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Secondary Traumatic Stress: 10.1177/1534765607299910 Hosted at Prevalence in Humanitarian Aid Workers in India

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Secondary Traumatic Stress: 10.1177/1534765607299910 Hosted at Prevalence in Humanitarian Aid Workers in India Traumatology Volume 13 Number 1 March 2007 59-70 ©2007 Sage Publications Secondary Traumatic Stress: 10.1177/1534765607299910 http://tmt.sagepub.com hosted at Prevalence in Humanitarian http://online.sagepub.com Aid Workers in India Siddharth Ashvin Shah, Elizabeth Garland, and Craig Katz Background: Humanitarian aid workers (HAWs) who of lower socioeconomic status (SES) (p < .001) aid traumatized populations experience emotional, reported higher trauma scores compared with those cognitive, and physical consequences. This study of higher SES. Conclusion: Substantial STS exists documents the extent of secondary traumatic stress among HAWs 5 months after widespread mass vio- (STS) in a group of HAWs in Gujarat, India. Method: lence. To bolster resilience appropriately, preventive A standardized 17-item self-report questionnaire, the measures must focus on the prevalent types of trau- STS Scale, evaluated STS symptoms and severity in matic stress in HAWs. workers belonging to humanitarian organizations that provided psychosocial aid to traumatized people in Keywords: burnout; compassion fatigue; work stress; India. Results: All the HAWs (N = 76) reported humanitarian aid worker self-care; occupational haz- STS as a consequence of their work; 8% met criteria ard; relief worker PTSD; secondary traumatic stress; for posttraumatic stress disorder (PTSD). HAWs vicarious traumatization everal occupations expose their practitioners to survivors’ stories of fear, pain, and suffering may to victimized individuals or traumatized com- develop deleterious emotional, cognitive, and physi- Smunities. Primary traumatic stress is the term cal consequences (Carbonell & Figley, 1996; Collins used for individuals who respond with intense fear & Long, 2003; Danieli, 1996; McCann & Pearlman, or helplessness after experiencing a traumatic event 1990; Salston & Figley, 2003). Workers like HAWs, firsthand. Secondary traumatic stress (STS) occurs as who are not trained clinically but do this work in the a result of indirect exposure to trauma through a course of duty and/or out of compassion, have not firsthand account or narrative of a traumatic event been studied adequately. (Zimering, Munroe, & Gulliver, 2003). For the pur- The adverse psychological impact of working poses of this article, humanitarian aid workers (HAWs) directly with people who have experienced trauma has are nonclinician employees or volunteers who may been discussed in the nursing, emergency medicine, (a) ask details of or (b) provide care to those exposed and psychotherapist literature (Alexander & Atcheson, to severe physical or psychological trauma. The pro- 1998; Carson, Leary, de Villiers, Fagin, & Radmall, fessional literature shows that clinicians who listen 1995; Hodgkinson & Stewart, 1991; Melchior, Bours, Schmitz, & Wittich, 1997; Wall et al., 1997). From Psychosocial Assistance Without Borders and the Center for Whether it is disaster work in the field or clinical Integrative Medicine at George Washington University, Washington, work in professional settings, the occupational hazards DC (SAS); Department of Community and Preventive Medicine, of such work may include episodes of nightmares, Mount Sinai School of Medicine, New York, NY (EG); Depart- sleeplessness, hopelessness, and other forms of STS ment of Psychiatry, Mount Sinai School of Medicine, New York, NY (CK). that appear to be linked to working with psychologi- cal trauma (Figley, 1995). The concept that trauma Address correspondence to: Siddharth Ashvin Shah, Center for Integrative Medicine, 908 New Hampshire Avenue, Suite 200, can occur indirectly is consistent with the Diagnostic Washington, DC 20037; e-mail: [email protected]. and Statistical Manual of Mental Disorders (4th ed.) 59 60 Traumatology / Vol. 13, No. 1, March 2007 criteria A for posttraumatic stress disorder (PTSD), p. 758). There, the Compassion Satisfaction and which asserts that traumatization is possible without Fatigue Test (Figley, 1995) found the following lev- being personally harmed or threatened with harm. els of compassion fatigue: extremely high 27.5%, Traumatization can occur through contact with nar- high 11.7%, and moderate 15.4%. ratives of primary traumatic stress. Like clinicians, Finally, there are a range of studies that identify HAWs come in close contact with such narratives of protective or intensifying factors vis-à-vis occupa- traumatic exposure. tional traumatization (Baird & Jenkins, 2003; Brady, The adverse psychological consequences of Guy, Poelstra, & Brokaw, 1999; Chrestman, 1995; working with primarily traumatized individuals have Ghahramanlou & Brodbeck, 2000; Kassam-Adams, been described in various ways: secondary traumatic 1995; Johnson & Hunter, 1997; Stamm, 2002). In a stress disorder (STSD), compassion fatigue, com- very large review of primary, nonoccupational passion stress, and vicarious traumatization (McCann traumatization during disasters, Norris, Byrne, and & Pearlman, 1990; Pearlman & Saakvitne, 1995). A Diaz (2001) concluded that the following factors worker can experience negative changes in professional cumulatively increase the risk of adverse outcomes functioning, self- and worldviews, sense of security, in adults: self-capacities, and psychological needs (Saakvitne & Pearlman, 1996). This psychological morbidity • Female gender often goes unnoticed until people decompensate • Age in the middle years of 40 to 60 with more serious consequences such as clinical • Ethnic minority group membership Poverty or low socioeconomic status (SES) depression, anxiety problems, substance depend- • • The presence of children in the home ence, burnout, or PTSD. Frequent, numerous inter- • Psychiatric history actions with survivors of trauma might increase the • Severe exposure to the disaster likelihood of developing STSD (Figley, 1999). • Living in a highly disrupted community While STSD can result from acute, subacute, or chronic exposure to stress, the category of burnout is Insofar as HAWs work in hazardous conditions, generally used to refer to exhaustion from the cumu- they risk primary trauma exposure whose outcomes lative buildup of stress (Figley, 1999; Maslach, 1982; might follow the above personal vulnerabilities. Maslach & Jackson, 1986). It is characterized by “a However, the question remains as to which personal state of physical, emotional, and mental exhaustion factors of HAWs cause vulnerability with regard to caused by long term involvement in emotionally secondary exposure. demanding situations” (Pines, Aronson, & Kafry, 1981, p. 3). Burnout is not strictly based on psychi- atric diagnostic criteria for traumatic events or trau- Humanitarian Aid Workers Operating as matic symptoms. One study documents how HAWs “Barefoot Counselors” may underestimate both how much stress they would experience and the extent to which they would use In India, as in other countries suffering shortages of less adaptive coping mechanisms, such as alcohol professional mental health workers, HAWs who are and cigarette consumption (Britt & Adler, 1999). not trained in mental health treatment find them- A study done in 2002 in Australia found that selves in a position where they have to provide impor- 27% of the community mental health case managers tant psychological support. In the 1960s and 1970s, who worked with the traumatized experienced extreme in regions of China with few or no fully trained distress from this work. A study of Oklahoma City physicians, there were barefoot doctors who were trauma workers found that 64.7% of them suffered actually peasants who had been given a “crash from symptoms of PTSD (Wee & Meyers, 2002). course” to diagnose/intervene in cases of rural infec- Data from the response to the World Trade Center tious diseases and maternal health. HAWs in India attacks are currently being analyzed, with one of the constitute an informal, unorganized system of “bare- first published studies showing that “a substantial foot counseling.” For many communities, they are proportion of clergy and others in the tristate New the only source of counseling by default. Yet most York area are at significant risk for compassion HAWs do not receive a crash course on counseling; fatigue” (Roberts, Flannelly, Weaver, & Figley, 2003, they improvise on the job and in the field. Secondary Traumatic Stress in Humanitarian Aid Workers / Shah et al. 61 Typically, these humanitarian workers are execution squads, public maiming, and police com- employed for roles such as arranging housing, secur- plicity (Human Rights Watch, 2002, 2003; Medico ing food, transporting people, sharing legal aid, and Friend Circle, 2002). HAWs from a variety of serv- providing client advocacy. However, they find them- ice organizations responded to this pogrom of vio- selves operating as barefoot counselors insofar as lence. The first author (known to some Indian they also take up the following roles: providing emo- organizations for doing psychosocial work) received tional support, counseling for sexual trauma, con- the following e-mail from a HAW organization direc- ducting play therapy, and making referrals to tor on June 26, 2002: therapists/psychiatrists. They may also provide psy- chotherapeutic services during multiple client visits, We ourselves are feeling burnt out as a team . lis- and they typically do this sensitive psychological tening, taking statements and testimonies, on the work with little or no formal training. latter part distributing relief and now presently mak- Other factors leading to unrecognized trauma ing affidavits
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