Why Trauma-Informed Care?
Child soldiers forcibly separated from families, fed amphetamines and compelled to engage in violent acts. Twelve-year-olds sold into slavery or sexual trafficking. Third-degree burns covering the body of a young mother unable to nurse her child. Amputated limbs left lying in public spaces. Ground covered in bodies as far as the eye can see. Human cries of pain, with minimal pain medicine available. Refugees isolated in camps without access to food or water.
These are just a random selection of images of human beings’ experiences of humanitarian crises. Our fellow human beings are going through intense suffering, and those of us working in humanitarian crises are likely not only to be moved by compassion but also to be traumatized by the exposure to such intense suffering. This is especially true in global health, where providers routinely and selflessly promote the welfare of others and, in doing do, can suffer unexpected harm.1
It is common and temporarily adaptive to proceed as if we are immune to this intensity of suffering and trauma, to focus on the immediate needs of the day, and to set our own well-being aside. While this may be effective and even necessary during a shift where primary attention is required for applying tourniquets and avoiding bullets, this is not sustainable practice for practitioners who wish to continue in the field of humanitarian medicine. Nowhere are healthcare providers as subject to as many varied forms of stress and trauma as in humanitarian crises.2,3
The practice of medicine exposes providers routinely to suffering and trauma even outside of crisis situations. In responding as we aspire to, with empathy and compassionate action, we recognize that vicarious or secondary trauma is invariable. The construct of trauma exposure syndrome provides a useful model for addressing the mental health sequelae for providers experiencing trauma both during and after their work in the field. Trauma response is increasingly recognized as a normal response to an abnormal situation. It may be less pathologized among healthcare providers, who tend not to think of themselves as suffering from a psychiatric disorder such as depression.
The special circumstances of caring for those in mass humanitarian crises must lead us to re-examine and redefine what exactly we can hope for in terms of burnout prevention and resilience promotion under these intense and extreme circumstances. Unique, non-normative experiences in humanitarian crises can lead to a variety of maladaptive behavioral responses, including complicated grief, substance abuse, risky sexual behavior, and numbing and dissociation.4 These experiences are associated with and can lead to more complex stress response syndromes, including burnout, depression, trauma exposure syndrome, and anxiety-related syndromes.5,6
These syndromes have an impact on providers professional and personal lives, their ability to provide care to patients, and their ability to care for themselves, their families, and loved ones.7 Addressing this is an ethical issue, as we have a moral obligation to ensure we are not sacrificing our own on the altar of caring for others in great need. It is also an imminently practical issue, as we have an interest in ensuring that our healthcare work force continues to function and provide quality care in humanitarian crises. The prime directive of being a first responder is not to become a victim yourself. We have the opportunity to be at the forefront of this movement, to recognize the risks to teams and individuals, and develop best practices in protecting providers.
Possible Psychological Syndromes in Healthcare Providers in Humanitarian Crises
Burnout is characterized by three categories of loss8:
• Energy, leading to exhaustion and emotional and physical depletion
• Compassion, leading to apathy and cynicism
• Efficacy, leading to disengagement and ineffectiveness
A provider suffering from burnout might say, “What started out as important, meaningful and challenging work, becomes unfulfilling and meaningless.”
Signs and symptoms of burnout include diminished empathy; more adverse events (mistakes or poor judgment); working less or leaving the profession altogether; heightened irritability; and social isolation or inability to speak of one’s pain.
Signs and symptoms of depression include depressed mood, feelings of sadness, guilt, anhedonia, rumination; self-criticism and low self-worth; difficulty thinking; and suicidal ideation or action.
Signs and symptoms of PTSD include persistent and frightening thoughts and memories of the experience; behavioral effects, such as substance and alcohol use, damage to personal relationships, depression, and suicide; and chronic illness.9,10,11
Signs and symptoms of grief comprise emotional intensity and lability, and waves of painful feelings followed by periods of emotional quietude. Usually self-esteem is not impaired as it is with depression. Grief is often confused with depression and may overlap with it, but not necessarily.
Signs and symptoms include repetitive thoughts and obsessions, distressing emotions ranging from fears to panic, and compulsive behaviors.
All the principles of psychological and spiritual first aid aimed toward caring for patients with psychosocial and spiritual suffering outlined in Chapter 16 apply equally to providers.
Unique Stressors for Healthcare Providers in Humanitarian Medicine
• Death and loss: Death is often framed as a failure in the healthcare field in general, and in particular in humanitarian crises. The extensive onslaught of death and loss of patients as well as possible loss of colleagues is unique in mass crises. Providers also uniquely experience “unnecessary deaths and injury”: the phenomenon of watching individuals die or come to harm who might not die in an alternate location, time, or situation with a different set of resources. This may engender inner conflict and moral distress between ones’ internal sense of justice and what one externally observes.
• Personal safety and basic needs: Accessing shelter, food, water; avoiding harm from human-made and natural violence; and avoiding infection (e.g., Ebola, infectious outbreaks, war and conflict areas, ongoing mass injury such as with flooding) are all stressors for workers in humanitarian crises.
• Physical stress: Sleep deprivation and exhaustion, the extent to which providers may work without sleep or breaks, may be extreme in humanitarian crises.
• Moral distress: Observing social disparities in access to medical resources can produce distress.
• Sense of endlessness of work: The inability to truly “finish” a day’s work creates an internal struggle with the need to place boundaries around the work and focus on self-preservation, while also observing an endless line of patients, many of whom may die before being seen.
• Vicarious trauma through recognizing suffering: Providers experience total pain vicariously in observing physical, emotional, existential, and spiritual suffering.
• Witnessing physical disfiguration and morbidity: These include severe skin syndromes such as Stevens-Johnson syndrome, tetanus, burns, damage to and loss of limbs, facial disfiguration and loss of vision, and injuries related to weapons that have characteristic mutilating effects (e.g., from improvised explosive devices [IEDs], machetes, chemical weapons).
• Isolation: Providers may be isolated either from colleagues or from other providers; they are typically far away from their families, loved ones, or personal sources of support.
• Lack of autonomy and voice for dissent: The response to a crisis may be orchestrated by a number of organizations, with different resourcing, goals, and leadership structures. Orders may come from unclear locations, and providers may have minimal insight into or control over how and when decisions are made, often without a venue to express concerns.
• Team-related stressors: These include unclear roles, expectations, and leadership.
• Existential suffering: Observing these forms of trauma can trigger providers to question their meaning or purpose, as well as why these traumas occur.
• Challenges in measuring and reducing suffering: There may be a paucity of ways in which to quantify suffering, thus challenging organizations to measure and decrease this metric. Humanitarian aid organizations may measure the number of deaths, but may not measure the number of deaths with high levels of pain or suffering, challenging one’s ability to improve this outcome.
Resilience in the Context of Caring for Those Affected by a Humanitarian Crisis
Humanitarian crises engender unique sources of trauma for individuals and teams providing care in these settings. Given the striking impacts of trauma, basic knowledge needs to be shared with healthcare providers in humanitarian crises situations—that trauma syndromes are both an occupational hazard and, with training and practice, a preventable or reducible harm.
Definitions of resilience for healthcare providers usually address one’s ability to respond to stress in an adaptive way, the ability to “bounce back,” and “the rapidity with which one recovers from adversity.”12
One core way to think about trauma exposure in healthcare is to recognize the signs of dysregulation of one’s own nervous system and to learn timely interventions aimed at this dysregulation and hyperarousal that can be used in the field to help ameliorate some of these symptoms.
The skills and practices needed for sustainable caregiving under normal circumstances may be quite different from those needed in crisis situations, where there are added barriers, including tremendous time pressures and urgency to providing care, lack of needed resources, lack of functional lines of communication, and highly stressful conditions such as chaos and danger. A provider is unlikely to be able to use most resilience tools that are gaining traction in current medical training, such as reflective practice, mindfulness, and positive psychology interventions such as gratitude and appreciation. We must tailor our approach to resiliency in the context of these limitations.
Figure 17.1 provides some examples of ways to practice resilience in the field. Other methods are as follows:
• Brief debriefing: Discuss events or experiences, build connections between team members, recognize each others’ emotional experience; name what you are experiencing without fear of reprisal.
• Acknowledge emotional response to an event: Emotional processing can be done as time allows to relieve distress and emotional numbing and exhaustion. Name and acknowledge emotions being felt.
• Short mindful practices: These involve grounding, taking a mindful breath, practicing “the pause.”13
• Self-compassion: Acknowledge your limitations in the context of mass suffering.
Practices in the Field for the Team
The most critical thing team leaders can do to support team members is to build mutual trust and psychological safety.14 Trust and a sense of safety are the bedrock of all teams in palliative care, even more so in humanitarian crises in which providers may be activated and dysregulated emotionally much of the time. Some ways to establish trust and a sense of safety include the following:
• Team debriefing: Whether in the field or afterward, impromptu or planned, 5 minutes or 30, having a process that provides for the psychological safety of all participants is essential.15 Emphasize effective, open, and respectful communication. Practice and model inclusivity and diversity of discipline. Empower all members of the team to speak, and encourage everyone to give and receive feedback freely.16 If there is only one practice you adopt, this should be it.
• Model vulnerability: Normalize how traumatic experiences impact providers (i.e., combat the belief that providers in these settings are “tough” and not affected by suffering). Emphasize common humanity and humility: “We all make mistakes, struggle with X.”
• Affirm relationships, connection, and belonging: Focus on what the team is doing well. Express appreciation for each other. Recognize successes by all team members. Find things to be grateful for even amidst great suffering.
Practices for the Team When out of the Humanitarian Crisis Setting
When and if the crisis passes, or the provider is no longer working in the setting of the crisis, we suggest the following resilience promotion practices:
• Team debriefing: This involves processing grief and trauma, focusing on the emotional dimension, possibly debriefing with colleagues, or professional therapy.
• Integrating one’s experience into one’s assumptive world: This can happen through writing, storytelling, creative expression, and sharing with compassionate colleagues—this is a reflective process that takes time. Some guiding questions for reflection include the following: What moved me about my experience? What distressed me the most about my experience? What did I learn from this experience? What would I tell someone who was thinking of doing what I just did? What meaning does it hold for me that I did this? What values of mine did I understand better as a result of this experience?
• Embracing post-traumatic growth: It is of utmost importance that practitioners who work in the field of humanitarian medicine receive support, to make the experience positive and meaningful in the long term. Educating providers about trauma ahead of time, as well as highlighting growth after the experience, can be life-saving. Although in this chapter we have focused on the challenges of this work, we also want to emphasize the profound meaning and value it can provide to those who choose it. The majority of people ultimately respond to trauma with healing and growth.
A Call to Arms for Organizations
Best practice trauma-informed care requires an organizational and systemic response to recognizing the effects of trauma and providing preventative and proactive healing and treatment for providers. A complete approach would include preparative training for providers prior to being in the field, identifying experienced trauma, and providing healing practices and mental health referrals as appropriate, both on site as well as after returning home. This requires a fundamental overhaul of a system that has historically not acknowledged the effects of trauma on providers. It also requires a recommitment to the well-being of practitioners providing this much-needed and precious care.17,18
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