Providing support for Red Cross volunteers and other humanitarian workers following a security incident or a disaster
30-06-1997 Article, International Review of the Red Cross, No. 318, by Barthold Bierens de Haan
Dr Barthold Bierens de Haan , ICRC Medical officer responsible for stress management
In the early hours of 17 December 1996, six members of the Red Cross team working at the ICRC hospital in Novye Atagi, Chechnya, were murdered in their sleep by a group of masked men using weapons fitted with silencers. A seventh delegate was wounded but managed to escape with his life.
Providing support in the aftermath of the Novye Atagi tragedy
On the morning of 17 December 1996 an ambulance plane took off from Geneva, bound for the northern Caucasus to pick up the wounded delegate who had survived the previous night’s massacre. On board the aircraft were three senior ICRC staff members: the Delegate General in charge of operational activities in Eastern Europe and Central Asia, the Chief Medical Officer of the Health Division, which was responsible for the surgical hospital in Novye Atagi, and myself, as the medical officer responsible for providing staff with support and advice on stress management. On the spot, these three people were to share a dual task: first, investigating the causes of the tragedy and considering the operational decisions to be taken as a matter of urgency (in particular as concerns security), and secondly, providing support for our colleagues and helping them to cope with their collective shock and grief.
We landed in Nalchik early enough to be there when our colleagues arriv ed from Novye Atagi. Their convoy appeared at about 10 p.m., after a slow trip of more than eight hours on a road made treacherous by snow. Christophe Hensch, the wounded team member, who had been given first aid on the spot, was seen to immediately. He gave us his eye-witness report on what had happened and was then safely installed in the ambulance plane. An hour later the aircraft took off for Geneva, where Christophe was hospitalized. The same evening, during a meal eaten together, the remaining members of the team gave us their initial account of the events of the previous night, and then everyone tried to get some sleep.
The next day we assembled all the members of the delegation so as to inform them of the aims of our mission. I then started the “emotional debriefing” of the survivors of the attack. All 13 people who had been at the hospital during the fatalnight were present, together with two other team members who, exceptionally, had been away that evening. The session lasted two and a half hours; everyone had an opportunity to give his or her own account of “that night” and share the resulting emotions with the group.
In the afternoon we all went to the Nalchik mortuary, where our colleagues’ bodies were placed in their coffins. Then a long convoy made up of a lorry bearing the six coffins and some 15 other vehicles set off for the airport in Mineralnyye-Vody, 100 km away. Before the remains of the deceased, the survivors and those accompanying them were flown out later that evening, a ceremony was held in one of the airport hangars. Opposite the coffins draped with ICRC flags about 100 people gathered: the survivors of the massacre, other delegates returning to Geneva, and also all the delegates who were to remain on the spot. In the freezing cold and amidst the roar of aircraft taking off and landing, a sober and moving tribute was paid to the six victims. Finally, all those present filed past the coffins in a slow procession.
A similar ceremony was held on the tarmac at Geneva Airport in the presence of members of the local authorities, members of the Committee, senior ICRC staff and representatives of the National Societies
Meanwhile, in Nalchik, I continued my work of listening, encouraging the sharing of emotions and providing collective and individual support for the staff remaining in the field: a first group of 25 Chechen hospital employees was received on the day of national mourning, then the five staff from the Grozny delegation. Finally, there was a meeting of all the expatriate staff of the Grozny mission and of the offices in Nalchik, Khasavyurt and Nazran. All of them were given the opportunity to talk about the tragedy and to express their views on the future of the ICRC’s operation in the northern Caucasus.
The second emotional debriefing was held six weeks later, bringing together the 14 survivors from the hospital, this time including the wounded man who had not been able to take part in the debriefing in Nalchik, a nurse and myself. This series of interviews consolidated the work of offering support and preventing post-traumatic stress disorder (PTSD), while favouring the grieving process.
Support offered in the case of collective trauma caused by the death of one or more members of a Red Cross team
When a serious incident involving the death of one or more members of a Red Cross team occurs, the trauma experienced by the survivors makes a special type of support necessary. In such a case a whole series of measures must be implemented or at least envisaged.
— A “rescue” team must immediately be sent to the scene. This team should comprise the person from headquarters responsible for the geographical zone in question, who will take the necessary operational decisions, and a person whose sole concern is to help the survivors manage their emotions and grief. In a manner of speaking, these two people, unscathed and not directly involved in the incident, represent and symbolize the response which an organization’s headquarters should offer to staff in the field when a tragic event is likely to temporarily weaken everyone’s resistance and affect the leaders’ management capacities. These “rescuers” are sufficiently far removed from the tragedy; moreover they have experience of similar situations.
— The emotional debriefing (critical incident stress debriefing — CISD) should be carried out in the two or three days following the event. It preferably takes the form of a group session, assembling all the survivors of the disaster in a quiet room on the delegation’s premises. A group leader (in this case the doctor from headquarters) lays down two rules: everyone is free to express his or her feelings and everything that is said will remain confidential. The group leader also underlines his prime concern: to allow everyone to give his or her own version of the incident and share his or her feelings with the whole group. Progressing stage by stage, the leader then seeks to obtain a precise and detailed account of the facts, everyone’s recollections and reflections, and a description of the emotional reactions and symptoms that persist after the trauma (such as disturbed sleep, states of anxiety or nervousness, repeated flashbacks). Finally, the group leader emphasizes that these stress reactions are entirely normal and describes how he sees the future of the entire group. This may mean the continuation of activities, a period of rest or a return to headquarters. One advantage of such an exercise is that it makes it possible to identify staff members who might need individual support.
— A funeral ceremony in the presence of the coffins is essential and should not be overlooked. Such a ceremony gives the group of survivors, those close to the deceased and the accompanying personnel a sense of solidarity and togetherness. It helps each of them to start the grieving process, favours the continued sharing of emotions and introduces an indispensable spiritual or religious dimension.
— The rapid return of the survivors together with their colleagues’ remains on board a specially chartered aircraft is an important symbol for survivors and families alike. This concludes the first phase of the support programme and the emergency action taken by headquarters.
The stress-management and support programme for staff on mission
Most governmental and non-governmental humanitarian organizations are currently setting up stress-management and support programmes for staff on mission. The emotional burden and the various forms of stress to which these staff members are exposed are so great that their he alth, safety and operational efficiency might suffer in the long term. In addition to the arduous nature of humanitarian work ( cumulative stress ) and the problems of personal relations that may arise within any human group ( basic stress ), staff may have to cope with traumatic stress reactions associated with the dangers of war, terrorism and insecurity.
These three types of stress must be examined in the field and managed according to the same principles.
— The stress reactions observed in the field are normal. They are an indication not of pre-existing mental instability but of a crisis situation which everyone must learn to control. This crisis m anifests itself in different ways in each individual and is the result of abnormal critical events which are the source of sometimes violent trauma experienced in varying degrees by volunteers on mission. Each individual remains responsible for his or her emotions.
— The management or control of these stress reactions is the responsibility of the head of delegation (or the person responsible for the operation), who proposes measures of support for the people concerned, based on attentive listening, an emotional debriefing and/or the granting of a period of rest. These measures should be proposed immediately, on the spot, in all simplicity and in the hope of achieving a rapid return to normality.
The stress-management programme comprises three phases: a briefing before the assignment, support during the assignment and protection on return from the field. Different people are involved in the different phases: trainers during courses preceding departure to the field, leaders on the spot during the assignment, and finally, on return, those responsible for planning human resources.
The programme requires the cooperation of all members of staff: everyone, whether in the field or at headquarters, must feel concerned. Although the doctor in charge of stress management is responsible for drawing up the programme, giving advice to various sectors of the organization and providing support for senior staff in the field, it is the latter who have to put these measures into effect. The magnitude of the disaster — involving the death of staff members or otherwise — is therefore the factor that determines whether action by ICRC headquarters is required.
Favouring a pragmatic approach which does not depend on medicine or psychiatry, this programme is essentially based on a good team spirit and reliable leaders who are aware of the problem of stress among staff and are trained to control it. The programme should benefit from the sense of solidarity that prevails within the International Red Cross and Red Crescent Movement. This should be especially true in the case of a disaster on the scale of the Novye Atagi killings. A tragedy such as this calls the work of the entire Movement into question, undermines its fundamental principles and leaves humanitarian agencies and volunteers in total disarray.
The aim of the programme is not to help people tolerate the intolerable or to inure volunteers to the stress inherent in field operations, but rather to enable all members of staff to share their feelings with sympathetic listeners and so be given a chance to recover without suffering any after-effects; in other words to provide a form of consolation.