Why mental health for humanitarians matters
Stressors of the road
I think back to the last weeks of my deployment, pulling a suitcase through a new confusing airport, unpacking and repacking, moving rooms, moving teams, moving countries. My soul running winded trying to keep up with my ever time-zone changing body. As both a counselling therapist and a humanitarian aid worker I started wondering about the mental health impact specific to humanitarian settings.
According to research by Antares Foundation and the Centers for Disease, approximately 20% of international humanitarians struggled with depression after coming back from the field. In addition 12% were suffering with anxiety after their return, also increasing significantly over the course of their field work. Similarly for aid workers working in their home countries, between half and two-thirds suffered with depression, and half struggled with anxiety (Antares, p.8). These are no small numbers!
As a humanitarian before considering various ways to care ourselves or our team, it is important to understand what contributes to these symptoms specifically in the humanitarian setting. This blog will look at the unique stressors faced by humanitarians including: witnessing suffering, physical impact, insecure locations, low self-efficacy, lost connection, team tensions, poor quality of rest, workload, and disillusionment. As you read I invite you to reflect on which of these stressors resonates with you and how it is effecting your wellbeing. Understanding these stressors is important as such awareness is the starting place to protecting and restoring the mental health of ourselves and our teams.
Witnessing suffering
As a humanitarian it is a privilege to serve the most vulnerable, yet with this comes bearing witness to human suffering. You may hear stories from survivors and see first-hand the effects of poverty. As we witness injury occurring to others it also naturally injures us. This is also called vicarious trauma. One of the impacts of trauma, whether direct or vicarious, is an altering in the way we understand ourselves, others, and the world. We take what we have seen and heard and try to integrate this into an enlarged understanding of reality. While painful, this can be a process that leads to growth and personal depth. However, within the context of humanitarian work we are often so busy, and such experience so normalized, that there can be little room to acknowledge, honor, and give room for the impact of bearing witness. Another fallout from bearing witness is the concept of compassion fatigue, when we begin to numb emotionally after over-exposure to human suffering.
Physical impact
As children we played a game called "washing machine" where we would spin around as fast as we could until we fell over, complex I know! The humanitarian aid lifestyle can have a similar washing machine effect on our bodies. Here are some of the factors taking a toll:
When changing time-zones, the body looses sleep and has to adjust its rhythms, having a similar wear-and-tear effect as shift work. It's not uncommon to feel run-down or sick after traveling.
Although seemingly inconsequential adjusting to various different climates, particularly if extreme, takes energy reserves.
It may be more difficult in remote locations or with busy schedules to get adequate nutrition, such as vegetables or protein.
Tropical illness, such as from ingesting unclean water, is not uncommon, leaving you returning home clinging to an unhappy stomach.
We have often heard how important exercise is for our health and in beating stress, yet in many insecure contexts options for exercise can be restricted. Perhaps you are limited to a compound and unable to walk in the streets, parks and gyms being only a hazy dream.
Humanitarians face difficult living conditions in order to reach disaster areas. These realities can be both mentally and physically tiring.
Chronic (long-lasting) stress hormones fatigue the body over time, including weakening the immune system. We'll look more in depth at stress factors in a moment.
Our bodies and mental wellbeing are interconnected, if our bodies are under stress so too necessarily are our minds and emotions.
Insecurity
The places where we go to provide aid are also places where there is likely to be insecurity. This may expose us to life threatening situations as well as the cumulative stress of being in an insecure location. Examples of the most commonly reported incidences include nearby gunfire, break-ins, being chased, life-threatening illness, or the unexpected death of a colleague (Antares, p.10). National aid workers and their families also have the additional stressor of being directly impacted by the disaster effecting their communities.
When we face danger, our bodies gear up so that we are able to quickly respond in what is commonly known as the fight or flight response. Following the event our bodies then down-regulate or calm, aware that the danger has passed. However, in insecure contexts our bodies may not as easily calm. Instead we can remain chronically at a heightened level of hyperarousal (or stuck in fight or flight). Our bodies are doing this to try and keep us alert and safe, however, over extended periods of time being in such a heightened state can be physically draining. This kind of stress is known as allostatic load. Even when the situation is calm there are still certain daily realities that can add allostatic load over time. For example maintaining contextual awareness and monitoring the situation for deterioration.
Low self-efficacy
Having a sense of self-efficacy, or a trust in your capacity in your given role, is a buffer against the stressors you encounter. Conversely, in a high stakes environment a low sense of self efficacy can contribute as a significant stressor. One of the realities of the humanitarian context is that many aid workers find themselves facing a steep learning curve after deployment to a new location. Even those who are experienced in their role encounter a new culture and complex contextual realities that take time to understand. Staffing gaps, covering for colleagues, and learning on the go can also effect ones sense of self-efficacy. Time for training, hand-over, clear job descriptions, and supervision can be hard to find in the daily press to meet urgent needs. Within this field, staff are more frequently faced by critical decisions. Such choices can hold very real consequences for others as well as contain complex ethical dilemmas. Without support or self-efficacy such dilemmas can be a source of intense stress and moral injury.
Lost connection
One factor that consistently shows up as playing a central role in resiliency is social connection and physical presence. So how does this play out in the humanitarian context? Moving between countries on various deployments can naturally disrupt our social support networks. Aid workers can find it hard to maintain connections with those back home. After a long day of work on a computer turning to a screen for social connection can feel exhausting. Living in new cultures and the experiences of humanitarian life can change our sense of self and be hard to communicate to family and friends. Likewise, as life continues back home without us, there can be a sense of emerging disconnect from our home communities. This can be a source of anxiety for those working internationally. In addition, in moments when a family member or a friend is unwell or in need of support, we may feel a sense of helplessness far from our loved one. With the distance from home we naturally rely more heavily on our team for social support, however, humanitarian teams face their own challenges to connection and stability.
Team tensions
The intensity of the humanitarian context can be something that facilitates particularly meaningful friendships, yet it can also make humanitarian teams more vulnerable to fracture. Many returning from the field will sight relational tensions as the greatest stress they faced during their mission. You can find team stress anywhere in the world, but there are certain unique factors to consider in humanitarian contexts, lets take a look at these.
Context. In many insecure locations you are living within a walled compound unable to walk outside. Within this space there may be limited privacy for those calls home and that ugly cry you need. You may live, work, and socialize exclusively within your team. In addition to the intensity of living proximity there are also external pressures at play. It is rewarding to contribute to life-saving work, yet this brings with it the collective pressure of responsibility. This can come along-side facing life-threatening situations with your team. Such a high stakes reality turns up the stress volume for teams seeking to respond together.
Another element to consider is the potential for team isolation. You might have a small expat team (as small as one or two) in a given location. Such isolation means that unhealthy team dynamics have the potential to develop without being tempered by external accountability. Power differentials and geographic isolation, may also make it harder for concerns to be raised.
The humanitarian field is by nature transient. The relationship fatigue born from high turn-over can effect team atmospheres. All the various stressors we have been discussing can contribute to high turn-over rates which in turn increases team transiency and adds pressure on the more seasoned staff.
Additionally, team atmosphere can be effected by heavy workloads making it harder to find time to enjoy being together. Without the counterbalance of enjoying your colleagues as persons, you can start to associate one another only with feelings of stress.
Culture. Working with people from around the world can be wonderfully enriching and perhaps your favorite part of the job! However, sometimes misunderstandings can result due to cultural miscommunications. There may also be historical tensions between nationalities that creep unawares into daily interactions. One of the challenging things with culture is that much of it happens below conscious awareness. We may feel hurt and not be able to pin-point why. We are all creatures that gravitate to what feels secure and known, especially in environments where there is the discomfort of the unfamiliar. Therefore its not surprising that in international teams groups can form along cultural lines, reducing a sense of belonging.
Poor quality rest
With the stressors we have discussed so far it is easy to see the importance of quality rest for humanitarian aid workers. RnR is a life-line for many humanitarians, providing a chance to step outside the emergency context. However, some sight that the logistical effort of planning their trip can feel stressful. Exploring a new destination can be exiting, and often a draw to the life-style, however, navigating new locations can take energy. While some want to spend this time alone, for others if they are unable to coordinate their RnR with a colleague it can feel lonely.
In most cases, once a year humanitarians take home leave. This time of reconnection with family and friends is a vital source of both rest as well as social support. However, it can also be experienced as stressful. After being away for a year there can be many relatives and friends looking to spend time. The limited time can put pressure on these visits to be particularly meaningful. Home leave can also be the one time to complete life administration tasks from taxes to vaccinations. So home leave can quickly become a series of valuable yet tiring social commitments and administrative tasks. Another reality is that due to living primarily abroad, many humanitarians give up their home or vehicle. This means that on return they face renting, coach surfing, and relying on others for transportation. Not having their own space and independence can make it harder to rest.
End of contract.
For humanitarians the work cycle is unique. Contracts vary between an average of six-months to two years. At the end of a contract a humanitarian will face an often much needed period of time without work. However, while a needed break, this time can be filled with the uncertainty of looking for and deciding on the next right step. Similar to home-leaves, living abroad means they may not have their own place or vehicle to return to. With an uncertain amount of time off-contract it can be hard to plan these extended stays. If the individual decides to move out of the humanitarian sphere, they may face challenges re-entering their former profession. There can also be a psychological challenge transitioning from a high adrenalin, high meaning, and high responsibility role back into to daily life. In addition some find reintegrating back into their community challenging after being so long away. This can also be a time when the experiences of the field catch up to us as we try to process all that happened. There can be a grief process of loss, after leaving a country, team, and role that has become loved and where there was a sense of belonging. If entering this time in a place of burnout, post-traumatic stress, or sickness navigating these logistical and emotional requirements can feel especially daunting!
Workload
The nature of emergency work, particularly at the onset of a crisis, is that there are urgent needs and often limited resources. This means emergency workers can carry unremitting workloads. Working without regular rest intervals tires our reserves. This stressor can contribute to many of the other stressors: Increasing the wear and tear on our bodies with added fatigue; lowering a sense of self efficacy as we juggle multiple demands; effecting time spent with our team; reducing the quality of our rest; and adding to disillusionment when the weight of the work feels heavily bureaucratic .
Disillusionment
A sense of meaning and purpose is a source of immense strength no matter our walk in life. When living and working in disaster contexts this becomes particularly important. As we bear witness to immense human suffering and overwhelming need, being fortified by a sense of our place and purpose can strongly protect us against the discouragement that can so readily flounder those serving. Humanitarians are often hard working idealists wanting to make a difference. As we come crashing into the realities of bureaucracy, overwork, team distress, corruption, and hampered programming, we can become seriously discouraged. According to Antares et.al "one fifth [of humanitarians] reported feeling emotionally exhausted due to their work and nearly half reported that they felt a lack of personal accomplishment throughout their work" (p.8). Similar to bearing witness, the experience of disillusionment can result in an existential confusion. We can struggle with emotions of disappointment, anger, and shame. Disillusionment (along with chronic stress) can also contribute to the symptoms of burnout, finding we are loosing interest in our work and feeling exhausted and helpless.
A road worth taking
So then knowing these stressors and their impact on humanitarians where do we go from here? I hope that this blog has first raised awareness of the stressors faced by humanitarians, second given you compassion for yourself or other humanitarians experiencing distress, and third highlighted the importance of protecting ourselves and our teams against these stressors. As the world faces a growing number of humanitarian disasters we need healthy and compassionate people able to respond! We also need resilient teams to stand together and make a difference. As much as this blog has focused on the challenges of humanitarian life, this path also holds an equal measure of richness and beauty all its own. In my next blog, part two, "The Resilient Humanitarian" I'll explore how we can protect and restore ourselves and our teams on this road worth taking.
Further reading for the curious
Antares Foundation (2012). Managing stress in humanitarian workers: guidelines for good practice. www.antaresfoundation.org
Headington Institute (2014). Resilient responders: social support. Dr. James Guy. http://www.headington-institute.org
IASC Guidelines on MHPSS in Emergency Settings (2007). Prevent and manage problems in mental health and psychosocial well-being among staff and volunteers. page 50, Action Sheet 4.4
People In Aid (2003). Code of good practice in the management and support of aid personnel.
