Over the past 20 years there has been growing attention to the psychosocial impact of working in post disaster and post conflict environments on humanitarian workers [Fawcett & Gray, 2010; Integrated Regional Information Networks (IRIN), 2010]. Having just spent most of the past 6 months in Haiti, working directly on the issue of staff support and providing psychological first aid to locals affected by the earthquake, it is clear to the author that, with the current trend towards increases in natural disasters, there must also be an increased trend to care for those who assist the victims and survivors of these events. Organisations deploying staff to complex humanitarian emergencies must prepare them for the immense challenges they will face, and must be prepared to weather the impact on their own organisations.
The increasing importance of staff support
This field report summarises the experience of the author, who has worked with many local Haitians, providing brief counselling and psychological first aid (PFA) sessions, and developed staff support programmes and services for several local nongovernmental organisations (NGOs) and larger international nongovernmental organisations (INGOs). In the six months since January 12, 2010, the author has provided over 350 individual, and more than 25 group, sessions and educational/informational sessions to Haitians nationals working with NGOs and to international staff deployed to Port au Prince, Leogane and Jacmel (all areas affected by the earthquake). To describe this as a disaster of unprecedented magnitude demonstrates the limit of language to describe human experiences of hardship and suffering. The comprehensive psychological first aid programme of the National Child Traumatic Stress Network (NCTSN) and the National Center for PTSD (NCPTSD, 2009) describes four elements that contribute to distress after disasters:
- Loss reminders (can be sights, sounds, places, smells, specific people, the time of the day, situations or feelings) such as seeing a picture of a lost one or seeing their belongings, for example, their clothes;
- Trauma reminders that can evoke upsetting thoughts and feelings about what has happened;
- Change reminders that remind someone of how life has changed as a result of the disaster (can be people, places, things, or activities);
- Hardships that place strains on the survivors and make it more difficult to recover (examples can be the loss of home or possessions, lack of money, shortages of food and water, etc). (NCTSN/NCPTSD, 2007).
All of these factors are abundant in Haiti. These reminders, simply stated, complicate the recovery or healing process, not only for directly affected locals, but also for aid workers assisting in rescue, recovery, and humanitarian efforts.
Challenges of staff support in Haiti
The environment in Haiti is exceptionally challenging and distressing. Having lived in Haiti periodically over the last 12 years, the author is well resourced with a personal support system. For many of my colleagues who arrived to assist, this was not as true. The challenges of the harsh environment and the ongoing stories of suffering, loss and distress, combined with the demands of the recovery efforts and the increased challenges of the rainy season, have created a ‘perfect storm’ of converging factors that erode a sense of strength, fortitude and wellbeing, in even the most resilient aid workers.
Even at this seven month mark, there are still human remains being found in the rubble that is only now being cleared. In the authors' experience, while waiting three hours for a broken down car to be fixed during one of the biggest torrential downpours of the rainy season so far, earthquake debris – some human – was clearly visible floating by in the disturbingly murky, ankle deep, water flooding the streets. The humidity, the immense surge in sheer numbers of vehicles on the road, caused by what the Acehnese (post Tsunami) referred to as ‘the second flood’ (referring to huge numbers of humanitarian aid workers, and also described by locals in Haiti as ‘the invasion of the extra terrestrials’), the sheer rise in all living expenses (food, housing, fuel) have made the already chaotic and dysfunctional Port au Prince a tangled quagmire of tired, overworked and under resourced people, vehicles and debris. Having assisted with several staff support efforts, it is definitely a hopeful sign that many organisations, which previously did not consider the staff support aspect of humanitarian response, have begun to do so now. Those who already had systems in place (such as major international NGOs such as Care, World Vision International, Oxfam GB) were able to respond to the staff support needs of their organisations more effectively, and are valuable resources to the those members of the INGO community wanting to include staff support in their international programming.
Since the earthquake, the author has received almost 30 requests for staff support assistance from local and international organisations. Working closely with one large INGO, and providing ‘smaller’ services to many local NGOs, the overall impression of the condition of staff support is that there is still a very long way to go. Humanitarian workers (national and international) are exposed on a daily basis to a wide range of stressful situations such as: 1) pollution and debris; 2) living images of destruction (and sometimes remains of human dead); 3) the loss of significant historic and culturally symbolic structures like the National Palace, and the National Cathedral; 4) workloads that remain impossible, even in those organisations taking weekends off; 5) lack of infrastructure, making excursions more challenging than usual (although the night life in Petionville, where many expatriates live and work, is picking up); 6) deteriorating security; and 7) increasing frustration by many local partners.
It is therefore frankly incomprehensible that at this point, appropriate staff support measures, structures and systems are still not in place in many organisations – especially as these, and other stressors, have been well documented (Curling & Simmons, 2010). Many international staff work closely with national staff, which continue to be burdened by increasing prices, loss of loved ones and homes (some loved ones were never found), and the aforementioned ‘invasion’ of expatriates. One of the most commons stressors, heard from many international staff, is the feeling of powerlessness to ease the burdens of local colleagues and friends. The security situation has contributed to the inevitable separation between locals and internationals, as curfews and transportation restrictions make mingling difficult. One international staff member tearfully described ‘feeling like I am looking through a glass window at my Haitian colleagues, and at this lovely culture—I want to reach through and touch it—but I can't’. In a support session for an expatriate manager who was processing a series of what might best be called ‘stress related losses’ in her programme, she described feeling; ‘so distant from myself I have absolutely no interest in my work any more’. Furthermore, in reference to the support available to national staff, she appropriately questioned; ‘where would I go if we had a critical incident? I don't even know what I would do, or where to go. That terrifies me.’
A case example of a staff support programme
In response to the earthquake, one NGO that had considered a staff support programme, but had not found funding for it, developed a local staff support programme with international consultant input. After the author provided the initial several rounds of individual and group psychological first aid, my colleague John Fawcett and I oversaw the development and implementation of staff support programme intended to be comprehensive in its support of both national and expatriate staff. The programme was developed to ‘embed’ culturally congruent and meaningful staff support and wellness activities into the organisations daily operations.
Phase 1: psychological first aid
In the days following the earthquake, the author provided individual and group sessions to Haitian nationals working with a large INGO. These sessions were based on Psychological First Aid as made operational by The University of California at Los Angeles (UCLA), The National Child Traumatic Stress Network (NCTSN), and The National Centre for PTSD (2009). (See text box for information about how PFA was used in this programme in Haiti. See also Schafer, Snider & van Ommeren, 2010). Because the building used had been damaged in the quake, and aftershocks continued with fairly high frequency, most of this work was conducted outside. A lack of ‘safe’ indoor office space, elevated levels of fear indoors, and an initial lack of understanding about the authors' role, required a creative approach to delivering psychological first aid. The sessions focused primarily on stabilisation, safety and comfort, practical assistance (to the extent possible), encouraging connection to existing social support, and improving coping skills (see text box, below). Many of the ‘symptoms’ described by survivors of the earthquake were somatic in nature, and therefore many of the stabilisation activities were drawn from somatic psychology and dance/movement therapy practices. Specifically this included: basic breathing work (some drawn from contemplative practice), regulating core endogenous rhythms such as breath and heart rate through the use of breath work, music, and movement, and simple somatic awareness methods. These seemed to be very effective and well received by those seeking psychological support. Perhaps, this may well be because Haiti is a country with a rich, strong history of dance, drum and body based healing and cultural practices (WHO/PAHO (Pan American Health Organization), 2010).
It was striking that in previous post disaster periods in Haiti, such as the violence of 2004–2005 and the hurricanes of 2004, 2005 and 2007, such services were only utilised by small groups of people. This time however, there were always lines of people waiting for a session. Almost everyone self-identified as being traumatised and as ‘needing psychology’. Sessions were held anywhere there was space (i.e. a couch was moved under trees in a private area, as per the request of the office staff, or chairs were moved into part of the garden, creating a sense of a traditional Haitian lakou: a family and community gathering and healing place). Eventually, when people felt more comfortable to return indoors, a small office was designated as a ‘wellness space’ and was furnished with a comfortable couch and chairs, fresh flowers daily, small objects of spiritual or symbolic significance (such as angels, hearts, and seashells), and essential oils were always available. Findings and observations from this phase were used to form the basis of the assessment further carried out in Phase 2, which informed the proposal for the ongoing programme.
Phase 2: Needs and resource assessment and training of a local staff support team
The activities in phase 1 consisted of the provision of individual and group psychological first aid to all national staff in all sites of operation. Phase 2 consisted of continuation of psychological first aid, and an ongoing needs and resource assessment, along with recruitment of a local staff support team. Five local ‘wellness team members’ were hired from a pool of psychologists, nurses, and educators, and subsequently trained to provide brief individual and group consultations to a national staff of 1500. Their training and ongoing work is part of a larger programme meant to provide a range of support services – from crisis response to general support – and, while the training was thorough and comprehensive, their ‘job descriptions’ were left broad enough for adaptation and innovation as necessary.
The training was a three day programme, opened to other international organisations, and covered a range of topics including: understanding the causes of stress; identifying signs of stress; and coping strategies to mitigate stress and trauma responses. Information on the range of traumatic responses (i.e. primary to secondary trauma) was also included, and the sessions included ample time for group activities to process the new information in the local cultural context(s) (i.e. Haitian culture, organisational culture, etc.). Another primary module covered monitoring staff stress, and participants were given tools and information to design their own (individual or organisational) monitoring systems or programmes. Participants were also introduced to basic information, as background only, on psychological first aid, critical incidents, and coping and debriefing after critical incidents. All modules included group discussions or experiential activities (i.e. role play on critical incidents or ‘stressed out’ staff, and subsequent organisational issues); somatic movement and breathing based methods for various manifestations of stress, and opportunities for groups to present their approaches, findings and ideas.
The training prepared them to provide what they named a ‘ti koze su byen et’ (a little chat about wellness) to every staff member. This informational session of 60–90 minutes shared information on common signs of stress, coping strategies, and encouraged input regarding needs, issues, concerns, and coping practices already in use. These sessions also included information about services and resources available, and as a result of these sessions, many staff sought individual support sessions. Each staff support provider was encouraged to innovate other programmes based on their particular talent, skill set and passions. Daylong retreats at places of historic significance, beach outings, sports and artistic activities were all ideas that were proposed (often by the local and international staff, not just the staff support team) and, in several instances, implemented. A lack of committed resources disabled the possibility for some of these activities in some sites; this may be a strong beginning argument for the inclusion of staff support as a line item on our budgets.
The staff who were also trained in basic crisis response, were deployed to several critical incidents within the first four months of the programme. A local licensed psychologist, who was hired to provide specialised services to anyone the team referred to her, was made available for post critical incident psychological support and group and individual therapy. The team was also encouraged to make referrals to traditional support persons such as ‘Dokte Fe’ (Faith or Plant Doctors), Mambo and Hougan (Vodou priests and priestesses), and Catholic priests, or other spiritual or community leaders, if necessary. Because the team were essentially peers to other staff members, the programme was set up for them to be able to refer people to specialised services rather than providing for them, themselves. Consultants were available for mentoring and support, and when needed, assisted with troubleshooting and start up programmatic glitches.
Phase 3: Teambuilding, ongoing training and mentoring
The author made several visits to provide additional training (practical self care skills; teambuilding; somatic, movement and natural therapeutic interventions to calm, centre and/or energise) and to devise and/or update reporting and monitoring, and evaluation systems. Use of essential oils and somatic and bodywork techniques were especially appreciated as these are congruent with Haiti's rich tradition of plant and traditional healing, and many of the traditional healers are affected, like everyone else, by loss, stress and a need to rebuild and re-resource. Several mediation sessions were also provided as a supervisory team was hired after the initial training, and their lack of the same training created some misunderstandings, misperceptions and miscommunications.
When the mentoring period ended, the staff support team submitted plans for an ongoing programme, which hopefully will continue to be funded. An important initiative was the inclusion of a wellness orientation for international managers who requested ‘support similar to what our national colleagues have’, as part of the orientation offered to each new recruitment. During information sessions on wellness for expatriate managers, many of them expressed how separated they felt from local staff. It turned that both expatriate and Haitian staff found it difficult to reach out because the attempts seemed to be thwarted by language, cultural, and organisational barriers. Local staff described feeling ‘unwelcome’ by expatriate peers, while the latter described the same feeling, in reverse. Local and expatriate staff made many plans, and implemented them, for activities with national and international staff together, such as ‘Happy Friday’ social hours, informal outings, and language classes. A Haitian staff member, fluent in English and with work experience in the USA, assumed responsibility for wellness briefings that occurred concurrently with security briefings.
Finally, as a specific example of an activity to address many international staff longing to know more about Haiti's rich and generous artistic culture, we invited several colleagues from other INGOs to a local Haitian traditional dance class at a local dance troupes’ studio. The local dance troupe and community dancers were delighted to learn of others' interest in their culture. The activity was not only cultural; it provided an opportunity for physical activity, which is known to decrease stress and enhance wellbeing.
The future of staff support: lessons learned from Haiti
There are many lessons to learn from the ongoing experience of Haiti, a few are listed below:
- Staff support programming should be based on experiential learning, rather than rigorous implementation of protocols and checklists.
- The importance of local input and consideration, and inclusion of experiential ‘stress management’ activities, in the development and implementation of staff support programmes that are intended to assist national and international staff, is crucial for accessibility and efficacy (Anonymous, 2010). If ‘stress management’ workshops are intended to be part of these programmes, the same sensibility applies; rather than arguing for the development of protocol or standardised staff support/stress management programming, it may be wisest and more prudent to draw on the extensively growing body of knowledge accumulated over the past 20 years (Fawcett & Gray, 2010; WHO/PAHO, 2010). It would then be possible to build on the successes of organisations that have successfully institutionalised staff support into their international programming, with documentation and sharing of how local cultural context is integrated into these programmes.
- Staff support programmes need to use local cultural input
- It appears, at least anecdotally, that international staff can also benefit from an infusion of local cultural ‘intelligence’, as the tendency for national and international staff to remain separated was a major complaint of both international and national staff in Haiti. The perceptions of difference that this sense of separation contributed may also lead to frustration and communication issues at the work-site (both well known to contribute to cumulative and chronic stress and burn-out), which in turn can contribute to low morale, apathy and conflict among team members.
- Staff support needs to be an integral and essential part of humanitarian programming and not something ‘extra’ or something that one could consider only if there are resources
- Almost universally, the overall importance of staff support programming as an consistent and unwavering component of all international humanitarian endeavours seem to be moving from a novel idea to an organisational necessity, especially for those organisations sincerely dedicated to providing humanitarian assistance that is truly humanitarian.
The less successful aspects of the described programme in Haiti relate to the lack of support for international staff and the lack of precommitted resources. Simply put, the understandable and common (post disaster) changes in organisational structure and leadership that occurred as a result of the earthquake, contributed to a change in sentiment about the span, focus and continuity of the staff support programme, and the support for the international staff component ‘dried up’.
More and more organisations create a 1% (approximate) of their budget line item for security costs. The same amount could be apportioned to staff support which, while seemingly a ‘softer’ science than security, is actually directly linked to security. For example, when people are exhausted, unwell and/or burned out they are more likely to take risks, whether due to exhaustion or to apathy and ‘numbing’. Therefore staff support programming needs to be an integral part of all international humanitarian programming.