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Comfort for the comforter

By Lesley Botez

Traditionally, psychological support within the Movement has centred on the needs of victims. However, recent world events have shown that relief workers themselves are at risk from stress. Now that this has been recognised, what steps are being taken to protect delegates from its ill-effects?

A series of accidents in the late 1980s and early 1990s, such as the disaster in which a car ferry sank off the Belgian coast, brought the issue of “psychological wounding” to the attention of European Red Cross Societies. The tragedies threw light on the needs of victims who had not seen the destruction of their homes or possessions, but who had suffered the loss of loved ones and witnessed scenes of horror. In these cases, the usual assistance such as food, blankets and medical care was secondary to providing psychological support.

“The term ‘psychological wounds’ applies to survivors of an accident who are physically unharmed but psychologically traumatised. It also aptly describes the con-dition of many humanitarian workers who have been involved in crisis or trauma,” explains Dr Barthold Bierens de Haan, ICRC delegate psychiatrist in charge of stress management programmes. “Just as rescue workers, police, fire-fighters and health-care personnel at home are subject to intense emotional reactions in the course of their duties, so Red Cross and Red Crescent delegates and humanitarian aid volunteers, working abroad in emergency or disaster situations, suffer severe stress or psychological overload reactions.”

The Federation has divided those who need access to psychological support into roughly three categories: the victims themselves; people in contact with the victims such as friends and relatives; and, since 1994, rescue workers and volunteers. The Federation’s Relief Health Adviser, Dr Jean-Pierre Revel, who develops and coordinates psychological support programmes to cope with the stress experienced by victims, widened his scope to cover delegates after fighting flared up in Kabul, obliging the Federation to close its delegation and evacuate its delegates. Some of the delegates, mainly health workers who were not accustomed to war situations, received psychotherapy after their experience.

This approach was not new to the Movement. Already in 1982, the Amer-ican Red Cross was aware of how stressful conditions could affect relief workers. Red Cross personnel in Santa Cruz, California, were the first to benefit from a programme of psychological support, set up for relief workers assisting victims of the mud slides that had devastated the region. By 1990, disaster mental health teams were providing psychological services to chapters elsewhere in the United States.

Jill Hofmann, an American social welfare officer and psychotherapist on loan to the Federation, explains how psychological treatment for delegates differs from traditional psychotherapy: “This type of therapy is aimed at discharging emotions. It does not dig deep into the past.”

The ICRC’s stress management programme has been operational since 1992 and contains three components: training before leaving on mission and support during and after the mission. It begins with an introductory course attended by all new delegates. Delegates are made aware of the range of emotional reactions they will experience and of the need to discuss their feelings.

Dr Revel is also adamant about the importance of this preparatory stage. “Adequate preparation not only defuses the situation, it also helps to boost confidence so that delegates are better equipped to handle difficulties and are ultimately more efficient.”

A special course has been devised for future senior personnel and heads of delegation at which they are trained to recognise stress in their staff. They are encouraged to identify likely reactions to traumatic incidents, which are not necessarily obvious in the heat of action. “They are advised to look out for minor behavioural changes, increased alcohol intake, reckless
driving, slight changes of character, abusive, depressive or aggressive statements, and self-neglect on the part of their colleagues,” explains Dr Bierens de Haan.

The ICRC has also introduced a field debriefing at the end of a mission. In the case of Rwanda, both the ICRC and the Federation organised rapid de-briefings in the field.

Finally, after a difficult mission, delegates are granted an additional period of rest to ensure an adequate interval be-tween assignments. Whenever possible, high-risk missions are alternated with low-risk assignments.
Results of the first 100 ICRC debrief-ings have confirmed the importance of adequate debriefing and follow-up. Although 38 per cent of the subjects were suffering from immediate or delayed-onset traumatic stress, and 49 per cent, most of whom had returned from Rwanda, from cumulative stress, some 85 per cent of these were able to leave on another mission within a few weeks after airing and dealing with their feelings.

By helping its staff to withstand the hardship involved in humanitarian activity, the Movement hopes to assist and protect precisely those who volunteer their services to bring assistance and protection to the innumerable victims of war and disaster.

“In the most inhumane conditions, human values such as group solidarity and strength of will are essential in the fight against adversity,” concludes Dr Bierens de Haan.

The Example of Rwanda

When the massacres began in Rwanda on 6 April 1994 ICRC delegates were eyewitnesses to scenes of unprecedented horror. The first accounts related by a delegate returning to Geneva headquarters were so harrowing that an immediate group debriefing was organised for relief workers leaving Kigali, with the aim of preventing psychological wounds.

On 19 April 1994, Dr Barthold Bierens de Haan arrived in the Burundi capital, Bujumbura, to run a psychological debriefing session for ICRC expatriates.

When they arrived in Bujumbura, the delegates from Rwanda were in a state of depression, rather than anxiety or fear as is usual after a security incident. The group of expatriates felt guilt and remorse at what they perceived to be their abandonment of those in danger, helplessness in the face of radio
pleas that they could not answer, wounded that they could not assist, friends and colleagues that they could not protect.

The debriefing in Bujumbura was the first to concentrate on the emotional reactions of delegates who have witnessed a catastrophe. It represented a new approach in other ways too. It was held a mere 24 hours after the delegates had left the hell of Kigali. This allowed them time to calm down but did not allow too much time to elapse following their departure. It also took place in the field, not in Geneva headquarters, emphasising the op-erational aspect of the exercise. Finally, participants were debriefed as a
group, not on a one-to-one basis, thus avoiding feelings of isolation and helplessness.

“The debriefings were conducted with a non-medical, ‘positive outcome’ approach in mind,” explains Dr Bierens de Haan. Sitting in a circle around a table with drinks and cigarettes, the group began, little by little, to open up. Facts were retraced, thoughts and emotions expressed.

Dr Bierens de Haan has concluded that this new style of debriefing is a worthwhile exercise. “A debriefing is useful as it diminishes mental suf-fering and feelings of failure and guilt. It is also simple enough to be run by a layperson with a good understanding of the ob-jectives and needs.”

Although it is too early to evaluate the longer-term effects of this sort of counselling on prevention of post-traumatic stress disorder, the symbolic impact of the exercise is clear. As Dr Bierens de Haan says: “Field personnel start to wonder whether the ICRC cares about their health and lives, and so the effect of sending someone from Geneva to run the debriefing is considerable. Rapid intervention also makes it possible to spot those people who need more specific assistance and who should be taken in hand by a specialist when they return to their own countries.”

Lesley Botez
Lesley Botez is a staff writer in the ICRC’s Communication and External Resources Department.

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