Hurting the helpers – Trauma and how it can affect aid workers

Many thanks to James Clifton and Roger Mills for this guest blog.

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Aid workers, operating in disaster areas or war zones are often exposed to acutely distressing, traumatic sights and experiences. Often, aid workers are witnessing horrific scenes on a daily basis, leading to a build-up of traumatic experience. And in addition they are far from their usual support systems of friends, family and the normal securities of home. The cumulative effect of this can have a very damaging effect on mental health. In this article we look at one aid worker’s account of his experience in the Balkans and how it affected him. And we go on to discuss the ways in which trauma exposure can have a damaging effect.

During the early 90’s James Clifton founded an NGO delivering humanitarian aid to refugee camps in the former Yugoslavia. He describes how his experiences in the Balkans affected him and the people he was trying to support:

‘During the first year my desire to support those in difficulty far outweighed my need to support myself and my internal narrative was to discount any discomfort I felt about my experiences, mainly because my life was far simpler in comparison, (or so I told myself).

Uncomfortable emotions or thoughts about what I had witnessed were deleted and ignored and I just focused more on the practicalities at hand with fundraising and getting the aid delivered as quickly and directly as possible.

During the second year the organisation was growing and this meant that I would be spending more time in the field. Again my motivation was to be immersed in helping others as much as I could, having direct contact with individuals and families that were daily traumatised by the conflict.

One of the things that I witnessed was the amount of alcohol that was being used and I soon realised that dependency was rife amongst the refugee camps. I could clearly acknowledge that the increase in alcohol intake could be a coping strategy for these individuals yet I was unconsciously in denial about my own daily intake of alcohol.

Working longer hours and taking little care of my physical needs started to have an accumulative impact on me. Irritation and weight loss and disturbed sleep started to enter into my life.

During year three, relationships that I held dear to me started to dissolve as I became much less tolerant, with what I referred to back then as ‘The Worried British Well’ I felt that most people’s complaints back in the UK just disappeared into insignificance and I had little time to listen to others ‘small talk’. I felt justified in my anger.

On one of our medical aid runs to a hospital that housed and cared for a cross section of children with disabilities, (displaced by the war) we came across a funeral procession in a village. Taking a break from driving and awaiting the procession to pass, we sat in the rubble of local coffee shop and struck up a conversation with the owner. He was, like many before him very keen to share his experiences and as usual I would listen and hear what they had to say. I had always found their culture very open in what they were willing to share even without me asking. (Or maybe this was a deeper need to share or diffuse the stress?).

Suddenly there was a loud explosion and smoke rising in the distance above the old town. This was not the first time my heart had raced, and my default to ‘run away’ from these types of situations had been re-wired into ‘running toward’.

So with a camera in hand to record the event (essential for help in awareness and fundraising) we ran toward the blast.

I arrived at the scene, a graveside vigil and a memorial reef hidden with explosives had turned the funeral into a bloodbath. UN peacekeepers were on the scene very quickly and we were physically and forcefully removed within a few minutes of arriving (which initially felt like hours).

Although I had recently started to acknowledge some accumulative stress (lack of sleep, weight loss, irritability, mood swings, substance dependency to name but a few) I still saw this event as an opportunity to get a story back to the UK which would support us with fundraising for a television interview we had lined up on morning TV back in the UK.

Over the following days the images of that event started to play a major part in my daily thought process, coupled with more frequent elements of the accumulative stress (described above). Often I would feel either hyper aroused or on hyper alert and sensitive to noise as it increased anxiety and increased paranoid thoughts.

Eventually things became too much and I took a fortnight holiday in India.

A few days into my trip I met a Vietnam war veteran who took one look at me and said I looked like I was ‘shell shocked’. Suddenly the penny dropped and as the days went on my body started to shut completely down and I spent the best part of a fortnight in bed.

I stayed in India for 8 weeks and decided there was no way I could return to my position at the NGO. The fourth and following year was a year of recovery physically, psychologically and emotionally piecing myself back together. The burnout I felt was extremely frightening and I was not sure whether I would fully recover.

Reforming and repairing the relationship with all aspects of myself with essential support and learning from others took the next best part of 2 years, a difficult experience that led me into working with and teaching others as I do now.’


James’ reactions to his experiences are a powerful example of what cumulative exposure to traumatic stress can do. He charts a gradual decline in which the milestones include increasing use of alcohol, irritability, loss of appetite and weight loss, and relationships beginning to break down. The horrific attack at the funeral then precipitates even more acute symptoms such as flashbacks, hyper-arousal and anxiety all driven by increasingly paranoid thinking.

Trauma reactions like these are often bewildering and extremely frightening to the people going through them. But why do we react the way we do to trauma? One key point is that we remember traumatic events differently from how we remember a ‘normal’, non-traumatic experience. When we have a normal experience, in the aftermath we will usually be left with fairly incomplete memories. A few images of what happened perhaps. You might remember the topic of a conversation, but by no means the whole thing. And the experience will feel as if it is already firmly in the past.

With trauma it is different. When we go through a traumatic experience a series of hormones are released into the system as part of the automatic physical reaction known as the ‘fight or flight’ response. One of these hormones, cortisol, temporarily damages a part of the brain called the hippocampus which is used in the formation of memories. The result of this is that the sensory and emotional experience of the event that you get when it is actually happening gets stuck in you. It is as if the memory is fixated in the present tense. Typically when people have had traumatic experiences, even if the event happened months or years in the past, they will tell you that it feels as if it happened yesterday.

So what does trauma do to us in the aftermath?  As we have described, all the elements of the experience – what you saw, heard, smelt, tasted, the physical sensations you had, what you thought and felt – all these different aspects of it get stuck in you in a vivid and alive form. Because of this trauma survivors often find that they re-live their experiences. They might have flashbacks of what happened as James did, with vivid pictures or sounds or even smells of the event coming into the mind in an out of control way. Things that remind you of what you experienced can also trigger huge distress and anxiety. You might think obsessively about your experience or have nightmares that relate to it.

Trauma sufferers also, often, become great avoiders. You might start avoiding things that connect you to what happened. You don’t want to talk about it or listen to other people talking about it. You avoid activities which would remind you of the event. Some people shut down emotionally, as if their unconscious mind wants them to avoid having any feelings at all, leading to a state of emotional numbness which though different from the active pain of remembering the event, is disabling in a different way as everything feels pointless and without value

There are lots of other reactions that are common which psychologists group together under the label ‘hyper-arousal’. Traumatised people often become much more generally anxious – James’ paranoid sensitivity to noise is an example of this. You might feel uneasy walking down the street, or in crowded places like supermarkets. Anywhere where you do not feel in control of what is happening can cause you strong anxiety.

With recurrent thoughts about what you experienced and recurrent shots of anxiety you will be frequently having fight or flight reactions with some potentially difficult physical consequences. Trauma sufferers very often have hugely disturbed sleep patterns. Like James they may find that they lose their appetite and so lose weight. Constant headaches, muscle aches, skin disorders and a greater vulnerability to infections (due to a lowered immune system) can also be part of the picture.

 

Another common reaction is being easily prone to irritation and anger (sometimes to extreme anger). This was one of the earlier signs in James gathering state of traumatic stress and it is very normal for trauma sufferers to have a very short fuse when faced with frustrations or with people who fail to appreciate what you have been through. Because of this, trauma survivors often find that their personal relationships suffer and may break down which only adds to the difficulties they are facing.

The catalogue goes on. When you’ve been exposed to traumatic events normal functioning can be very difficult. Your memory often suffers, you can’t concentrate, you get emotional at little things. You might have difficulty with decision making and find that things that you used to enjoy and got a lot out of now feel meaningless to you. It is no surprise that people who are going through this will often turn to forms of self-medication like alcohol or drug abuse, in an attempt to anaesthetise themselves. Heavy alcohol use was endemic in the Balkan refugee camps as James described. Depression is also often a part of the picture and at its very worst trauma survivors can suffer so terribly that they take become suicidal.

It is by now clear that there is a wide range of distressing and often very disabling reactions that people who have been exposed to shocking, traumatic situations can experience. The good news though is that there is a great deal that you can do to mitigate these reactions. People who are prepared for the possible impacts of trauma through appropriate training tend to deal much better with trauma situations than those who haven’t had this kind of preparation. Workshops like the Achilles Programme developed specifically for NGO workers about to go into the field by Integration Training provide an awareness and a range of techniques which can significantly reduce vulnerability to trauma reactions.

Also, for those who have developed significant trauma reactions, the last 20 years have seen striking advances in psychotherapy treatment. Two forms of treatment recommended in the UK by the National Institute for Clinical Excellence (NICE) are particularly effective – trauma focused Cognitive Behavioural Therapy and EMDR (Eye Movement Desensitization Reprocessing). These two treatment modalities have been strikingly successful in helping many trauma sufferers and can be effective even years after the trauma happened.

In brief

Reactions that you might experience after exposure to shocking traumatic events:

Re-living  reactions

  • Obsessive thinking about the event
  • Flashbacks
  • Strong anxiety and physical reactions at reminders of the event
  • Nightmares

Avoidance reactions

  • Avoiding talking or thinking about what happened
  • Avoiding situations, people or anything else associated with the trauma
  • Emotional numbness

Hyperarousal and other

  • Generally high levels of anxiety (e.g. in the street, crowded places, any situation where you don’t feel in control)
  • Anger and irritability
  • Poor concentration, memory, decision making
  • Difficulties in interpersonal relationships
  • Self-medicating (alcohol or drug abuse, risk behaviours)
  • Depression
  • Suicidal thinking

Physical reactions

  • Disturbed sleep patterns
  • Headaches, muscle aches
  • Digestive problems
  • Skin problems
  • Lowered immunity with increased vulnerability to colds, flu etc
  • Loss of appetite/comfort eating leading to weight loss or gain

 

Useful resources

For more information about Trauma Focused CBT or to find a TFCBT therapist see the website of British Association for Behavioural and Cognitive Psychologies

For more information about EMDR or to find an EMDR therapist see the website of the EMDR Association UK and Ireland

 

James Clifton and Roger Mills are psychotherapists specialising in the treatment of post traumatic reactions and stress. Their contact details are:

James Clifton
www.jamesclifton.co.uk
James@jamesclifton.co.uk
07733 306639

Roger Mills
www.counsellingwestend.co.uk
roger909@btinternet.com
07980 543999

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You can find out more about the Achilles Initiative here and on Integration Training’s website. You may also be interested in seeing Integration Training’s video on Stress & resilience tips for staying happy, healthy and sane