luxury or necessity?
Listening and validating feelings of stress are important
when providing psychological support.
For most of the last century, agencies
involved in emergency disaster relief provided affected populations
with four elements of basic human needs: food, water, shelter
and physical care. It was only during the last two decades
that emotional well-being became a concern
and considered by some as the fifth element of basic needs.
In 2001, what was once merely an awareness is now translated
into action. Humanitarian relief agencies are slowly, but
steadily, integrating psychological
support into their services. Policymakers and donors must
now consider that emotional trauma in the aftermath of conflicts
and disasters is a major barrier to the sustainability of
any recovery investment. The sooner
the psychological intervention, the sooner a community becomes
self-sufficient and actively participates in its own evolution.
Red Cross, Red Crescent asked journalist Iolanda Jaquemet
to examine the subject.
"Catalino, Catalino!" At the sight of the Salvadorean
Red Cross volunteer, the kids run barefoot from among the
banana trees. It is time to play, to block out the memories
of the earthquakes and to forget, for an hour, the aluminium-roofed
shelters now called home. The little ones laughingly form
a circle and join in the games organized by the volunteers.
Next, it's the high point of the day: the piñata, a
huge doll made of cardboard and multicoloured crêpe
paper, which the children hit with sticks until, to their
cries of delight, its swollen stomach disgorges a cornucopia
of sweets. They scramble for the bounty, as the first raindrops
begin to fall.
In January and February 2001, two violent earthquakes left
nearly 9,000 dead or injured and more than a million displaced
or homeless. This was a major disaster for a small poverty-stricken
country of 6.2 million.
The Movement responded immediately. Following Hurricane Mitch
in 1998, the Federation had already established an office
on the spot. "Within 24 hours, we identified an urgent
need for psychological support," says Iain Logan, former
head of the Federation's operations in Central America. An
old hand in the humanitarian field, he knows that the population
has just undergone a major trauma as serious as any conflict:
the earth, which had always been there, disappears beneath
your feet without warning. Sounds and smells emanate from
the depths. And it seems never-ending as for two months, thousands
of aftershocks follow one after the other.
El Salvador has seen its share of misfortunes that have taken
their toll on bodies and minds. "I am only 31 years old,
yet I've already lived through a long civil war, Hurricane Fifi,
two other big earthquakes, Mitch, and now this. Not to mention
the everyday violence and social delinquency," laments
one National Society employee.
What is stress?
"Stress" is a technical term to describe the body's
natural response to an assault. Just like metal when put under
pressure, the human body can remain elastic, warp or break.
There are different kinds of stress: first, basic stress,
which is very common, for example, among humanitarian workers
at the beginning of a mission. The build-up of daily assaults,
even minor ones, can lead to accumulated stress, all the more
dangerous because it is insidious. The most common symptoms
are innocuous and non-specific: fatigue, disturbed sleep,
aches and pains, digestive disorders or headaches. A serious
incident, however, such as an attack, hostage-taking or disaster,
can trigger post-traumatic stress, which if prolonged, can
develop into post-traumatic stress disorder (PTSD).
Psychological first aid
The American Red Cross dispatched an expert in psychological
support to the area. Barely two weeks after the first earthquake,
Dr. Joseph Prewitt Diaz had trained 120 Salvadorean Red Cross
volunteers. They were grouped into "mental health brigades"
and worked alongside several partner National Societies such
as the American, French and Italian Red Cross Societies. Accompanied
by psychologists and psychiatrists from the Ministry of Health,
the volunteers paid house-to-house visits.
"We don't mention mental health that would create
barriers," says Patty Herrera, one of the volunteers.
"We ask them if they have lost a loved one, if they have
stomach pains or headaches..." And out pour the problems
children who wet their beds, nightmares, palpitations, depression,
the fear of it all happening again. "To begin with, people
wanted material assistance," continues Patty. "But
in the end, they were happy simply to talk and asked us to
Each time, the same simple principles are applied. The psychosocial
assistance teams allow people to talk about their suffering
and fears. They listen sympathetically and validate their
feelings. They also provide clear and factual information
because rumours make stress even worse. During the first round
of visits, the most serious cases are referred for specialist
treatment. For the rest, there are follow-up visits and group
sessions, to enable participants to share their experiences.
It is more a case of post-trauma prevention than treatment:
being able to talk often mitigates complications later. "People
need this kind of help within 30 days," says Oscar Morales,
secretary general of the Salvadorean Red Cross. "After
that they internalize their pain, sometimes with fatal consequences."
From the outset of this particular disaster, the Salvadorean
Red Cross, its partners and the Federation gave a broader
dimension to conventional concepts of relief assistance, as
its name, psychosocial support, suggests. Group sessions are
organized with school-teachers (600 of whom have been trained
in psychological first aid) and community leaders. Discussion
and relaxation exercises are combined with first aid, medical
consultations and courses on a balanced diet for children.
Indeed, children require particular attention. The American
Red Cross combines play, colouring books and puppet and clown
shows to focus the children on life after the earthquake.
To address the psychological needs of affected adults, group
sessions allow fears and other stress-related emotions to
surface. "I saw men cry in public during group therapy,"
adds Fatima Palacios, a psychologist from the Italian Red
Cross. "That is quite a cultural revolution in a country
that glorifies the 'macho' image of the invulnerable male."
It was the same during the debriefing sessions which brought
together 1,200 volunteers and staff members. "All the
participants told us it was the first time someone had listened
to them," says the sessions' organizer. "They didn't
want to talk about it at home. At work, they were afraid their
bosses would think them weak if they confessed to emotional
problems, and would drive them out of the Red Cross."
For the first time, these men and women were able to acknowledge
openly that it is emotionally exhausting to absorb other people's
suffering all day long.
Two years ago, during Hurricane Mitch, National Societies
mounted a classic operation combining relief and medical assistance.
Now in 2001, the Salvadoran Red Cross is setting up the first
psychological support programme in Central America with assistance
from its partners. This programme is one of the first to integrate
emotional needs of affected people as an integral part of
an emergency response. This is the fruit of a seed first sown
about ten years ago. Today it is recognized that a victim
is not only a body to be healed, fed and protected, but also
an emotional being, whose mental equilibrium can be upset
by a trauma. Disasters earthquakes, nuclear accidents, conflicts
cause psychological wounds. Although invisible they are
just as real and can take a long time to heal. "Early
and adequate psychological support helps people cope better
and therefore assists them in making appropriate and healthy
decisions. Psychological support aims at helping people to
help themselves, a society needs active survivors, not passive
victims!" says Lise Simonsen, the psychological support
officer at the Federation's secretariat.
There have been several milestones along this road. Back
in 1917, the work of Dr. Salmon brought to light the psychological
trauma suffered by combatants in World War I. He documented
that the quicker and closer to the battlefront a soldier receives
psychological assistance, the greater his chance of recovery.
Just as a broken leg mends better the sooner the fracture
is treated. Decades later, the Viet Nam war popularized the
concept of PTSD (post-traumatic stress disorder) to describe
the long-term complications following a traumatic event and
the United States began to apply the principle of rapid intervention
not only in battle but also following critical situations
such as air crashes.
Kosovo: Red Cross mental health workers focus on outreach
to identify those in need of psychological suport services.
While intervention for those directly affected by trauma
and disasters evolved, so did the recognition of the psychosocial
needs of "secondary victims". In Europe during the
1980s, a series of ferry disasters shocked the northern parts
of the continent. The region's Red Cross Societies were confronted
by the distress not just of the survivors and the families
of the deceased, but also that of the lifesavers, ambulance
crew and firemen. Secondary victims suffer high stress levels
during incidents of mass casualty, when children are involved
or when bodies are in a horrific state.
These experiences prompted the Red Cross Red Crescent to
hold a conference on psychological support in Copenhagen in
1991. Two years later, the Federation and the Danish Red Cross
created the Reference Centre for Psychological Support in
Copenhagen. The centre guides National Societies interested
in developing their own programmes. Dr. Jean-Pierre Revel,
one of the Movement's pioneers in psychological support, represented
the Federation at the 1991 conference and recalls "a
mix of enthusiasm and scepticism about establishing programmes
in this area".
On 26 April 2001, six ICRC staff were murdered
in the Democratic Republic of the Congo. Sadly, this was not
the first tragedy of this kind to strike the Red Cross Red
Crescent. However, the Red Cross worker has long symbolized
the phlegmatic humanitarian worker who must at all costs
"keep up the façade", even when faced with
a serious incident. To express emotion would seem indecent
in view of the victims' suffering. But in May 1992, the death
of a head of delegation, killed in an attack on a convoy to
Sarajevo, upset these certainties. ICRC's Dr. Barthold Bierens
de Haan remembers both a "general gloom at headquarters"
and a rather abrupt response: "The flag was lowered to
half-mast, followed by a minute's silence. Then it was back
to work." This psychiatrist, with a long experience of
working with traumatized patients in hospitals, told himself
that "something must be done". He found an attentive
ear in the field and at the headquarters.
The change in approach coincided with the
arrival of a new generation of delegates, at once ready to
express their emotions and more demanding, wanting to know
their destination and the risks involved. We are witnessing
an evolution from the idealist motivated by a "higher
calling" to the humanitarian professional. Concurrently,
ICRC had become concerned by the high staff turnover and increase
in ill-health and dependencies (especially alcohol). Delegation
life was also pinpointed: overwork, difficult living conditions,
a sense of powerlessness vis-à-vis the victims and
interpersonal tensions. It was found that stress can lead
to security incidents because it upsets a person's healthy
capacity for analysis. Today, the ICRC's Stress Unit works
closely with the person in charge of security. A greater understanding
of the role of stress has led to the establishment of an "emotional
debriefing" to round off the operational debriefing.
The statistics are consistent: one delegate in four suffers
stress-related health problems during his or her mission and
5 per cent experiences post-traumatic stress.
Upstream, there is prevention. During training,
delegates learn what to expect in the field and are encouraged
to recognize their own limits. Since last year, a pilot programme
has enabled them to reflect more deeply on the relationship
with the victims. Evaluation missions are also carried out
in the field: "On our return, we make suggestions to
the desk officers, to the human resources department and to
the security unit, and we are listened to more and more,"
says Dr. Bierens de Haan. And, of course, there are the crisis
interventions, such as after the killings in April, when a
doctor was sent out straightaway, along with the director
of operations and the delegate general for Africa. "The
most important thing is that your employer acknowledges your
suffering and empathizes. This should become institutional
practice," added Bierens de Haan.
Then came a turning point: the emergence
of new types of conflict and greater exposure of humanitarian
workers to large-scale atrocities. These were the conflicts
in Somalia, Liberia, Croatia, Bosnia and Herzegovina and,
in 1994, the Rwandan genocide. A number of organizations found
themselves obliged to take into account not only the trauma
suffered by the victims, but also that of their staff and
on an unprecedented scale. According to nurse Sinead O'Donovan
and Dr. Michel Baduraux of the United Nations High Commissioner
for Refugees (UNHCR), "From 1989, we conducted the first
debriefings of delegates who had witnessed massacres. But
there was no institutional policy. After that, our colleagues
returned more and more often from war situations. They would
break down in tears for no apparent reason. So we had to do
something in a more structured way."
The most recent milestone was in the spring of 1999 with
the mass exodus from Kosovo. The masses taking refuge in Albania
and Macedonia were rapidly provided with material assistance.
But a problem remained: these were the victims of terror.
"Before, psychological support was considered complementary,
foreseeable only once survival needs were met," comments
Jean-Pierre Revel. "In the case of Kosovo, the absence
of an epidemic or nutritional crisis helped us realize that
we should deal with the issue of psychological support during
the emergency phase." It is a measure of the progress
made when you consider it was ten years before a psychological
support programme was set up for the victims of the Chernobyl
Early in the 1990s, both the Federation and the ICRC took
specific steps to address psychological support. The Federation
employed a psychotherapist for its delegates and for interventions
following major humanitarian crises, such as in the case of
Kosovo and the earthquakes in Turkey. In 1999, the ICRC created
a "stress unit" for its delegates and more recently
added a psychological component to its traditional activities,
such as in Algeria, where the institution supports a Red Crescent
programme for rape victims and children affected by violence.
Employers have found it a worthwhile exercise to pay attention
to the psychological needs of their workers. Since the introduction
in 1990 of a vast psychological support programme, the American
Red Cross has seen a dramatic fall in the number of volunteers
leaving the organization following disaster relief work.
Simultaneously, National Societies have launched a number
of successful programmes documented in a recent and enlightening
Federation publication, Psychological support: best practices
from Red Cross and Red Crescent programmes (2001). The World
Health Organization (WHO) has stepped up its consultations
and has designated mental health as the theme for 2001. UNHCR,
UNICEF and a few non-governmental organizations (NGOs) (namely
Care and Médecins sans Frontières) have set
up programmes for victims, while taking a more systematic
approach to providing support to their own staff.
Remembering to laugh: a natural remedy to
Prevention is better than cure
Mette Sonniks, who runs the Reference Centre in Copenhagen,
works closely with a growing number of National Societies.
Although today the centre and its objectives are widely recognized,
she is often invited not by the management but by the staff.
This enables the centre to apply a bottom-up approach, but
the downside is that if management does not see it as a priority,
the resources are not made available.
Resources are a real problem, especially during major disasters.
In El Salvador, only 2 per cent of the population directly
affected by the quakes received psychological support (21,000
people of a total of 1 million). An expert in the field at
the WHO, Mary Petevi reels off some hair-raising statistics:
"Currently 1.8 billion people live in conflict zones,
in transition or in situations of permanent instability. Of
these, 10 per cent are traumatized, and 10 per cent will develop
dysfunctional behaviour. That's 360 million human beings in
desperate need of support. But with current resources, there
is no way we can meet those needs."
The extent of the problem is even greater justification for
adopting a non medical, community-based approach. Suffering
is not a disease and to treat victims of stress as psychiatric
cases is counterproductive. Since individual treatment is
often too expensive and alien to many cultures, the solution
lies in "training by relay". This simply means raising
awareness of the psychological dimension among volunteers,
first aiders, social workers and teachers to enable a community
to be self-reliant. There again, El Salvador provides an interesting
example. The National Society wants to institutionalize its
psychosocial support programme. With financial assistance
from the Federation, it hired a psychologist to make volunteers
aware of the emotional aspect of their work. The idea is to
decompartmentalize this area, and make it an integral part
of disaster preparedness and response.
The cultural dimension is clearly of prime importance. Psychological
wounds are universal, but the manner in which they are expressed
or dealt with vary from one culture to the next. Support networks
in many societies are facing a weakening of their traditional
coping mechanisms embodied in religion, family and community.
El Salvador is one such society where the psychosocial support
programme created a bridge that helped communities to recognize
their loss, to begin the healing process and to focus on rebuilding
their lives. Today, many experts are advocating that when
dealing with severe crises, modern and traditional methods
should be integrated to provide holistic relief assistance.
This places Red Cross and Red Crescent workers in a prime
position to practise humanitarian aid aligned with holistic
concepts of assistance as each National Society is an integral
part of its own society and culture. In El Salvador, volunteers
use religious references during their interventions. In Kosovo,
the approach is based not on the individual, but on families.
Also in the Balkans, the Danish Red Cross programme for children
affected by armed conflicts (CABAC) relies on respected local
figures such as schoolteachers to help children.
Disasters also uncover deep-seated problems. In El Salvador,
the media has never spoken so much about domestic violence
as it has since the earthquake. This poses a serious ethical
question: can one be content to provide psychological support
after a disaster in countries where life itself is a disaster?
"What good is psychotherapy to a mother who has nothing
to feed her ten children?" asks Mary Petevi of WHO. She
is an advocate and a promoter of creating a new approach to
aid: integrating psychological, social and material assistance.
This may be the opportunity for the humanitarian world to
rethink its conventional modus operandi and to systematically
view human beings holistically, in their physical, psychological
and emotional entirety.
Iolanda Jaquemet is a freelance writer based in Geneva.
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