After writing my last piece (“Security For Humanitarian Workers”), I started to think further about the psychological stress put on relief workers. A brief evidence search revealed increasing interest in this area, particularly in the last ten years. In 1997 there were roughly 136 000 relief workers assisting around the world, this rose to 290 000 in 2008. Worryingly with this increase came an increase in the rate of attack of humanitarian workers from 4 to 9 per 10 000. In 1998, for the first time ever more UN aid workers were killed than peace keeping soldiers and in 2000 the number of humanitarian deaths had risen to 375 of which 69% were violent.
This flurry of facts illustrates the increased call for humanitarian response around the world, but also that the kind of response provided is now more dangerous and more involved than ever before. An unavoidable characteristic of relief work is the experience of primary or secondary trauma, primary trauma being a personal experience and secondary being a vicarious experience, i.e. hearing it through the person it happened to. It is well documented that a personal experience of trauma or catastrophe is a risk factor for mental illness, in particular post-traumatic stress disorder (PTSD). Evidence has also shown that secondary trauma increases the risk of developing PTSD. Mental health clinicians who work with traumatized or sexually assaulted patient have a significantly higher PTSD diagnosis rate compared with other clinicians.
There is a bundle of evidence which shows that relief workers suffer from considerably higher rates of mental illness than a general population. The prevalence of PTSD in a general population is around 3.5%, which increases to around 7.8% for lifetime prevalence. The prevalence of PTSD in relief workers has been witnessed to be as high as 17%. The largest study to date on mental illness in relief workers found 43% of the 267 subjects were suffering from one of the following: PTSD, Depression, Anxiety or Burnout. In the UK the Mental Health Foundation state that 25% of the general population will have a mental illness at any one time. This indicates the risk of mental illness while on or after deployment as a relief worker as much higher than in a general population. All this evidence is quite new, the first peer reviewed literature review taking place only last year. It made me ask two questions. Why is this happening, and how can it be reduced?
Obviously those involved in relief work are more likely to be exposed to psychologically damaging trauma. It is the nature of the job, but of course of those exposed to trauma only a small few develop PTSD and other psychological illnesses and still the rates of psychological illness have been shown to be higher in groups of relief workers than they are in the army. Before deployment soldiers tend to receive a great many more hours of psychological preparation compared with relief workers. In recent years awareness has been raised about the need for psychological assistance for returning troops, however the need for this for returning relief workers is just as strong and an area that is extremely under-examined. Other factors which predispose people to develop PTSD include their available support systems, attitudes towards help-seeking behavior and presence of additional stressors. These are all factors which are altered in a conflict or relief requiring setting. Support systems are much lower, particularly for relief workers in rural or remote settings, compared to what they would be at home or even in an army base camp. Health seeking behavior also tends to be altered for relief workers. It is not uncommon to find relief workers putting other people’s health and wellbeing above their own, meaning they may force themselves to cope with more than they can manage, potentially making them overwhelmed and causing long term psychological damage.
It is understandable that relief work predisposes people to PTSD and other psychological illnesses, and that in most cases preparation before departure is inadequate, as is support on return. The idea of debriefing after traumatic experiences and after deployment has been used to try to reduce the incidence of psychological illness. However there is evidence which suggests that debriefing can actually increase the risk of psychological illness post deployment.
While writing this, I’ve learned that the area of psychological illness in relief workers is an area of growing and important research. However, the research as yet has merely shown the existence of a continuing problem. Next steps need to evaluate current, and develop new ways of preventing the high incidence of PTSD and other psychological illness. Prevention requires intervention at every stage of a relief worker’s journey, before, during and after deployment. The psychological wellbeing of these philanthropic workers should be as important as their physical wellbeing. Commonly the people providing relief to those who need it are volunteering their time and skills to help in any way they can. It is a terrible thought that these generous people should suffer during and after deployment from psychological distress in order to give everything they can to those who need it.