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Psychological support:
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 come back."




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.

Slow progress

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 nuclear disaster.

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 stress

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
Iolanda Jaquemet is a freelance writer based in Geneva.

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