long (2003)Appendix BCode of Conduct for The International Red Cross and Red Crescent Movement and NGOs in Disaster Relief.Appendix CPeople in Aid Code of Good PracticeAppendix DSphere Humanitarian Charter and Minimum Standards in Disaster Response ................
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