Throughout July FD Consultants want to highlight the diverse expertise and professionalism amongst its associates. Claire Pooley is a senior BACP accredited psychotherapist with 30 years’ experience. She is a trained Traumatologist, Accredited EMDR practitioner, Supervisor and Trainer. Below Claire writes about her recent work, and her experience as an associate for FD Consultants. My training in the 80’s as a Mental Health Nurse lacked any consideration for a Psychologically Informed Environment. The structure of the day was centred on the needs of the multi-disciplinary team – ‘we know best’. We were the ‘well’ and the patients were the ‘unwell’. The separateness was enshrouded in keeping our professional boundaries. Our own personal welfare was also a non-concern of the hospital and I didn’t meet an Occupational Health team even at the beginning of my nursing, at the early and naïve age of just 17. We gave little attention to the patient’s possible experiences of trauma and yet, on reflection, I have little doubt that most of the patients I cared for would have experienced, or were experiencing, some form of trauma. We also didn’t spend any time on how the impact of the patient’s lives would have on our own. We used a “sic” sense of humour to laugh off any difficulties and would not dare to share any personal vulnerabilities. I currently facilitate workshops within a large Homeless/Housing project who have not only embraced the Psychologically Informed Environment (PIE) approach but they have rolled out compulsory courses to ensure Trauma Informed Care (TIC), Reflective Practise and staff welfare are a high priority in the workplace. I find this organisation a breath of fresh air. At the beginning of each training day, I ask the attendees about their understanding of PIE and TIC and sit back and watch the energy and enthusiasm emanate in the room. It is not just a whim or a paper exercise, they believe in it and, at its best, it truly works for them. At worst, particularly for some of the lone workers, it would appear that more needs to be done to provide appropriate staff support. This is a work in progress. So what do we understand by these two concepts? Psychologically Informed Environment (PIE) recognises the gaps in services, particularly for those with complex and interrelated issues and provide the non-clinically trained staff responses for an appropriate and improved support provision. The approach ensures a service develops:
Trauma Informed Care (TIC) is an approach which can be adopted by organisations to improve awareness of trauma and its impact and ensure their service provision offers effective support and prevents the possibility of re-traumatisation of those using or providing the services. Those using the approach:
Researchers have found that those using the TIC approach within organisations have better informed staff on Trauma awareness, they provide more of an emphasis on emotional and physical safety, they promote opportunities to rebuild control and provide a ‘strengths-based approach – helping to support and identify strengths and coping mechanisms. A superb example was shared by a trainee recently on one of the courses where she was struggling to remain client-centred whilst working with someone who “poisoned every act of kindness”. She was left feeling angry and was struggling to cut off at the end of her working day and felt a strong resistance to returning to work the following day. She was able to approach her team manager who called a ‘Reflections Meeting’, where staff were encouraged to talk about the feelings of “when things get tough at work”. She was able to share her experience and realise she was not alone and between them, found each other’s strengths and abilities to address the situation. She spoke of moving from “anger to compassion to healing” through the process and describes a collective sense of supportiveness and holding. During my work with FD Consultants, I have witnessed these approaches within some of the Humanitarian teams whilst providing preventative and trauma-focussed therapies to their staff. I have heard individuals who have felt held and supported through some very isolating and stressful traumas and have witnessed a non-judgemental and holding within their team, HR and management. Thus strengthening the resourcefulness of the individual and the team. They know they can speak out and raise difficult issues and believe they can be supported to carry out their goals. A safer place to work. Recognising the Covid-19 Crisis as another traumatic event in so many ways, I have been working with Fiona to roll-out a programme of trainings to help staff and managers work through their issues, from stress management through to a Crisis Management approach. I have also returned to the NHS to provide my local hospital staff with a programme of group therapies (GTEP RISC), which helps the staff to process some of their experiences and the effects that Covid-19 has had on them. Both are forms of Trauma Informed Care. For those who have not adopted this approach, I highly recommend it. Fiona Dunkley’s book, recently re-launched in a paperback form, “Psychosocial Support for Humanitarian Aid Workers: A Roadmap of Trauma and Critical Incident Care” (Dunkley, 2018) highlights the TIC approach and the need for proactive prevention and staff resilience. For organisations looking for employee psychological support, FD Consultants are the trauma specialists and well-being service who will best deliver a reliable, quick, and bespoke support system in the workplace. FD Consultant’s team of accredited specialists will offer ongoing support to help manage stress, prevent burnout and provide specialist trauma care where required, enabling your staff with the tools to cope, and recover more quickly References:
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As part of the Coronavirus humanitarian response, FD Consultants have been carrying out consultations with humanitarian aid staff preparing to deploy. Having supported humanitarian staff prior to, during, as well as following deployments for many years and, in consideration of the unique and unprecedented circumstances of Coronavirus deployments, we have consolidated some reflections and considerations. Coronavirus Deployments The humanitarian sector recognises how Coronavirus responses will draw parallels to other familiar humanitarian scenes. In terms of deployments this might mean political violence or civil unrest, movement restrictions, curfews, being separated from loved ones with often unreliable internet and little time to communicate name a few. As well as, of course, the variety of related difficulties common to epidemic response, including stigmatization by the local population, managing PPE shortages and, carrying the responsibility for others’ lives. These are understood as a ‘part of the work’. Circumstances specific to Coronavirus deployments, on the other hand, are an evolving reality. Humanitarians are being asked to manage additional concerns. For example, as deployed staff you might be the vector of the virus to the vulnerable groups you are supporting. You may also be carrying concern for loved ones back home with you into a deployment aimed at addressing the same ‘danger’. Or, having to accept being ‘stuck’ for a period in your deployment country because of travel restrictions. Furthermore, as one staff member put it, “we’re very much on borrowed time.” And yet, there is the 14-day mandatory isolation upon arrival, which might include remaining isolated from fellow colleagues staying in the same location. Where, from the relative comfort of your accommodation, you will be supporting ‘remotely’ the crisis work going on within close proximity to you, knowing that local and other colleagues are ‘in the thick of it’. Possibly resulting in experiencing feelings of loneliness, guilt or frustration. With all this in mind, it is understandable, if not normal, to imagine that even the most well seasoned humanitarian will feel tested in ways their prior deployments have not. Coping strategies and resilience in Coronavirus deployments “You don’t know how long it’s going to take, how long you will have to be there to be sure things are up and running. You have to accept that before you go and let go of the ‘need to know”. This is how a humanitarian explained the way they manage some of the uncertainties faced in emergency deployments. At the time it struck me that this ‘letting go of the need to know’ was somehow both practical as well as self-compassionate. Coronavirus deployments not only carry the inherent stresses of emergency deployments but also unique personal and professional dimensions. Both practicality and self-compassion could go a long way towards encouraging resilience in such circumstances. As described by a number of staff, resilience is the ability to balance being highly adaptive to a fast-changing situation and set of needs with maintaining personal and professional boundaries so as not to burnout. Similarly, it is the ability to know when to say ‘I am out for now. I have to sleep, or rest, or be alone’, so you can remove yourself before you explode or make an unnecessary mistake. This inner voice that is letting you know it is time to take a break, however brief or inopportune, cannot be ignored. It is also about appreciating how teamwork is at the root of any successful deployment, as was repeated by all staff. This involves trusting, relying on, as well as supporting your team. Finding ways to communicate what you need to, at the same time letting go of moments of hostility or rudeness ‘till after deployment’. Coping, psychological wellbeing and, perceived sense of control When we are stressed it is often a product of overwhelm, of feeling out of control. In emergency deployments, particularly at present, where certain variables are entirely unknown, supporting our ‘perceived sense of control’ is key. Research into stress related coping styles has shown that ‘Engaging’ coping styles support our ‘perceived sense of control‘ and, in turn, our psychological wellbeing. Active confronting, for example, refers to directly and consciously facing the stressor, in a “hands on” way. Reassuring thoughts allow us to put things in perspective and to look for ways to acknowledge that, “it's not the end of the world.” Unsupportive coping styles, on the other hand, involve what are called disengagement strategies. When passively react, for example, we “wallow” in negativity, not really addressing the stressor. When we have a palliative reaction we disassociate from the stressor by letting the stressful event numb you. When avoiding we don’t address the problem directly but instead disengage from the situation and avert attention from it through escapism, wishful thinking, self-isolation, undue emotional restraint, and/or using drugs or alcohol. Sometimes we will shout at a colleague, which might be a sign we haven’t listened to the ‘switch’ telling us its time to take a break. All of these reactions are natural, even healthy, within limits. When they become the norm is when we need to reassess. How can FD Consultants support staff? FD Consultants, through their pre-deployment resilience consultations, psychological evaluations, mid and post deployment consultations, as well as trauma assessments and follow up trauma counselling, are well placed to support staff through all phases and experiences on deployment. Mid and post deployment consultations, as a means to ‘checking in’ on staff wellbeing, are recommended now, more so than ever, given the particularly intense and unprecedented circumstances in which staff are deploying. These provide an opportunity to talk through some of the deployment specific circumstances they may be facing, and how they can best cope. Get in touch with us today Author: Arianna Rondos (Associate, FD Consultants) What we see is a new type of war veteran, the international humanitarian worker, returning from the battlefields unable to escape the horrors there. It is obviously very important that aid organisations begin considering seriously the factors affecting their project personnel. Someone must be able to spot the danger signals at an early stage, and help exposed personnel in dealing with their situation (Smith et al, 1996). Relief workers today are faced with situations which generate more stress than straightforward natural disasters. This happens in a context in which the usual support mechanisms of family, partner or close friends are absent. Furthermore, the culture in the humanitarian community, which may be one of bravado and competition in emergency situations, does often not allow the space for discussing issues such as psychological stress. Despite mounting anecdotal evidence that stress and its consequences are key occupational health hazards, humanitarian agencies have not moved quickly enough to minimise the risks to the psychological well-being of their staff,. Some common problems Some of the common stress-related problems seen in relief workers include burnout, psychosomatic disorders, and risk-taking behaviour such as alcohol abuse. Unlike domestic rescue workers who are periodically exposed to short stressful events, relief workers may suffer exposure to chronic low levels of stress by, for example, residing in insecure environments for many years. It is in this setting that stress may be cumulative. Burnout is probably the most commonly used lay term associated with cumulative stress. It is a process that is usually gradual in onset. Symptoms can be grouped into five categories (Kahill, 1988):
Acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) are more formal diagnoses related to exposure to severe traumatic stressors such as a direct assault or abduction (primary traumatisation) or witnessing the death or abduction of a colleague (secondary traumatisation). The phenomenon of tertiary traumatisation is also increasingly recognised (Jensen, 1999). Examples include being witness to mass violence or listening to first-hand accounts of traumatised people. ASD appears relatively quickly after exposure to a particular stressor and, by definition, resolves within a month. It includes a spectrum of emotional reactions, cognitive changes such as confusion, and symptoms of mental and physical hyperactivity. PTSD symptoms appear from one month to three months after a given event. Symptoms usually involve flashbacks to the events and a state of being hyper-alert. Symptoms may become chronic and extremely debilitating. In their attempt to find a new internal equilibrium, relief workers may also respond to unresolved stress with more subtle behavioural changes. One such reaction has been termed “enmeshment” and is akin to survivor guilt with an over identification with the beneficiary population (Smith et al, 1996). This reaction may be more common in the younger, more idealistic relief worker. By contrast, avoidance reactions of distancing, withdrawal and denial may be more common among experienced personnel. Finally, relief workers may exhibit self-destructive behaviours such as working to the point of exhaustion, consuming excessive amounts of alcohol, or engaging in unprotected sexual encounters. Problems exacerbated by the humanitarian sector Many of these problems may be exacerbated by factors particular to the humanitarian sector. For example, relief workers do not usually benefit from being in a well-trained, tightly knit unit with a clear command structure. In addition, training and briefing, particularly with regard to psychological issues, is generally inadequate. This is particularly pertinent for those organisations which deploy a high proportion of first assignment volunteers. Third, aid workers are often called upon to perform duties outside their realm of professional competency and experience. Finally, there is the pressure when the drive to ensure the visibility of their own organisation may over-ride questions of the appropriateness or quality of interventions. Two other issues deserve mention because they are relatively modern sources of tension in the humanitarian sector. First, is the pressure of discovering that one’s internal mandate in terms of personal ethics and preferred approach does not match the mandate of a particular organisation. Second, is the changing culture of humanitarian work. Organisations are more self-critical than previously and are increasingly putting resources towards evaluating their activities. Inevitably external criticism, even if constructive, leads to a re-assessment of an individual’s perception of his/her own effectiveness. The latter is particularly true if individuals have an unrealistic expectation of what they may achieve under any given circumstance. Recommendations An individual has three levels of resources, personal, social and organisational, at his/her disposal with which to tackle demands. Organisations should seek to strengthen these resources wherever possible. The personal level: Selection and training are key areas where organisations could better support their personnel. In the past the key qualities organisations have looked for when selecting personnel are flexibility, maturity, adaptability, ability to work in a team and past experience in emergency situations (McCall & Salama, 1999). While experience is crucial, this must be tempered by the knowledge that stress can be cumulative, especially in the setting of aid workers going directly from one emergency to the next. Individuals who have a past psychiatric history including that of alcohol abuse or those with a recent significant life event such as a relationship break up should be regarded as being at higher risk of psychological distress. More effort needs to be made to ensure that an individual understands and is comfortable with the mandate of the organisation and has a realistic expectation of living conditions, security conditions, potential risks including to psychological health and what can be achieved in the circumstances. Some examples of best practice in this setting include being interviewed by the person directly responsible for the project by telephone or in person, and in-depth discussion of hypothetical field scenarios that illustrate some of the complex trade-offs inherent in humanitarian work. Studies in various settings have shown that untrained, poorly briefed staff suffer most from stress-related illness (Ursano & McCarroll, 1994). Briefing and debriefing should be mandatory and in person. It should cover an individual’s personal and emotional reaction to their work environment, not merely the programmatic or administrative issues encountered. A briefing and debriefing by a psychotherapist should represent the standard for all emergency assignments. Mental health professionals working in this role should themselves ideally have experience of humanitarian emergencies. Training courses should cover stress management techniques (types of stress, coping strategies, how to access help within the organisation), cross-cultural issues, team building/conflict resolution strategies, as well as the ethical frameworks and moral dilemmas of humanitarian relief. Courses should also help to prepare recruits for the task of adapting their professional skills to an environment which may demand a very different orientation. The social level: Organisations should be more willing to accommodate couples on assignment, particularly if both have relevant skills. Unless situations pose extreme risk, couples themselves should be given the autonomy to weigh the benefits and risks of the presence of an accompanying partner. Managers should consider flexibility in breaks so as to maximise, wherever possible, couples’ time together. It is also important that those responsible for recruiting understand the team dynamic in each particular field and attempt to match new recruits to a field that will potentially suit them. The organisational level: Formal policies on the prevention of stress in the humanitarian sector are frequently non-existent or incomplete and vary significantly from one organisation to the next (McCall & Salama, 1999). Strategies for improving briefing, training and debriefing need to take place in the context of organisations developing clear, written and comprehensive policies on the psychological health of their employees. Within the framework of institutional policies, mechanisms to support relief workers in the field need more detailed elaboration. A formal mentoring system for new personnel or the designation of a particular individual chosen by his peers in the field to act as the support person for that particular area are two examples of current practice. Policies on the use of critical incident stress debriefing (CISD) also need to be put in place. CISD may be a useful technique particularly in acutely traumatic events such as a line-of-duty death. Furthermore, organisations should come to a consensus on the most appropriate methods for psycho-social follow-up of employees so that they are able to determine what happens to their workers after leaving the organisation; the success with which they negotiate the difficult transition back into their former environments, as well as the proportion that suffer psychological distress. Anonymous cross-sectional surveys at regular intervals are one possibility. Finally, there must be a recognition of the effects on empathetic field managers of coping with the stress of numerous employees. In effect this is a form of tertiary traumatisation and they too must be able to recognise the symptoms of stress in themselves and call in re-enforcements if necessary. Peer support networks of regional managers often occur on an ad hoc basis but this could be made more formal. Conclusion Unfortunately, humanitarian emergencies are becoming more common. Concurrently the humanitarian sector is becoming larger and more professional, and we are seeing a new type of professional: the career relief worker. These environments, however, are not ordinary work places; they expose individuals and organisations to new dilemmas and new challenges. Staff turnover is high and burnout is common. Perhaps the crucial element in the achievement of the humanitarian goal today is the development of a stable and experienced workforce whose energies are effectively harnessed through more enlightened organisational policies. When seen in this light, the psychological support of relief workers is simply part of the employer’s duty and responsibility. It is not an optional extra. The nature of the human spirit is resilient and strong; we thrive for survival against all odds. ‘I couldn’t possibly describe [PTSD] as an illness. All my research, all my years of clinical experience, had led me to believe it was a survival tool: perhaps our ultimate survival tool’ (Turnbull, 2011). Trauma impacts our mind, body and spirit; it invades our internal and external world. Critical incidents, whether man-made or natural disasters, are becoming more prevalent and assiduous, creating a climate of fear. This fear creates a societal trauma spilt, between those becoming more exclusive or inclusive towards our fellow human beings. The core principles of humanity, neutrality, impartiality and independence are more necessary than ever. To heal from trauma, we need a supportive trauma-informed community. As Martin Luther King reflects, ‘we are caught in an inescapable network of mutuality … whatever affects one directly, affects all indirectly’ (Ramalingham, 2013, p. xi). I strongly believe healing communities and countries suffering from trauma will lead to a more cohesive, inclusive and peaceful world. There is the light and dark side of the coin in aid work: the exposure to trauma, and the joy of life. One image that stays with me is ‘the tree of life’. An aid worker in the Ebola clinic in Sierra Leone painted an image of a large tree trunk, and as the children, who had survived Ebola, left the clinic they would paint their hands and leave their handprint, creating leaves on the tree that represent survival: ‘the survival tree’! When we recover from trauma we can dance freely. As the tree that sways freely in the breeze, we all have the right to breathe the air of freedom. Much has been written about ‘post-traumatic growth’ (Joseph, 2011), where individuals who survive trauma become stronger, more resilient and turn the negative experience into something positive to help heal others. A great example of this is the Assistance Association for Political Prisoners (AAPP) based in Yangon, Myanmar, which has trained former political prisoners in counselling to offer psychosocial support to other political prisoners (Michaels, 2014). My experience of PTSD, over 20 years ago, took me on a journey where I transitioned from working in advertising to becoming a trauma specialist therapist, trainer, speaker and writer. I wanted to use my experience to help others and prevent individuals from suffering in silence for years. Findings from the UNHRC mental health guidelines noted: ‘Approximately one-third also indicated some unexpected benefits associated with stress exposure during the course of humanitarian work, including realising they are stronger than they thought, feeling closer to others, deriving more enjoyment from work, and developing stronger religious faith’ (UNHRC, 2013, p. 80). We need to embed psychosocial practices into an organisation’s culture. Trauma exposure is a foreseeable risk, and there is sufficient research to confirm that the impact of trauma exposure can have a detrimental impact on an individual’s mental health, including risk of burnout, acute stress and traumatic stress. The material in my book, Psychosocial Support for Humanitarian Aid Workers, aims to provide guidance to organisations and individuals, and hopefully encourage consistent good quality psychosocial support within the humanitarian aid sector. Let’s lead by example, let’s be at the forefront of good psychosocial and trauma care and let’s ensure that organisations and individuals are competently trauma-informed. Get your copy of the book today from Amazon. The case study below presents a first-hand experience of how EMDR works. I came to therapy after experiencing trauma symptoms following a trip to Turkey where I witnessed a violent failed coup d’état. Despite having triggered the emergency/security protocol while in Turkey, upon my return I was not offered counselling to debrief the incident. The incident was considered important as the executive director and other senior managers were being briefed on my situation twice daily while still in Turkey. In that sense, I did not feel my organisation supported me in dealing with the fall outs of the incident. I had to request for help through HR and it was almost two months before I was able to see a counsellor. Through this experience, I wondered whether other colleagues who may not have been as comfortable going to see a therapist, or afraid of the stigma attached to doing so, would have requested the support. I believe my organisation should make post-incident debriefing mandatory, as part of the incident management protocol. It would help those who may need a little bit more encouragement to seek help. EMDR addressed my PTSD symptoms effectively. It enabled me to understand why I was reacting the way I was, rather than being left to feel weak or stupid for experiencing such distress. It has now been over six months since the treatment and I have not experienced any symptoms in that time. The changes in how I felt and the reduction of the symptoms I was experiencing was quick. I now feel that the issue is resolved and this is not something I will continue to carry with me. (Chris, aid worker) There are several different approaches to psychotherapy, which can be confusing if you are searching for a therapist. It is important to be aware that some therapists will state that they work with trauma but will not have had specialist trauma training. In basic terms there are three main approaches to psychotherapy: Psychodynamic, Humanistic and Cognitive Behavioural therapies. I would describe myself as an Integrative therapist, and therefore I work with a combination of these approaches. Additional trauma specialist models include: Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), Eye Movement Desensitisation Reprocessing (EMDR), Narrative Exposure Therapy (NET) and Sensorimotor Therapy. There are other models of working with trauma but further research is needed into the efficacy of these various approaches. All trauma approaches aim to help the client to create a trauma narrative, find meaning in the event, and reduce the trauma symptoms, whether through talking, drawing, play or writing. Most trauma models follow a three-step treatment programme: stabilisation, processing and integration (Herman, 1997). EMDR: how does it work? Francine Shapiro, PhD, Senior Research Fellow at the Mental Research Institute, Palo Alto, California and Executive Director of the EMDR Institute, California, is the ‘originator and developer’ of EMDR (Shapiro, 1989). Since then, EMDR has been adapted and reworked based on the research and contributions of therapists and researchers the world over. Initially used as a treatment with Vietnam veterans who weren’t recovering, it has since proven successful in treating various other presentations, including anxiety, phobias, addictions, depression, complicated grief, abuse and performance anxiety. The unique feature in EMDR therapy is that it uses bilateral stimulation (BLS) whilst processing the distressing memory (Shapiro, 2005). BLS can be conducted by following the therapist’s hand as it moves from left to right, watching a light bar, or tapping. The same can also be achieved through listening to alternating bilateral tones or holding buzzers. The BLS alleviates negative cognitions, negative emotion and unpleasant physical sensations associated with a traumatic or distressing memory. An important concept of EMDR is the ‘Adaptive Information Processing (AIP)’ theory (Parnell, 2007). This means the client begins to reformulate and update dysfunctional self-beliefs and replaces them with positive self-reflecting beliefs. Therefore, EMDR promotes our innate healing process and reformats dysfunctional information to functional, so that it becomes adaptive information processing. ‘Just as the river flows to the sea and the body heals the wound, EMDR clears the trauma and brings integration and wholeness’ (Parnell, 2007, p. 6). In discussing EMDR, Professor Gordon Turnbull states: ‘Therapists and patients were reporting that problems that had been resistant to years of psychotherapy were being resolved in a very short amount of time – sometimes within a few sessions’ (Turnbull, 2011). In my experience of working within the field of trauma for over 15 years I have never witnessed such a powerful and successful way of working with traumatised and anxious clients: ‘EMDR works effectively and helps the client return to work quickly and safely after a traumatic event’ (Dunkley & Claridge, 2012). The EMDR protocol sets out an eight-phase treatment plan:
For more information on EMDR Treatment I encourage you to buy my new book Psychosocial Support for Humanitarian Aid Workers, available via Amazon. |
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