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Psychosocial support

Superheroes need
not apply


First aiders in some of the toughest spots in the world drop their superhero image.


Blood everywhere, death everywhere, fear everywhere. Being an emergency medical staff member is always stressful, but 2004 was particularly tough in Israel. Workers sometimes spent their shifts collecting body parts. Ambulances made frequent trips to the morgue.

In the midst of it all, an Israeli newspaper asked a senior manager of the Magen David Adom, Israel’s National Society, how his volunteers and staff were coping. “My people are tough,” he replied. “If they are not tough, they should not be here.”

Often seen as superhuman, emergency responders are trained and equipped to respond to whatever awaits, be it a broken leg or a mass-casualty accident. Their humanity makes them strong, but it is also sometimes their greatest weakness. Feelings of failure, guilt and sadness — in many ways the antithesis of everything they stand for — are not always easy for first aiders to accept.

Fortunately, the attitude is changing. Chaim Rafalowski, director of the Magen David Adom’s emergency management department, explains that a simultaneous drive from both the top and the bottom is helping to create a psychosocial support system for staff and volunteers.

“People have emotions and we need to help them cope,” says Rafalowski. “At the same time, people in the field are asking for a place to vent their feelings. Finally, there is a cultural change in Israeli society. Magen David Adom is going with the flow.”

The wheels of change were set in motion after the conflict with Lebanon in 2006. This year, the Magen David Adom, with support from the International Federation Reference Centre for Psychosocial Support and the Austrian and French Red Cross Societies, will disseminate information on psychosocial support and increase its peer support programme. Mental health professionals are backing the effort.

Unwritten contract

Emergency medical staff come to the scene with little knowledge of what awaits them. This tension can also lead to stress. Ready to respond to basic needs, they wait for, and fear, the ‘bad’ calls. The possibility of saving a life is often there, but things can go wrong. The worst is when a person dies while in the worker’s care.

“It is an ego issue,” says Rafalowski. “The saying among emergency medical staff is that ‘nobody dies in my ambulance’. When people die it breaks the unwritten contract — they should not die, we should keep the patients alive. This brings about a feeling of failure, and no one likes to fail, especially superheroes.”

Through the psychosocial support programme, Rafalowski hopes to make it easier for staff and volunteers to accept difficult situations. He says that especially the young volunteers, who make up half of Magen David Adom’s volunteer force of 10,000, need to learn this. “The younger you are, the more ideological you are and the more adrenaline you have,” he says. “You think you will save everyone. This is a powerful drive if put within realistic boundaries.”

Jonathan Caspi, 17, has been a volunteer for two years. He spends all his free time on Magen David Adom activities. He hopes to be a medical doctor one day and is driven mainly by the feeling of helping people.

“My friends and I have seen lots of bodies,” Caspi says, “but nothing has bothered me that much. Still, we will probably need psychological help. I guess it will come back to haunt us.”


The Austrian Red Cross has provided peer support to its workers for about ten years.

“People need to know what the system can do for them,” says Harald Legner, a Salzburg ambulance worker for 16 yearsand a peer supporter for eight. “The knowledge that someone is there for you is more important than anything else. It makes people feel safe at work.”

Barbara Juen, a professor of psychology at the University of Innsbruck and a long-time Austrian Red Cross volunteer, was instrumental in creating the peer support system in Austria and is now helping the Magen David Adom to implement a similar structure. “Setting a programme like this up is really a way to say we care for you,” she says.

Ofer Lachme, a Magen David Adom paramedic in Tel Aviv, echoes these sentiments. “When our leaders went on television and said, ‘Our people are tough’, it was hard for me,” he says. “It felt like no one thought about us. No one cared, not even our managers.”

‘Bad’ jokes

Juen emphasizes that implementing a peer system does not mean banning humour
and sarcasm. “When we started there was a fear that everything would have to be serious,” she says. “This is not the case. Volunteers and staff can talk to the peer supporter about their feelings and make ‘bad’ jokes about the incidents. First aiders are more sensitive to stress reactions in others and themselves, but they may keep their protection shields.”

While most cases are solved within the team, Legner and his colleagues are always available. Carefully selected and specially educated, they also link the workers to professional psychologists when necessary. Most often, however, information and the opportunity to talk is what is needed.

Through information sessions, the workers learn to recognize stress signs, and increasing numbers are asking for help. Quiet and safe places for difficult conversations are set up, contact details are easily available and confidentiality is guaranteed. Legner says he sees the difference.

“Before, people would leave the organization if they experienced a bad situation,” he says. “I tell them that they are not stupid or weak when they react to a situation, they are only experiencing normal reactions to an abnormal situation. We have much less turnover now.” Juen confirms this. “Now, the older guys take care of the younger ones,” she says. “They take more responsibility for their colleagues.”

Need for peers

Both National Societies emphasize the value of psychosocial support from peers. “In the acute phase, workers only accept help from others with field experience,” Juen says. “This is why the peer model is effective.

“The added challenge in Israel is the much higher stress level, for both the ambulance personnel and people in general,” she says. “The Magen David Adom needs an even better structure to make the peer system work.”

Head of the ICRC mission in Jerusalem, Katharina Ritz confirms that the situation in the region is difficult.

“Staff and volunteers of National Societies are at the forefront of every emergency, often putting their own life at risk,” she says. “Every time there is an attack in Israel or in the Palestinian Territories, volunteers go to assist the victims — sometimes in their own neighbourhood. They might find neighbours, friends or even relatives among the dead and wounded. We tend to forget that the carers also need to be cared about. Providing psychological support to staff and volunteers is, therefore, extremely important.”

Too much

Karin Unterluggauer, a psychologist and long-time member of the Austrian Red Cross Crisis Intervention Team, confirms the value of the peer support system. Ambulance personnel call the teams when extra support for victims and relatives is required, mostly in cases of death or traumatic stress.

“We only have bad calls,” she says.

While this means they know better what they will face on the scene, it also means their work is challenging and support is vital.

“Once we were responding to the third incident in one shift, the sudden death of an infant,” she explains. “We spent four hours on the scene. It was really too much. My colleague had to leave the house to cry and I also had to restrain myself. I could not invite the mother to talk with her dead child because I knew I would break down. I could not meet my own standards.”

In conversations with the peer supporter, they worked through their emotions. “It was only then that I realized how hard it really was,” Unterluggauer says. “I let down my guard during that conversation.”

Not superwoman

Maya Dror has been a volunteer and staff member of the Magen David Adom ambulance service for 17 years. She is pleased the National Society is going to provide psychosocial support.

“Once, I responded to a terrorist attack,” she says. “We collected the bodies. I remember lifting a detached head. Blood was dripping from it. We took the bodies to the morgue. I went home, took a shower and went on with whatever I was doing before the call. How could I do that? I do not feel like a superwoman, there is no reason why I should not be disturbed.”


First aiders help people injured in a crash involving about 100 vehicles in Austria in March 2008.





Åsta Ytre
Åsta Ytre is a communication adviser at the International Federation Reference Centre for Psychosocial Support.

The International Federation Reference Centre for Psychosocial Support is hosted by the Danish Red Cross. Its mission is to promote and enable the psychosocial well-being of beneficiaries, humanitarian staff and volunteers.
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