Resilient workers in

traumatic environments
Dr Debbie Hawker
For slides & references see
www.resilientexpat.co.uk/
talks.html
Resilience definition

The ability to anticipate,

withstand and bounce back
from external pressures and
shocks (UNICEF, 2011)
50% of aid workers
develop a psychological
disorder (Lovell, 1997)
What helps some cope
well while others dont?
How can we strengthen
resilience in workers?
 Organisational:
Selection,
Training,
(Family) support,
Debriefing
Emotional domain:
Validating emotions
Kevin: Traumatic situation (Pakistan)

Normal stress symptoms (tearful)

I should cope better

Maintained/ increased symptoms

Katie: Traumatic situation (Syria)

Normal stress symptoms

This is normal. Ill take some time off

& relax and look after myself

Symptoms reduced
Emotions: Research
Those who think I must be going
mad or I shouldnt feel like this
when they have normal trauma
symptoms are more likely to develop
PTSD (Ehlers, Mayou & Bryant, 1998)
or depression (Lovell, 1997).

Normalising (this is normal) assists

calming (Hobfoll et al., 2007)
So what do we do?
Train workers (during briefing &
debriefing) to normalise and
validate their emotions &
trauma symptoms
Kidnap example

Woman who was kidnapped for 1

year

Worst part was when fellow

hostage was released

She allowed herself to cry for 3

days after his release
 Organisational:
Selection,
Training,
(Family) support,
Debriefing
Social domain:
Social support research

Social support is a major

protective factor following
trauma (Hobfoll et al., 2007;
Bonanno et al., 2010; Brewin et
al., 2000; Dunmore, Clark &
Ehlers, 1999, 2001)
Isolation example
We live on a street with no name,
on the top floor of a villa with no
number. We have no landline, no
letter box, we live out of the city
centre The phone never rings,
no mail plops into our non-
existent letter box, people dont
pop in when just passing. I can
say hello and how are you in
Albanian but thats about it with
my neighbours
So what do we do?
Help workers build and maintain
good support networks
Allow enough time for this (holidays)
Team building; cohesion
Access to internet
Provide information, practical help
and emotional support after trauma
(psychological first aid)
Provide help when they return home,
to reduce isolation
Professional help available for those
who need it
Example: Terrorist attack
in Pakistan (school for
children of missionaries)
The families who evacuated
home seemed to have more
difficulties than those who
stayed together and supported
each other
 Organisational:
Selection,
Training,
(Family) support,
Debriefing
Physical: Health
research
Chronic stress has a negative
impact on health
Healthy behaviours build
fitness, energy & stamina and
so contribute to resilience
Regular exercise is associated
with mental health benefits
(Salmon, 2001)
Sleep deprivation
decreases resilience
(Leproult et al., 1997).
(3) Physical domain:
Healthy behaviours
Alcohol induces the stress
response (Tsigos, & Chrousos,
1995).
Aid workers engage in
Emergency sex and other
desperate measures! (Cain et
al., 2005)
Help Im going to
Darfur! What we did
Considered exercise
opportunities in restrictive
environment (skipping rope;
DVD; weight training)
Provided health information,
including sleep hygiene
Offered health checks
Help Im going to
Darfur! What we did
Monitored working hours
Compulsory R & R & holidays
Social events without excess
alcohol
Healthy food & drinking water
available
Addressed guilt about self-care
while others are needy
Indigenous staff in
Burundi
Providing mosquito repellent to
prevent malaria made a huge
difference to the resilience of
the night guards
 Organisational:
Selection,
Training,
(Family) support,
Debriefing
Cognitive domain:
Problem solving research

Poor problem solving skills are

associated with hopelessness,
angry outbursts and suidide
attempts; training in problem
solving is an effective mental
health intervention (Cuijpers et
al., 2007)
Cognitive domain:
Problem solving research
Problem solving is calming &
increases control, predictability,
self-efficacy, sense of mastery
& hope (Hobfoll et al., 2007)
Problem-solving is a skill which
can easily be taught (e.g. 7
steps - Fairburn et. al., 2008).
So what do we do?
Train workers to spot problems
early, consider various options
and implement effective
solutions
Train staff to anticipate and
plan for change
Offer mentoring in problem
solving
Nepal: Stay or go?

Helped aid workers problem

solve whether to stay or
evacuate during a civil war
Hostages: Stay or go?
Couple held for 15 months,
problem-solved whether and
how to try to escape
Also problem-solved how to
spend their time
And decorate their space
And stay fit and sane
They insist you CAN prepare
mentally
 Organisational:
Selection,
Training,
(Family) support,
Debriefing
Spiritual/ philosophical

a) Sense of meaning
b) Forgiveness
c) Gratitude
d) Nature
e) Mindfulness & silence
Spiritual/ philosophical:
(a)Sense of meaning
Life & death environments
often lead to spiritual questions
(McKay, 2011).
Sense of meaning
Humanitarian workers are willing to
endure suffering because they
believe they are doing something
worthwhile.

If they become disillusioned and feel

their work is meaningless they are at
high risk of depression (Lovell,
1997); violation of meaning is a risk
factor for PTSD
Sense of meaning: Body
handling
72% of police officers involved
with handling corpses after a
disaster used the coping
mechanism of thinking about
the positive benefits of the
work (to help grieving families),
and this helped (Alexander &
Wells, 1991).
Sense of meaning

Woman whose husband was

kidnapped 4 years ago: I know
we were meant to be there
this helps her cope

Frankl (1946) meaning in a

concentration camp
Rwanda (Bilinda, 1996)

It was like being in the tiny

pinpoint of calm at the centre of
a massive whirlwind ... I have
been stripped in one fell swoop
of so much that made up my life
my husband, my home, my job,
some of my dear friends ...
Rwanda (Bilinda, 1996)

But at the bottom of it all, God

is still there. I know he is still in
control, and that he will bring
good out of all this ... It's
inexpressibly painful. But in a
way it's a mysterious and
awesome privilege.
So what do we do?
Help workers develop and
maintain a sense of meaning in
their work e.g. through team
opportunites to reflect on the
bigger picture and celebrate
achievement.
Encourage them to keep
thinking about the positive
benefits of their work
So what do we do?
Help them rebuild a meaningful
world after trauma
 Spiritual/ philosophical:
(b)Attitude
Forgiveness helps people
recover physically,
emotionally, and mentally,
compared to holding on to
hostility and resentment
(Luskin, 2002).
Attitude

Gratitude is associated with

greater happiness, better
sleep, more energy & better
health (Emmons, 2008).
(c) Experiencing nature (from
gardening to wilderness
backpacking) increases sense of
hardiness and self-efficacy (Davis,
2008)
Need to be creative in some
locations (e.g. bowl of water)
Spiritual/ philosophical:
(d)Mindfulness
Mindfulness (awareness,
slowing down & meditation) has
been associated with
improvements in mental health
(Baer, 2003).
Silence may help reduce blood
pressure and heart rate, and
lower arousal (Larsen &
Galletly, 2006).
Spiritual/ philosophical:
(e)Organised religion

Religion often provides

psychosocial support, positivity,
motivation, and faster recovery
from trauma (Fiddian-Qasmiych
& Ager, 2013; Smith,
McCullough and Poll, 2003)
So what do we do?
Show respect for the place
of spirituality and ritual in
well-being (especially for
indigenous staff)
Provide time & opportunities
for spiritual development
(e.g. retreats)
So what do we do?
Train people to expect that
their beliefs may be
challenged by this work
Thank staff - model
gratitude
Faith-based organisations
may find it helpful to
consider theology of
suffering
 Organisational:
Selection,
Training,
(Family) support,
Debriefing
Organisational domain
(CISM)
(a) Selection
(b) Placement
(c) Preparation
(d) Support
(e) Debriefing
(f) Family support
(See the Code of Good Practice in
the management & support of aid
personnel www.peopleinaid.org)
Organisational domain
Organisational factors play a major
role in developing resilience
E.g. In a study of 21 agencies, aid
workers with the UN reported fewer
psychological symptoms than other
aid workers (Ager et al., 2012)
although the UN acknowledge they
still have room for improvement
http://www.unhcr.org/51f67bdc9.html
Organisational domain:
(a) Appropriate selection
Consider resilience and
psychological issues during
assessment (Lovell-Hawker,
2011).
E.g. Ask how candidate has
handled stressful situations in
the past
Organisational factors
(b) Placement
Consider where the candidate
should be placed e.g. need a
supportive environment? Good
access to healthcare? Urban vs
rural
Examples: Vegetarian; working
with prostitutes
 Organisational factors
(c)Preparation
Psychological preparedness
reduces risk of trauma
symptoms (Basoglu et al, 1997)
e.g. those who are tortured
cope better if they were
mentally prepared for torture
Briefing covers
Role requirements
Normal stress responses
Stress management (Solomon,
2003)
Security
Cultural issues
Work-life balance
Staying calm under pressure
(simulation training)
Wheelchair & croc?
Organisational factors
(d) Support
On-going support available e.g.
mentoring, supervision, security
advice, counselling if needed
Additional support after trauma
aimed at providing sense of
safety & reducing arousal
Limit unnecessary paperwork
Good administration and
rewards
 Organisational factors
(e) Debriefing
Controversy due to studies of
inadequate debriefing (see
review in Hawker, Durkin &
Hawker, 2011)
 Debriefing
Inadequate Adequate

Less than 45 mins At least 2 hours

Within 24 hours After 24 hours

Inexperienced Credible,
debriefers experienced
debriefers
For unprepared For trauma
victims workers
Adequate CISD is
effective for aid workers
About 25% of non-debriefed aid
workers had clinical levels of
traumatic stress about a year
after returning home, compared
with 7% of debriefed workers
(Lovell, 1999).
I havent been able to tell
anyone about this. I cant tell
my wife, because then she
would feel traumatised too. I
couldnt tell my colleagues,
because they had all seen
similar atrocities and were
already coping with too much.
The thing which kept me going
was knowing I would be able to
talk about it during this
debriefing. That saved me from
going under.
Debriefing emergency
service personnel
Associated with significantly
less alcohol use and
significantly greater quality of
life (Tuckey & Scott, 2013).
Debriefing military

Battlemind psychological
debriefing for military
personnel is associated with
fewer symptoms of PTSD and
depression, and fewer sleep
problems (Adler, Castro &
McGurk, 2008; Adler et al.,
2009)
Debriefing occupational
groups
Debriefing appears beneficial
for groups of people working in
traumatic environments (Ardent
& Elklit, 2001; Jacobs, Horne-
Moyer & Jones, 2004)
What we offer

Regular debriefing for those

working in chronic stress
situations, to deal with
cummulative stress
Refer for professional help when
necessary
Organisational factors
(f) Family support
Support from families is a protective
factor (Blachetire, 2006).
When looking at factors which
impact negatively on international
assignments, marital breakdown
comes top of the list, followed by
childrens education
(Expatexpert.com, 2008)
Organisational factors
(f) Family support
Reintegration protocols that
include families may contribute
to better outcomes and staff
retention (McCormack et al.,
2009)
Family support: What we
do
Include the family (e.g. partner/
children) in briefing and debriefing
Regulate working hours to allow
enough family time
Support family members (McKay &
Hulme, 2009; Simens, 2011).
Minimize frequency of relocations
Family support: What we
do
Enable families to stay in touch
when separated (e.g. fund
phone-calls or internet)
Help children deal with trauma
(www.childrenandwar.org)
Example: Children in
Nepal
Earthquake zone
Civil war
Bombs & airport attack
 Organisational:
Selection,
Training,
(Family) support,
Debriefing
These are some pieces of
the puzzle;
more
should be
done for
indigenous
staff