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Psychologically Equipped: Practical Recommendations to Better Prepare Humanitarian Professionals for Field Missions White Paper Series No. 2

Staff well-being: Individual and organisational issues By Alessandra Pigni Psychologist and Consultant

“Some people have resistance to the whole idea of taking time for themselves. [...] Even the degree to which you can really be of help to others depends directly on how balanced you are yourself. Taking time to ‘tune’ your own instrument and restore your energy reserves can hardly be considered selfish. Intelligent would be a more apt description.”

~ Jon Kabat-Zinn (1990, 2005: pp. 43-44), founder of the Mindfulness-Based Stress Reduction Program at the University of Massachusetts Medical Centre

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About the author

Alessandra Pigni I am a psychologist and consultant. I craft individual and organisational strategies to prevent burnout, 'get unstuck' and promote healthy work environments. My mantra is that 'changing the world starts from within'. My vision is shared on www.mindfulnext.org which represents the evolution of the project once known as Mindfulness for NGOs.

This White Paper Series is based on a LinkedIn group discussion (in the Humanitarian Professionals Group) that I launched in May 2011 around a statement and a question: “Humanitarian aid workers are often psychologically unprepared for field missions. Any views on this from field and headquarters staff?”. Hundreds of comments keep pouring in, and the debate is still open. Contributions used in the White Paper Series are published anonymously to respect confidentiality.

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White Paper Series No. 2

Staff well-being: Individual and organisational issues

Introduction

In this section of the White Paper Series I will address the main psychological issues

encountered by several humanitarian and development professionals1, and briefly illustrate the

human resources and staff care dilemmas faced by their agencies both in the pre-deployment

phase, and during the field missions.

Drawing on the material offered by the humanitarian professionals in the LinkedIn

discussion2, I will back up the aid workers’ reflections with literature, and research on

humanitarian psychology, organisational learning, and staff care. I will look into “the helper’s

psychology”’ which is crucial in the pre-deployment phase screening. I shall explore the idea that

aid workers may be greatly supported by practical psychological tools of self-awareness before

engaging in stressful field missions.

In the original chapter I offered a more detailed analysis of the different conditions that

affect aid workers: compassion fatigue/secondary stress reaction, alcohol and drug abuse,

vicarious trauma, traumatic-stress disorder (TSD) and post-traumatic stress disorder (PTSD). The

reader will notice that in this current version I am focusing on burnout and on the role of

organisations. Why? Are the conditions mentioned above not real issues that affect aid workers?

They are, but not to the degree of burnout. In fact, a part from traumatic conditions which are

triggered by specific events and require interventions beyond my scope, the psychological

symptoms that people experience in the filed, including substance abuse, are often a sign of

burnout.

My professional experience has led me to appreciate how burnout is a 'man-made

disaster' which can be prevented, provided a caring and learning organisational culture, and an

attention on behalf of the individual to one's health, wellbeing, and sense of purpose.

1 Contributors to this White Paper Series are humanitarian professionals, development workers, as well as volunteers. I will use these terms and the term aid worker interchangeably to refer to all the people involved in development or humanitarian work in emergency and non-emergency contexts. Inspired by the approach taken by Loquercio et al. (2006), I aim at avoiding any “artificial distinction between expatriate/international and local/national staff, preferring to take a ‘whole workforce’ approach”. There may be sections of the report which will speak more to “expats” (after all I am one of them), though in my experience the issue of staff-care and psychological preparation is a concern of most employees across the board. 2 Please refer to chapter 1 for Background and Purpose of the White Paper Series.

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Pre-deployment

'For aid-workers self-awareness of one's strengths, weaknesses, coping strategies, both positive and negative, is essential'. (From a humanitarian professional)

Why are we driven to aid work? What are the psychological traits (and issues) of those who

take up a humanitarian career? We hear of wanting to make a difference, doing good, serving in a

meaningful way, travelling the world, helping those in need – these are the kind of motivations

that bring many to the field. 'Many may be trans-global citizens searching for their own roots –

there is a sense that they are of the world but don’t really belong anywhere' (Thomas, 2008: p.

51). As a provocation which may hold some truth, one contributor to the online discussion simply

put it like this: 'as the anecdote goes those who go into aid work fit one of these categories:

'misfits, medics, missionaries, mercenaries and madmen'. What shared traits impel them, and

why does question matter when it comes to psychological preparation? Why should organisations

be interested in this at all? All all aid workers are grown up people and it's their choice to be in the

field, far from home, often in stressful environments? We are not a business, why should we

invest resouves in this? This and other chapters in this White Paper Series will attempt to answer

these important questions.

My take on what drives many to aid work is very much in line with the ideas put forward by

psychotherapist Babette Rothschild (2010): those who get involved in helping/serving professions

often do it to heal personal wounds. As studies with medical professionals illustrate (Remen,

1996; Santorelli, 1999), “wounded healers” are quite common among health–care professionals. I

extend this analysis to the humanitarian community. The concept of the "wounded healer" can be

traced back to the ancient Greek myth of Chiron and his student Asclepius. Asclepius was a

physician who upon becoming aware of his own wounds created a sanctuary at Epidaurus in

order to treat others. It is precisely the awareness of his suffering and vulnerability that

contributed crucially to his capacity to heal. To a greater or a lesser degree aid workers may be in

a similar position: on one hand carrying our own psychological wounds, and on the other dealing

with other people’s suffering on an ongoing basis. This is where personal awareness crucially

comes into play.

What is your personal wound that brings you to aid work? As a psychologist I think that

addressing this question in a pre-mission interview is an essential step towards a critical

awareness of what draws us to this line of work. For me it is important to stress that being

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“wounded healers” is an asset that can breed authentic empathy. Empathy may be a word

that has lost some of its appeal in the professionalised humanitarian community, nevertheless

relieving the suffering of others still represents one of the driving values of aid work for many

professionals and volunteers. But unawareness and “untrained empathy” can be dangerous.

Awareness and self-reflection are the basis for effective action (Gilbert, 2005, pp. 67-

68 and Pigni, 2011). We often hold contradictory drives for choosing aid work: there may be a

sense of guilt, or the need to displace our personal problems onto someone else, combined with

the genuine desire to help people in need (Gilbert, 2005: p. 68). Most of us, consciously or not,

hold both positions, and bringing awareness to this “selfish altruism” (Vaux, 2001), is in itself a

first step towards a more aware, effective action. Addressing our needs for being in this line of

work, may help to rebalance power dynamics in the work-place and may allow one to realise that

the communities we are working with have a wealth of resources, and not only an arrays of

needs.

Unawareness around ones’ contradictory and paradoxical motivations for “doing good”,

instead of breeding empathy and an understanding of other people’s sufferings, contributes to

cultivating projections by keeping important issues in the shadow. It is often then that

humanitarian missions become an escape. Taking one’s unaddressed depression, anxiety,

difficult divorce, abusive background, etc. to a conflict or disaster zone is likely to amplify their

magnitude in the long run, and have a destructive impact on oneself, the team and the field

project.

As Vaux (2002, quoted in Thomas, 2008: pp. 54-55) argues from his decades of

experience at Oxfam: 'some [aid workers] may be escaping personal problems, seeking

acceptance and, working in the lives of the poor may be a way of resolving personal issues from

one’s own past'. A useful analysis is provided by the idea of “repetition compulsion” which refers

to the repetition of behaviours or life patterns. In her research on aid workers’ psychological

experiences in humanitarian contexts, Thomas (2008: pp. 54) points out how 'people are

unconsciously attracted to going through the same situation again and again, each time hoping

for a different outcome, but unwittingly and therefore inevitably re-creating the same result.

Therefore, from this larger psychological perspective, ultimately the choices made may be

identified as self-defeating behaviour'.

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When in the field, unaddressed underlying personal issues can surface and get triggered

by unsettling events in an unfamiliar environment. One could suggest that the lack of actual

self-care under an apparent guise of selfless, altruistic dedication is often in itself a

repeating pattern for many aid workers. They often carry in their bones a sense of: when it

matters, nobody ever comes to my aid. The words of Gilbert (2005: p. 68) still ring true, in fact

'often it may seem easier to run away from the self by engaging in endless activity and overwork,

rather than taking the time for internal reflection which could allow decisions regarding action to

be more thoughtful'. This is where 'commitment from aid agencies to equip their staff with greater

capacity for self-knowledge would not only provide aid workers with their greatest personal

strength in whatever circumstances they find themselves', but also minimise the risk of doing

harm to themselves and others in an increasingly complex world (Gilbert, 2005: p. 68).

A senior humanitarian professional commented on the importance of 'raising any "red flags"

in the pre-deployment interview, requiring staff going into high-risk assignments to complete an

in-depth, confidential pre-deployment consultation with an outside firm prior to beginning their

job'. I believe that preparation is essential, nevertheless stressors in the field cannot be predicted,

and missions do affect staff’s psychological health to a higher or lesser degree. For many the

questions “what am I doing here?” or “why am I here?” will emerge in the field, where it is

generally more problematic to address the underlying issues and contain them. I found that those

who were exposed to these questions before deployment, were beteer able to deal with the

disillusionment when the "honeymoon phase" ended. No one is suggesting that one can be fully

prepared. Awareness is only a first step towards a healthy field experience, but it is an important

one. Preparation for expected stress can also mediate the impact of traumatic events (Rothschild,

2000). The following paragraph will address the main conditions that are likely to affect aid

workers’ mental and physical health in the field, especially when there is no preparation and no

support during the mission.

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'A fair amount of people that go into [aid work] go

to ‘help’, but there are deeply rooted ulterior

motives masked by kindness and some

[professionals] are in denial of why they are doing

aid work. You really have to look at yourself

honestly […] Perhaps part of the preparation is a

self-evaluation.' (From a development worker)

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In the field, at last!

'What I find unfortunate is that a lot of organizations don't take enough consideration into how well a person is prepared for field-work. When someone cannot perform in the field, this leads to unfinished or delayed projects sometimes. More times than not, there is a loss of key expertise, since many people have a difficult time adjusting over the long term and opt to leave.' (From a development worker)

Humanitarian and development professionals’ burnout is a pressing issue. Self-care and

avoiding the risk of spiralling into physical, mental, emotional, psychological and spiritual

exhaustion are possible only when aid workers actively help themselves, supported by sound

staff care policies, and an organisational culture that allows for it. Staff care guidelines are

useless if in your office people are expected to to work 8am to 8pm, bring work home, be

available on week-ends, eat lunch in front of their laptop while answering emails, and be available

all the times because after all with smartphones it's easy. This means that mentally people are

not allowed to ever switch off. Individuals feel compeeled to take on board this organisational

approach, which affects not just our “world within”, but he world out there too and in the way we

engage with others (Rothschild, 2006). In other words 'living long-distance, fast-paced, change-

the-world "suitcase careers" is no different than being in the corporate rat race, or any other

pressure-cooker job. The causes are cool, the locations exotic, the pay terrible and the lifestyle

burned out.' (Lewis, 2013).

Stress and trauma are, to a greater or lesser degree, part of an aid worker’s job. Specific

psychological conditions such as burnout, compassion fatigue, vicarious trauma, and post-

traumatic stress disorder (PTSD) are common among frontline professionals, but can affect office

staff as well due to the pressure, the nature of the job, and the close contact with the reality of the

field. There is often an overlap of symptoms and a blurring of boundaries among these

conditions, and psychological labels are used here as a guideline that some may find helpful. The

bottom-line is that humanitarian work is mentally, emotionally and physically taxing and it

demands a caring organisational culture, rest and support beyond a drink with friends (Losleben,

2011), or a chat with colleagues.

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Issues faced by professionals: Stress and Burnout

'Sometimes our tolerance levels or ability to cope with stress reach their limit or tipping-point - although burnout may be very gradual, the signal can be quite abrupt. I have seen local and expatriate aid workers be highly effective in situations of armed/political conflict over many years, and then suddenly take a stupid risk or an ill-judged decision, or be scared in situations they've managed many times before - or start behaving 'out of character'. It often falls to sympathetic colleagues to recognise when this is happening as the person in question will be unaware (or deny) that anything is wrong.' (From a humanitarian worker)

Though priority is often given to trauma-related conditions following critical incidents, the

biggest issue faced by humanitarian professionals is pervasive and underlying stress, often

associated to loneliness and isolation, which can reach a saturation point leading to a syndrome

of physical and emotional exhaustion. This is often coupled with disillusionment and loss of

purpose. Many of us are familiar with this and – as a well-recognised syndrome - we call it

“burnout”. The term “burnout syndrome” was coined in the early 1970s by Herbert J.

Freudenberger, a New York psychoanalyst. He had noticed that his own job, which was once so

rewarding, had come to leave him feeling only fatigued and frustrated (Kraft, 2006). Humanitarian

professionals and frontline staff, who have once been passionate about their job, may end up

feeling the same. Freudenberger also noticed that

“Many of the physicians around him had, over time, turned into depressive cynics. As a result, those doctors increasingly treated their patients coldly and dismissively. Freudenberger soon began looking at examples outside of health care and found similar cases in many professions. Freudenberger defined burnout syndrome as a state of mental and physical exhaustion caused by one’s professional life” (Kraft, 2006).

Several humanitarian agencies may have witnessed similar phenomena in their staff

(however, without seeing it as a psychological syndrome that can actually be addressed), and

many of the professionals who offered their reflections in the LinkedIn discussion have

experienced directly or indirectly the devastating effects of cumulative stress, compassion fatigue

and burnout.

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Through personal and professional experience I have come to agree with the approach

taken by Jon Kabat-Zinn in his work Full Catastrophe Living: the problem is not stress, which is

unavoidable and it is part of life, especially in the field or in a the headquarters of a frontline

agency. The real issue is how we relate to stress, and this in turn depends on the depth of our

psychological framing of it. Most prevalent notions of stress emphasise the current, superficial,

behavioural manifestations of it, neglecting to take account of long-standing, underlying, structural

patterns of stress. Some of these patterns are in the blood of the organisation. The more

superficial our conception of stress, the more likely it is that superficial, behavioural solutions are

pursued (which tend to be unsustainable, unworkable and often add fuel to the fire). How do aid

workers relate to stress? When under pressure, the tendency is to push through encouraged by

the widespread “stiff upper lip” humanitarian culture. With very little staff care, the field can turn a

humanitarian dream into a nightmare. To help minimize the impact of stress, and prevent it from

spiraling into burnout, the words of a humanitarian professional offer space for reflection:

'The stress related to hardship and/or security issues is something that is very difficult to estimate before you are in the situation: for a "first missioner" there is always a "baptism" and you see there how you feel. On the other hand, what NGOs could do is decreasing the stress related to excessive workload and pressure. Creating a work environment in which people can just "do the job", not expecting them to "change the world in two months". A lot of empty rhetoric should be avoided about the "humanitarian spirit", "moral commitment", "sacrifice of the self" and the like. Humanitarian workers are normal people and as such they should be treated and as such they should see themselves, even when they are in the field. Yes, I think ‘normality’ would be a key solution'.

Evidence shows that among aid workers 'between 30% and 50% suffer from moderate to

severe levels of emotional distress, with 40% being at risk of burnout' (Loquercio et al., 2006: p.

6). Together with disillusionment and frustration, burnout represents the main reason for leaving

an organisation. In comparison, post-traumatic stress disorder (PTSD) only affects about 5%-10%

of humanitarian professionals (Loquercio et al., 2006: p. 6). When it comes to getting ready for

the field, even young or first-mission professionals expect to encounter conflict, natural disasters

and traumatic events. They know this is part of the work and they come with a realistic mental

acknowledgement of the risks and dangers. Nevertheless, they often come unaware of their

strengths and weaknesses, and do not know how to respond skilfully to the “demons” that

confront them in the field: team conflicts, loneliness, isolation, actual or perceived lack of support

and/or privacy, culture shock, bureaucracy, the politics of the work, etc. often add up to an

unbearable amount of stress. It is no surprise that studies report that 'a bad boss', and

dysfunctional team dynamics 'are more stressful than war' (AlertNet, 2006; Loquercio et al., 2006;

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Wingley, 2005). Preparing staff psychologically for these kinds of issues, plus recognizing

stress and burnout as an occupational hazard is the real challenge for humanitarian and

development agencies. In the words of a participant to the online discussion 'Many

organisations need to start recognising that the well-being of their staff is of equal importance to

the well-being of the beneficiaries they are trying to support. It can never be acceptable to allow

staff to reach the point of burnout'.

Culture shock: in the field...or back home?

“Culture shock” has been highlighted as an added stressor for which staff may need to

prepare, though for many professionals the novelty of a new mission, a new country, a new

environment are rather appealing, and the words of a contributor to the discussion seem

appropriate: 'If "culture shock" is something that hinders your own capacity, then I think you are

perhaps taking the wrong jobs'. In the case of expat aid workers and volunteers, in order to ease

the impact of possible culture shock I would view it as a personal duty - with the support of the

orgaisation - to educate themselves on the culture and the country that they are deployed to. The

truth is that it's far more likely that “expats” will recognise themselves in the comment offered by

another professional: “I never experienced 'culture shock' as an expatriate worker, but certainly

experienced 'reverse culture shock' in attempting to re-integrate into my home-country after 10

years away. In the end I gave up!”. Certainly culture shock can add to stress, but for many aid

workers “finding a place one can call home” seems a more impelling issue than adjusting to new

environments.

In the next session I will touch upon some of the issues that agencies need to deal with to

improve retention and organisational health.

Issues Faced by Organisations

“Belongingness and esteem are two basic human needs. People who have these basic needs met become much better workers”. (A. Maslow, Motivation and Personality, 1954)

Issue #1: Lack of Investment in staff-care

Even a quick glance through the comments provided in the LinkedIn discussion shows

how the analysis and recommendations delivered by Peter Salama in his excellent 1999 paper

The Psychological Health of Relief Workers: Some Practical Suggestions still have to find a place

in pre-departure preparation, and in field support. Because of the repercussions that staff’s

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mental health has on the team, on the beneficiaries, and on the project as a whole, staff-care

needs to be seen and addressed by donors and agencies as a matter of health and safety, of

project effectiveness, economic efficiency and sustainability (value for money of funding), and its

lack as a potential occupational hazard for the whole organisation, rather than being relegated

to an indulging matter of staff's personal well-being.

Definition from Inter Action (2008)

Security training in the pre-deployment phase needs to make space for both physical and

mental health. We know that low administrative costs are not necessarily conducive to good work

in the field (Schimmelpfennig, 2011). The same goes for saving on staff care: inadequate pre-

deployment screening and preparation, as well as poor field support often translate into a waste

of money and a loss of valuable human beings. When staff cut a mission short or do not go

beyond their first mission, it is the donors' money that is wasted. It is also the agency that suffers,

with the human resources department having to start from scratch. We all lose when good aid

workers burnout: it is a problem for all stakeholders - beneficiaries, colleagues, HQ, donors, and

of course of the professionals themselves whose lives are often dramatically affected. In the

words of an aid worker:

'Donors need to be aware of the importance of staff care and of how much money and human resources are wasted due to lack of support in the field and in the post-deployment phase. Staff care should be at the core of HR, both as a cost-effective, as well as a humanitarian measure'.

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Most professionals do not choose aid work because of the monetary benefits, therefore

what matters is often the implication that they and their work are valued. This applies across the

board to profit and non-profit organizations, and it is what keeps employees happy, engaged and

effective. It is important to take on board the fact that good physical and mental health (“mens

sana in corpore sano”, as the Latin motto goes) is connected to self-efficacy, which in turns is

linked to better work-performance (Csikszentmihalyi 1990); as it is crucial to acknowledge that

self-care correlates positively with care for others, and that ultimately staff care is a way to

enhance the organisational culture, value professionals, retain staff and improve projects on the

ground.

Issue #2: Staff Turnover

Staff turnover is not necessarily a negative thing. In fact, “functional” turnover includes the

loss of employees who were not performing well, and allows to bring in new blood and ideas in

the organization. As opposed to “dysfunctional” staff turnover, which includes the loss of

employees that did perform well. Dysfunctional staff turnover is a huge problem for NGOs, with

70% of professionals leaving their agencies due to poor management, lack of leadership and of

support, which translates into a waste of human and monetary resources, a lack of continuity, and

a loss of organisational history (Loquercio et al., 2006). A human resources manager of a large

INGO recently expressed to the author how difficult it is to see so many people leave out of

disappointment. Following a first mission she quoted a retention figure of about 20% “if we are

lucky”. The issue has been illustrated extremely well in Loquercio et al.’s (2006) paper

Understanding and addressing staff turnover in humanitarian agencies, and I refer the reader to it

for an in-depth analysis of a matter which is connected to staff-care. Donors and human

resources departments may want to bear in mind the cost of “dysfunctional turnover” when

budgeting for staff preparation and support.

Issue #3: The Impact of the Organisational Culture

The quality of organisational culure is the core issue from which the other two derive. The

LinkedIn discussion has clearly identified the need to transform the culture within many NGOs

and IGOs. Drawing from the aid workers' insights, one would say that most humanitarian

organisations come across to their employees as demanding, uncaring, and uninterested in

change within. All the efferts towards change are projected on the outside - an argument used to

justify the lack of internal development. The external image of the organisation - what the public

sees - is at odds with the experience of those on the inside.

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The Way Forward

The good news is that professionals are now much more aware of the psychological

implications and impact of aid work, and of the importance of looking after their own well-being in

the field and back home. Taking on board the reflections generously provided by humanitarian

and development professionals, agencies can transform their organisational culture, improve or

implement staff care programmes, while saving money by investing in prevention both in the pre-

departure phase, as well as in the field. A senior HQ professional illustrates how

'we have seen a shift in the profession over the past 5-10 years regarding the issue of psychological awareness and preparedness, with a growing number of humanitarian organisations recognizing the need to attend to both the physical and psychological security of their staff'.

The contributions to the LinkedIn discussion show how humanitarian and development

organisations would benefit from taking on board the requests coming from staff for pre-

departure psychological awareness, stress reduction, burnout prevention, and resilience

training, which are key elements of a modern staff retention policy, and a cost-effective option for

human resources departments. They are also tools to build sustainable and “learning

organisations" (Senge, 1994; 2004). Although it is obvious that no preparation can guarantee

perfection, nevertheless people can be psychologically prepared before deployment and be more

effectively supported in the field. Burnout shatters individuals' lives, and organisations can

prevent this by addressing the issues highlighted by the aid workers themselves.

Staff care and organisational development are not just about having a “cost-effective

strategy”; they are mainly about bringing “the soul back into aid work” (Lentfer, how-matters.org).

*** Next in the white paper series:

No. 3 Overview of the concepts of mindfulness and how they may apply to aid work