This document provides an overview of a webcast series on health and safety for humanitarian workers produced by Harvard University. The series addresses topics like stress, substance abuse, and burnout. The June 23, 2010 session focuses on stress and substance abuse, with guest speakers including Dr. Stephen Morris, Dr. Donald Bosch, and Dr. John Ehrenreich. They will discuss the causes and impacts of stress, as well as strategies for managing stress on a personal, organizational, and professional level. The document provides background on the guest speakers and outlines from the presentations.

2. Personal and family health

3. Professional satisfaction

5. Health and Safety on Mission: Stress and Substance Abuse Live Web Discussion – 23 June 2010 Mr. Claude Bruderlein Director Program on Humanitarian Policy and Conflict Research at Harvard University Dr. Stephen Morris International Emergency Medicine Fellow Clinical Instructor at Brigham and Women's Hospital at Harvard Medical School

6. Health and Safety on Mission: Stress and Substance Abuse Live Web Discussion - 23 June 2010 Stress plays a unique role in the professional and personal lives of humanitarian workers.The management of intense acute stress allows them to work in situations where others would fail. Stressors come from all aspects of the work, physical discomfort, sharing the tragedy of the situation, distance from support networks, intense responsibility, difficult relationships with clients and co-workers, and often unachievable goals. This seminar attempts to open discussion of the common nature of stressors among humanitarian workers, planning and management of personal stress, and untoward outcomes related to stress such as burn out, relationship dysfunction, and personally destructive behaviors. Through a moderated conversation experts from the field and health care professionals will explore the critical aspects of stress and stress management. Discussion with Dr. Donald S. Bosch, Director of Counseling Services at the Headington Institute Discussion with Dr. John Ehrenreich, PhD, Professor of Psychology, State University of New York, College at Old Westbury

7. Dr. Stephen Morris is currently the Harvard International Emergency Medicine Fellow and a Clinical Instructor of Emergency Medicine at Harvard Medical School. Stephen’s clinical training took place at the University of Washington School of Medicine in Seattle, WA, and at Yale Emergency Medicine in New Haven, CT. Stephen has worked in a variety of clinical and public health programs around the world, as well as education and development programs in the Americas, research in Africa and Asia, and policy and management work with the World Health Organization. He has experience in post-conflict and post-disaster settings, mostly recently as the acting medical director of a field hospital in Haiti.

8. Acute Stress 'Fight or flight response’ Examples- combat, post disaster, large population movement, witnessing extreme violence. Can be beneficial increases focus and attention motivates workers to get things done Overview

9. Acute Stress(continued) Can be harmful Acute 'burnout,' 'Shell shocked’ Unable to focus profound apathy emotional liability argumentative, irrational behavior, risk taking

10. Acute Stress * this can be mimicked by serious life threatening medical problems such as dehydration, electrolyte abnormalities and infection (meningitis)*

11. Prolonged Stress Examples Unpredictable work environment Witness to suffering and hopelessness Difficult living circumstances/deprivation isolation

12. Prolonged Stress Harmful effects 1. Physical Deconditioning Substance abuse (alcohol, tobacco, prescription medications) illness

13. Prolonged Stress 2. Emotional Depression and anxiety Apathy 3. Behavioral Loss of work productivity Interpersonal conflict with co-workers and clients Risk taking behavior (driving, sexual, professional)

14. Prolonged Stress 4. Substance Abuse A specific problem 'Self medication’ Research shows it increases in stressful missions Smoking, alcohol, illicit and abuse of prescribed medications are all common When identified usually will require professional help Places the whole staff at risk due to unsafe behavior Potentially life threatening physical affects Damages work environment and significant loss of productivity

15. What can be done? Personal Level Organizational Level Professional Level

16. Personal Level Healthy activities Debriefing not reliving- discussion of feelings and emotions surrounding the stressful problems identified Creative problem solving- how can we make this situation better-Improved housing, diet- Privacy- Personal time Activities (structured downtime (sport, personal communication time.) Contact- with family and friends- Exercise- Taking a breaks

17. Organizational Response 1. The organization has a writing and active policy concerning humanitarian workers stress, which addresses all aspects of pre, during and post mission stress. Screening and training, communication and education about worker stress. 2. Screening of new and current staff for levels of stress, suitability to the assignment, past exposures etc. 3. Preparation and Training including detailed description of work environments, expectations, living conditions, and if possible simulation exercises.

18. Organizational Response Example: in our last session we learned how simulation exercises of kidnapping had a positive affect on those who suffered actual kidnapping events, allowing them to remain calm and gain a clearer picture of their situation. Training is critical

19. Organizational Response 4. Monitoring of staff and appropriate response to problems identified. 5. Ongoing training and support of appropriate work environment to allow healthy response to stress

20. Organizational Response Example: Security often restricts movement of individuals preventing appropriate opportunities for exercise. A simple piece of exercise equipment can improve this situation and allow for healthy release of stress.

21. Organizational Response 6. Support in the situation of setting of severe acute stress. Example: local staff during a conflict or disaster often have affected family members, ensuring time to secure the safety and wellbeing of family will reduce stress and allow the worker to focus on the work that needs to be accomplished.

22. Organizational Response 7. Post assignment emotionally and culturally appropriate support. Offering counseling, monitoring and further training if needed. 8. Planning to address those adversely affected by trauma, or with identified unhealthy practices (substance abuse.) Clear indications and a protocol for contacting professional help.

23. Professional Level What can we as an organized professional group do to reduce the negative impact of stress on humanitarian workers? Mandated leave - standardized for all humanitarian workers. Mandated organizational compliance with a full range of training, planning and support services. Basic minimum package of support (living conditions, supplies etc.) Build professional organization to improve standards

24. Example Example: two large international NGO's are working in the same severe post disaster setting they both receive funding from the same donors. One NGO feels the work and situation is stressful enough that workers are rotated for a two week on one week off schedule. The other organization is using its normal operating procedure of a 'long' weekend (4 day break) every six weeks.

25. Why not a minimum standard? Would ensure support and training activities Could help to improve professional longevity Will continue trend toward industry professionalism

26. John Ehrenreich, Ph.D., is Professor of Psychology at the State University of New York, College at Old Westbury and International Associate, Antares Foundation (Amsterdam). He co-chaired of the panel of experts that developed the Antares Foundation’s Guidelines for Good Practice: Stress Management in Humanitarian Workers. (2006). His other writings include Coping With Disaster: A Guide to Psychosocial Intervention (1999; New York: Mental Health Workers Without Borders) and The Humanitarian Companion: Guide for Staff of Humanitarian Aid, Development, and Human Rights Projects (2005; Warwickshire, UK: ITDG Publishing).

27. 25 Sustaining the Humanitarian Worker : Managing Stress John H. Ehrenreich, PhD Professor of Psychology State University of New York Old Westbury, NY, USA and International Associate Antares Foundation Amsterdam, The Netherlands June 23, 2010 25

28. 26 The Mission of the Antares Foundation “…to improve the quality of humanitarian assistance and overseas development through advice, training and support” Activities: Training and Support of Staff (individuals & teams) Organizational Consultancies and Evaluations Conferences, Research and Publications Advocacy and Lobbying 26 26

29. The Perils of Humanitarian Work Insecurity and threats to well-being and health Exposure to recipients Challenges to values, ideals and beliefs Difficult living and working conditions Disruption of relationships and communication 27

30. 28 Consequences Darfur: 46% describe self as “emotionally stressed” (Augsburger et al, 2007) Study of returned international aid workers: ~ 50% at high risk of burnout, ~ 15 % clinically significant symptoms of depression, 46% high or moderate symptoms of PTSD (Eriksson, 2002) Study of returned international aid workers: ~ 20% high levels of emotional exhaustion, ~ 30% moderate to high depression, ~50% high or moderate levels of PTSD symptoms (Eriksson et al, 2003) Similar findings with national staff, human rights workers, first responders, etc. 28

32. Higher rates of illness and absenteeism

33. Less commitment to work, higher turnover

35. 31 But the worker is not alone …. “Emergency” Recipients/Survivors Donors Historical experience International standards Family Other NGOs Community Local political organizations Culture Homegovernment Local military, police Localgovernment 31

36. 32 The Antares Foundation Model for Intervention Analyze and plan responses with respect to three dimensions or “axes”-- Level: individual, team, agency, larger community Stress stage: Before stressor occurs, when it occurs, after stressor has ended Deployment stage: Standing practices, before deployment, during deployment, after deployment 32

38. Team (e.g., team builds trust, addresses intra team conflict)

39. Agency (e.g., agency selects managers based on ability to maintain team cohesion and trains managers with respect to monitoring worker stress and providing support, as needed)

40. Larger community (e.g., agency educates worker’s family with respect to “re-entry” issues and provides post-deployment support)33

41. 34 Team, Leadership, and Agency Interventions: Social Support Perceived social support is the key moderator of stress. Perceived social support is a protective factor, lack of perceived social support is a stressor. Social support functions both at time of stressful events and after events Social supports include Team cohesion and mutual trust Family and other support systems 34

42. 35 Team, Leadership, and Agency Interventions: Leadership Stress is reduced by leaders who have a “consultative” leadership style: Competent Confident but flexible Fair, just, reasonable Able to make decisions but with openness to information and feedback Know team members personally (and monitors their well being) Lead by example 35

43. 36 Team, Leadership, and Agency Interventions: Agency policies and practices Stress is reduced by management practices that are effective, efficient, transparent, and fair: Clear job descriptions Clear chain of command Efficient logistical support Clear safety and security systems, well implemented Good communications maintained Appropriate workload expectations Appropriate policies re work rotations, work schedules, rest breaks, days off, vacations Appropriate human resources policies (e.g., benefits, career paths, etc.) 36

44. 37 Prevent or reduce intensity, frequency, duration of stressor (e.g., anticipate stressors and change behavior to avoid; organize agency procedures to provide needed materials) Reduce vulnerability and increase resilience and maintain “stress fitness” (e.g., train workers with respect to stress management; organize work schedule to provide for rest periods; build and maintain sources of social support) Improve accuracy and efficiency of monitoring of stress (e.g., create “buddy” system; train team leader to monitor staff stress) Improve coping (e.g., stress inoculation training before deployment) Intervene to prevent long term effects (e.g., standing arrangements for psychosocial consultants after critical incidents; routine “personal stress review” at end of deployment) 37 Systems Approach Axis 2: “Stages of Stress Response”

45. 38 Points of Intervention Stressor ? Stress! Coping ? Resilience? Vulnerability? Appraisal © 2008, John Ehrenreich

46. 39 Systems Approach Axis 3: “Deployment Phase” Source: Antares Foundation (2006): Managing Stress in Humanitarian Aid Workers: Guidelines for good Practice 39

47. 40 Stress management and risk reduction addressing individual stress requires activities at each phase of deployment: Organizational policy plan (standing policies) (includes pre-emptive review of agency policies and practices, “stress impact assessment” prior to embarking on new programs/policies) Assessment and screening of staff Pre-deployment briefing and training Monitoring of stress in the field Ongoing training and support in the field Critical incident and traumatic stress support Operational debriefing, personal stress review, and re-entry support Ongoing support for continuing stress (post-deployment) Source: Antares Foundation (2006): Managing Stress in Humanitarian Aid Workers: Guidelines for good Practice 40 40

48. 41 An Example of the Antares Foundation Model in Action:An Integrated Program of Activities Aimed at NGOs Providing Services for Iraqi Refugees in Jordan and Northern Iraq, 2009-2010 Research Project: Survey of National and Regional Staff Working for Humanitarian Organizations With Iraqi Recipients in Jordan Staff Workshops: Stress Management for Staff Members of Humanitarian Agencies Managers Workshops: Stress Management for Operational Managers and Coordinators Staff and Manager Workshops: Psychosocial skills building Organizational consultations: Building a stress reduction culture and stress reduction practices in the agency 41 41

49. 42 ResourcesAntares Foundation http://www.antaresfoundation.org 42

50. 43 An Analytical Tool: The “Principles Matrix” Completion of matrix is followed by ranking “next steps” in order of priority, developing time frame, determining resources needed, etc. 43 43

51. 44 ResourcesInter Agency Standing Committeehttp://www.humanitarianinfo.org/iasc/content/ products/docs/Guidelines%20IASC%20Mental%20Health%20Psychosocial.pdf Action Sheet 4.4: “Prevent and manage problems in mental health and psychosocial well-being among staff and volunteers” The Inter-Agency Standing Committee (IASC) is the primary mechanism for inter-agency coordination of humanitarian assistance. It is a unique forum involving the key UN and non-UN humanitarian partners 44

52. 45 Resources: Internet Building Trust in Diverse Teams. Emergency Capacity Building Project,* 2007. (Oxfam GB) (http://publications.oxfam.org.uk/oxfam/display.asp?isbn=9780855986155) Understanding and addressing staff turnover in humanitarian agencies. D. Loquercio, M. Hammersley, & B. Emmens, 2006. (HPN Network paper Number 55) (http://www.odihpn.org/ documents/networkpaper055.pdf) Psychological First Aid: Field Operations Guide, 2007. (National Child Traumatic Stress Network). (http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/nc_manual_psyfirstaid.html ) Headington Institute website (http://www.headington-institute.org/) 45

53. 46 Resources: Print J. Fawcett (ed.) (2003). Stress and Trauma Handbook: Strategies for Flourishing in Demanding Environments (World Vision International) J. Ehrenreich (2005). The Humanitarian Companion: A Guide for International Aid, Development, and Human Rights Workers. ITDG Publishing. J. Ehrenreich (2006). Managing Stress in Humanitarian Aid Workers: The Role of the Humanitarian Aid Organization. In G. Reyes & G. Jacobs, eds., Handbook of International Disaster Psychology, Vol. 4 (Praeger) 46

54. Dr. Donald S. Bosch, is the Director of Counseling services for the Headington Institute. A clinical psychologist and psychoanalyst, Dr. Bosch received his M.A. in Theology (1978) and Ph.D. in Clinical Psychology (1980) from Fuller’s Graduate School of Psychology. He graduated from the Los Angeles Institute and Society for Psychoanalytic Studies in 1995. He is a Fellow of the International Psychoanalytical Association. Dr. Bosch has maintained a full time clinical practice in Pasadena since 1980. He has specialized in individual adult and marital therapy. He has worked intensively with individuals who have suffered severe traumas, including veterans, missionaries and survivors of sexual and physical abuse. Since 1984 Dr. Bosch has been part of the Clinical and Adjunct Faculty at Fuller’s Graduate School of Psychology. He has for many years been a supervisor at the Pasadena Mental Health Center, a clinic serving the economically disadvantaged. In addition he has helped organize and provide emergency shelter services to the homeless population in Pasadena for over 15 years.

55. Humanitarian aid work is one the most stressful professions... Stress is a given in aid work, whether in slow or rapid onset humanitarian emergencies, for both expat and national staff. In Haiti, for example, national staff experienced personal losses of colleagues, family, homes and work places. Most expats arrived on the scene jet lagged and already stressed by the deployment process. Then both groups faced the staggering enormity of the death and destruction.

56. Typical conditions encountered: - Poor living situations - team houses, tents, food and water challenges. - Challenged communications within and between organizations, between expat and national colleagues, and in staying in touch with family and friends. - Long and frustrating hours with lack of supplies and coordination, making accomplishing one's task difficult. - Security concerns often requiring early curfews and restricted travel. - Overwhelming need and despair of affected population often resulting in feelings of helplessness and hopelessness. - Etc., etc., etc.

57. The Challenge: how to manage stress in such difficult environments, or how to turn off the day's scenes and emotions, or how to let go of the task you didn't complete that must be done, or how do you change the channel in your head so you can sleep, or how do you go back to sleep when you awake after 3 hours and your mind is racing, or how do you work when you are sick yourself, or.......

58. What are the readily available means to self-regulate stress for many aid workers in such a situation? "When I step outside to smoke it gives me a moment to myself..." "I look forward to the red wine in the team house at night as a way to distance and laugh about the horror that is now in my soul..." "With the security restrictions I can't go for a run or often even go out to dinner. I drink because it is all there is to do..." "When I have sex it is all I am thinking about for that moment. It is one of the few activities that overrides the overwhelming reality of the day..."

59. With few other resources, the necessary and understandable need to "change the channel in one's head“ becomes linked to behaviors that can become addictive and destructive to oneself and family at home.

61. Prone to conflict, withdrawing, or both.

62. A feeling of no room inside, everything affects us, no shock absorbers.

63. Being unable to think well: everything is important and nothing is important.

64. Self-medicating with alcohol, tobacco, drugs or sex.

65. Prone to flashbacks, intrusive thoughts, avoidance.

66. Feeling mistrustful and paranoid.

68. Self-efficacy - with regard to emotional processing, technical and problem solving skills, and physical well-being and condition.

70. The Health and Safety on Mission Series is produced by: Program on Humanitarian Policy and Conflict Research (HPCR) Harvard University School of Public Health Sponsored by For more information on this series, please contact: hpcr@hsph.harvard.edu