EMN Malta NCP Seminar Psychological Trauma and Asylum

EMN Malta NCP Seminar Psychological Trauma and Asylum Seekers -Staff Support Dr Angela Busuttil Consultant Clinical Psychologist May 2016

South East England

“Aid workers cannot serve well unless we are well”.

Challenge • Enormous range of roles in working with asylum seekers Rescuers and emergency workers Those processing applications , Therapy staff and social workers, Interpreters Those working in facilities where asylum seekers are detained or living • Considering the psychological support of each requires understanding of the psychological demands of various roles and systems which offer support

Objectives The reasons to look after staff Why staff may need support How organisations can support staff How staff and teams support themselves Conclusions and Resources

Objectives Reasons to look after staff

Reasons to support Staff • LEGAL Organisations legal duty of care for health of their staff at work • COST IMPLICATIONS Absence from work Presenteeism Turnover of staff and cost of retraining new staff Most important –the Human Cost • ETHICAL REASONS

OCCUPATIONAL HEALTH AND SAFETY AUTHORITY ACT XVII 2000 with subsequent amendments Malta measures that need to be taken by an employer to prevent physical and psychological occupational ill-health, injury or death, shall be taken on the basis of the following general principles of prevention, that is by (a) the avoidance of risk; (b) the identification of hazards associated with work; (c) the evaluation of those risks which cannot be avoided; ………. . (i) by the development of a coherent overall prevention policy which covers technology, the organisation of work, working conditions, social relationships ……… it shall be the duty of an employer to provide such information, instruction, training and supervision as is required to ensure occupational health and safety And…………… (1) It shall be the duty of every worker to safeguard one’s own health and safety and that of other persons who can be affected by reason of the work which is carried out.

Evidence is that many organisations including NGOs in relief work struggle to meet the needs for psychological support for workers

Objectives Why staff may need support

Psychological Impact of Traumatic Events • Those closest to the impact of the event may experience most ψ impact • Psychological effects ripple out into the “disaster community” including staff • Remember “Hidden”staff • Impact mediated by trauma factors but also by characteristics of individual and their current situation

Impact of event on staff mediated by • Trauma related Factors • Organisational Factors • Personal Factors

Trauma factors associated with increased risk of developing problems-general • Severity of the trauma and dose response-duration, intensity, cumulative events • Direct exposure to the event as victim or witness, sometimes as perpetrator • Serious injury or threat to life(self/other)during event • Maintaining consciousness. . . Memory? • Interpersonal violence • Severe emotional reaction during the event and persisting afterwards, crying, shaking, vomiting, feeling apart from your surroundings (dissociation) • Felt helpless during the trauma • Events which include aspects of our innate fears (water and drowning, darkness being trapped, fire, heights and falling) Zeebrugge 1987 • Body handling • Events with personal meaning e. g. where children were hurt and injured especially if witnesses have children • Events where there is someone to blame rather than an “act of God” • Sexual Assault and Rape, CSA

Traumatic events specific e. g. for firefighters (Bergmann & Queen, 1986): • Death/ injury of colleague or child. • Rescue situations where it is impossible to reach a victim, especially a child • Rescue of a burn victim whose recovery is unlikely and suffering is great. • Multiple rescues of victims during which triage decisions must be made. • On the way to a fire, involvement in a traffic accident in which the emergency driver may be at fault.

Trauma , organisational and personal factors. Stressors for Rescuers & Military Personnel on Humanitarian duties (Greenberg et al 2015) • Identifying with Victims, Prolonged Exposure, Compassion Fatigue • Indecisive and Poor Leadership • Double Binds – rules of engagement • Poor support • Poor group cohesion • Lack of Information • Lack of rest and relaxation • Overwhelming conditions • Personal safety/Risk to own health and well being • Lack of support from loved ones or losses and concern for loved ones’ safety.

“The Drops Of Rain Make A Hole In The Stone, Not By Violence But By Oft Falling” Lucretius

Personal factors • Condition of the boat as it faces the storm • Previous storm damage? • How equipped is the boat for the conditions (training) • Can it get back to the yard for minor repairs (R&R) • Where is the anchor and safe harbours Biopsychosociospiritual preparedness

The evidence that this work is associated with more distress?

Frequency of reported distress in relief workers Quoted by Guardian July 2015 The Antares Foundation found that 30% of aid workers report symptoms of post-traumatic stress disorder (PTSD) after field assignments. 46% to 80% of national aid workers experience symptoms of distress. A 2013 study by UNHCR showed that 47% of staff experienced difficulty sleeping; 57% reported symptoms of “sadness, unhappiness, or emptiness”. Effects of Repetitive Exposure In northern Uganda, over 50% of national aid workers experienced five or more categories of traumatic events. Respondents reported symptoms associated with depression, anxiety disorders, and PTSD. Those who have suffered may seek to help others Picture emerges of psychological distress in workers being common and sometimes this can persist and become problematic 21

Hidden staff Interpreters-Impact of working with Asylum seekers • Often trained for legal aspects of work but not for psychological impact • Repeated exposure to detailed traumatic experiences my lead to Vicarious Traumatisation • May come from same community and may also have experienced some of the trauma being discussed • Individual experiences, characteristics, skills, and psychosocial makeup interact to shape how VT affects individual.

Psychology professions • Face to face with personal stories of events and their impact • EMPATHEIA to feel inside- Empathy evokes the same feelings in therapist. Distress may come from Work with distress of individual Helplessness at legal/social barriers Concerns of re traumatising client Looking after interpreter

Therapy and Support staff • British Journal of Social work compares UK and Australian workers. Robinson 2013. • Immigration policy in Australia and UK placed pressure on workers working with those subject to tight state controls and experiencing poverty/destitution. In NGOs in the UK, no supervision for front line social workers Guidance looks at risks of VT http: //www. startts. org. au/media/Resource-Working-with. Refugees-Social-Worker-Guide. pdf

Not all Negative - Emerging concept Vicarious Resilience Journal of Transcultural Psychiatry December 2015 • 4 areas identified VT, VR, work satisfaction, and cultural flexibility • Workers also build own resilience through seeing growth of those they work with http: //tps. sagepub. com/cont ent/52/6/743. abstract? rss=1

Objectives How organisations can support staff

HSE Standards – 6 Factors contributing to workplace stress Demand Workload, work patterns and the work environment. Control How much say the person has in the way they do their work Support Includes the encouragement and resources provided by the organisation, line management and colleagues Role Understand their role within the organisation and the organisation ensures that they do not have conflicting roles. Relationships Promoting positive working to avoid conflict Change How organisational change is managed/ communicated

Helpful guidance • Antares, Managing Stress in Humanitarian Workers, Guidelines for Good Practice (Antares Foundation) 2013 • Guide using 8 evidence based principles for helping organisations to define their own needs in relation to stress management and develop their own staff care systems. • Its strength is its focus on a theoretical model of coping • Attention to the bidirectional effects of individual, team and organisational factors https: //www. antaresfoundation. org/File. Library/file 6782. pdf

How can organisations help? Culture including training of execs and senior management Stress Management Policy Risk Assessments with aim at risk reduction Training and preparation for staff specific to their role On going support in situ and access to support for critical incidents • Clear clinical pathways for those needing intervention inc support for return to work • Review of lessons learnt in audit cycle • • •

Organisational culture • Culture that recognises from the top down that no matter how good the “ship” there are circumstances in this work when anyone can become overwhelmed and benefit from support • Culture needs to promote “psychological mindedness” • Without this any risk assessment, training or intervention is unlikely to have maximum impact

“Before I went to Iraq the UN checked my physical health, but not my mental wellness. Few aid agencies test the mental fitness of their staff; fewer have a comprehensive approach to wellbeing and senior managers rarely acknowledge the stress of aid work” New York Times

Stress Management Policy for organisations undertaking this work Positive indicators The stress management policy is contextually and culturally appropriate. The agency’s policy includes plans both for response to routine sources of stress and to critical incidents The agency recognizes that the differing support needs of different groups of staff The policy recognises that sources of stress can be personal , routine work related as well as major incidents and that the effects of these can interact and be cumulative.

Risk Assessment • Stress Risk Assessments should be undertaken with a view to looking at how the risks may be reduced • Issues of Screening staff. Complex -see Antares document for a good discussion. Not proven to prevent problems in staff but may help identify both to individuals and to the organisation additional support requirements

Training • Staff should be fully trained for the role they will carry out • Trained in stress and how to mange it • How to identify and when to seek help and from where they can obtain it • Especially important for volunteers

Rescuers and Military Personnel: Very well trained but…… May not be trained to deal with extremes of • Distressing scenes • Crowd control • Border control • Body Handling

Ongoing monitoring of stress • Can take place in supervision and management sessions and at annual appraisal • Needs to be a way of feeding back to the organisation if there are problems and links to assessment and support if needed

Critical Incident Support • Psychological First Aid advocated rather than Psychological Debriefing • Key role for Mangers in supporting staff and communicating sense of containment • Psychological First Aid care delivered in first few weeks after the incident to individuals showing acute stress reactions. Aims to establish sense of safety, reduce extreme acute stress-related reactions, strengthen coping mechanisms and social support, and connect individuals to resources/services that help them address their problems http: //whqlibdoc. who. int/publications/2011/9789241548205_e ng. pdf

End of Assignment Review and acting on unmet needs • Ensuring there is a time to review what has happened and how people have coped , lessons to be learnt • R& R may be helpful after particularly stressful period • Important to identify anyone who needs further help such as referral for assessment and therapy

Objectives How staff and teams support themselves

Resilience training for teams and individuals • Concepts of hardiness (Kobassa) but all can improve • Maintain flexibility and balance as we face stressful circumstances and traumatic events • There are behaviours, thoughts and actions that can be learned or developed. • Importance of the role of the Manager

Trauma Risk Management (TRi. M). • Started UK Military 1990 s , used in many uniformed services in UK. • TRi. M training aims to equip non-medical junior manager personnel to manage the psychological aftermath of a traumatic incident. • A proactive, peer group delivered management strategy…. aims to keep employees of hierarchical organizations functioning after traumatic events, to provide support and education to those who require it and to identify those with difficulties that require more specialist input’. (Greenberg et al, 2005; 2008). • Aims to reduce stigma associated with mental health, to help the early identification of those distressed after exposure to ψ tr auma • An extension of buddy-buddy support, a peer support network within a hierarchical structure. • The evaluation of TRi. M in relation to prevention of PTSD is still awaited

Appraisal and Coping- Adaptive Stress Model Concept Primary Appraisal Definition Evaluation of the significance of a stressor or threatening event. Secondary Appraisal Evaluation of the controllability of the stressor and a person’s coping resources. Coping efforts Actual strategies used to mediate primary and secondary appraisals. Problem management Strategies directed at changing a stressful situation. Emotional regulation Strategies aimed at changing the way one thinks or feels about a stressful situation. Meaning-based coping Coping processes that induce positive emotion, which in turn sustains the coping process by allowing reenactment of problem- or emotion focused coping. Outcomes of coping Emotional well-being, functional status, health behaviors. Dispositional coping styles Generalized ways of behaving that can affect a person’s emotional or functional reaction to a stressor; relatively stable across time and situations. Optimism Tendency to have generalized positive expectancies for outcomes. Information Seeking Attentional styles that are vigilant (monitoring) versus those that involve avoidance (blunting) Table from Glanz et al, 2002, p. 214.

Individual Team • Identify own triggers • Resilience building • Identify own coping styles +ve and –ve • Communication • Learn to use cognitive, social and behavioural adaptive coping mechanisms • Supervision and appraisal • Role of Managers • Time to reflect on own needs • Group supervision • Peer support

Either at individual management or organisational level seeking to strengthen the surviving and healthy part

Conclusions

Thank you angelabusuttil@nhs. net