Ethics for global mental health specialists · as a key to overcoming compassion fatigue. In their...

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Cherepanov

Ethics for global mentalhealth specialists

Elena Cherepanov

Key implications for practice� Ethicalguidelinessetbasicparameters

to navigate moral conundrums andmake competent decisions aboutchoice of interventions

� Guidelinesprovidetheframeworkforthe moral, professional, consistentand collaborative care for the mostvulnerable populations and streng-thensprofessionalcon¢denceinmak-ing di⁄cult decisions

� This paper identi¢es signs of burn-out speci¢c to ¢eld work and broad-ens understanding and implicationsof safety and self-care

Globalmental health work is an emerging specialis-

ation that focuses on serving culturally diverse popu-

lations around the world. International mental

health providers often work in the settings with com-

plex needs where they are confronted with mass

trauma and human su¡ering. This places special

demands on making independent, responsible, com-

petent and ethical decisions in often unique circum-

stances. Exposure to both the incomprehensible

failure of humanity and the incredible resilience of

impacted populations forces professionals to re-

examine their convictions and beliefs.This, in turn,

opensan opportunity for profound existential discov-

eries about the world, their profession and them-

selves. This paper argues that humanitarian

principles and strategic guidelines for psychosocial

intervention provides the conceptual framework

and operational guidance for mental health special-

ists to navigate ethical and moral conundrums in

response to pressing humanitarian psychosocial

needs, and to do this in amoral, professional, consist-

ent and collaborative way. Further, serving vulner-

able populations calls for higher standards of self-

awareness and self-care (Williams, 2012), with

safety an imperative and burnout prevention key to

professional competencies.

Keywords: burnout, ethics, global mentalhealth,humanitarianvalues, trauma, traumatourism

IntroductionThis paper aims to explore the role of multi-disciplinary humanitarian values withinthe ethics of global mental health work. Itisbased on a review of major documentsrelated to professional codes of conductwithin a humanitarian context, informalcommunication with mental health (MH)

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aidworkers, andtheauthor’s ownexperienceof providing mental health and trauma carein international emergency settings.Over the past two decades, global MH hasbeen rapidly gaining recognition as a vitalpart of international humanitarian relief sys-tems. Its contribution to the humanitariancause, violence prevention and making theworld a better place cannot be underesti-mated. MH specialists participate in emer-gency response, disaster relief work,capacity building and the development ofsustainable mental health systems. Theyrespond to ever increasing humanitarianneeds, provide psychological support foraidworkers, and treat, support and advocatefor those who are in dire need.They conductresearch, advise governments on mentalhealth policies and facilitate capacity build-ing by training local specialists. Some are

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Ethics for global mental health specialists

Intervention 2017, Volume 15, Number 1, Page 17 - 33

employed by non governmental organis-ations (NGOs) or private foundations, whileotherswork independently.Often, theyworkin complex and unsafe environments wherethey have to make quick and e¡ectivedecisions, under duress, in situations withhigh moral and ethical ambiguity. Ethicalchoices can face di¡erent challenges withinvarious areas of MH specialists’ activities.Chiumento, Khan, Rahman, & Frith (2016)studied ethical challenges to research in postcon£ict settings and suggested directionsfor their management.The authors describesix areas that pose ethical challenges. Theyare:Who conducts the research;Who fundsthe research; Ethical review; Voluntaryinformed consent; Community mistrust;and Risk to the research team (Chiumentoet al., 2016, p.17).A professional code of ethics serves to estab-lish personal, organisational, and corporatestandards of behaviour expected of pro-fessionals in most situations, and sets the rulesfor professional interactions. However, whenserving highly vulnerable populations in set-tings with complex needs and limited pro-fessional support, global MH specialistsoften face unique professional and personalchallenges. Therefore, ethical guidelines canassureaccountability, £agunethicalpracticesand assist international MH professionals innavigating complex situations, especiallythosewithnogoodsolutions.Atthesametime,unethical practices that impact the imageof the profession undermine the spirit ofhumanitarianism and compromise safetyandwellbeing of the peoplewe serve.Adoption and ongoing development of uni-versal humanitarian principles has beendriven by the crucial importance of coord-inatedresponse,andbymakingvariousmulti-disciplinary actors agree on basic principles.These values and principles are universaland aspirational by nature, and this papermapstheprocessofconsolidationandreconci-liation of multidisciplinary values as part of aprofessional decision making process. Theprinciples of humanitarian assistance, which

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are re£ective of positive and negative experi-ences accumulated by the humanitarianmovement, provide the conceptual frame-work for ethical decision making, andstrategicguidelines for psychosocial interven-tions serve as an operational guidance. Thereconciliation of moral and personal valuesin resolving moral conundrums is outside thescope of this paper and will be explored inthe future. In the context of humanitarianwork, ethics for global mental health workset practice expectations and rules for pro-fessional interactions.Professional and personal challenges ofinternational work put a heavy moral bur-den onMH specialists that, not surprisingly,takes a toll on their psychological wellbeing.When one’s worldview is shakenby exposureto mass su¡ering and severe trauma, ethicso¡er professional grounding and provideguidance. The Antares Foundation (Young,2015) found that 79% of the 754 respondentsto the survey on the Guardian Global Develop-ment Professional Network reported that theyhadexperiencedmental health issues relatedto aidwork,which emphasises theprioritisedimportance of safety, self-awareness, andself-care.This paper describes signs of burn-out that are common among global mentalhealth workers and o¡ers practical recom-mendations for its reversal.This paper structured in a following way: itbegins with the brief history and currentstate of global MH work in a changingworld, as part of the humanitarian move-ment where an ethical, consistent and colla-borative response is built upon sharedsystem of international values. This systemof values re£ects successes and fallouts ofhumanitarian relief and sets the conceptualframework and multidisciplinary standardsfor professional interventions. Analysis ofthe unique professional and personal chal-lenges of the ¢eld work demonstrates theneed, in broad points of reference, for ethicaldecisions in morally ambiguous situations.The multidisciplinary values are exploredthrough the lens of psychosocial

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Cherepanov

intervention, where values consolidationand reconciliation o¡er insight into poten-tial areas where they may con£ict. Thesepresented values include: the universal prin-

ciples of humanitarian assistance that provideaspirational guidance; and the guidelines forpsychosocial interventions that o¡er operationalguidance. The paper ends with prioritisingthe safety and self-care imperative in inter-national work, lists common burnoutindicators in ¢eld work and o¡ers recom-mendations for its reversal.

Global mental healthin a changing worldNGOs have been incorporating mentalhealth (MH) and trauma modules into dis-aster relief since the early 1980s when theprofessional community came to realise theimportance of attending to both medicaland MH needs in emergencies. Even so,the routine employment of MH specialistsdid not happen until almost a decade later.Additionally, only in the most recent yearshave psychosocial modules for survivors ofsexual andgenderbasedviolence or complexemergencies (armed con£ict, genocide, fam-ine or epidemics) becomeapriorityof huma-nitarian relief (Cherepanov, 2016).The 1990 s saw a rapid growth in inter-national mental health programmes aftertrauma support modules became the goldstandard for humanitarian response.Already by 2012, Me¤ dicins Sans Frontie' res(MSF) sta¡ had held 191,300 individualand group counselling sessions in the Rus-sian Federation, Sudan (Darfur), Iraq,Congo, Kashmir, and other countries(MSF International, 2012, p.12). Accordingto Cherepanov (2015), international workchanged the landscape of mental health; itincreased interest in the cultural dimensionsof trauma and recovery, and the appreci-ation for human resilience. She further sta-ted that a culturally competent global MHspecialist learns about cultures by studyinghow people cope with life adversities. This


international experience also questions thewestern understanding of trauma and theapplicability of western treatment modelswithin di¡erent cultural and social contexts(Summer¢eld, 1999). Since then, inter-national MH work has been consistentlymoving away from operations based on pre-conceived professional notions and culturalstereotypes, and is now more than ever inneedof developing relevant standards of careandwell designed, culturally valid, evidencebased practices. It also has become evidentthat this work requires a special set ofprofessional skills, cultural and personalcompetencies and thorough knowledge ofinternational humanitarian values and prin-ciples of humanitarian assistance. It is worthnoting that humanitarian values themselvesare a work in progress, and their develop-ment is re£ective of the struggle that hasled the humanitarian community to estab-lish a consistent multidisciplinary approachto these complex phenomena, where themeasure of success is saving human lives.

Ethics of global mentalhealth workEthical challenges of direct services andpro-gramme development revolve around therole of MH providers in settings with com-plex psychosocial needs arising from workwith severely traumatised populations(Cherepanov, 2016).It has long been recognised that traumaexperience creates special vulnerabilities insurvivors. These include: impaired schemasand beliefs; unmet psychological needs forsafety, trust, personal power, or control;and issues around esteem. According toBraak (2002), these factors mandate higherethical standards for those working withtraumatised populations. Williams (2012)recognised the impact of trauma work onthe professional and personal lives of trau-matologists, and emphasised that someprofessional competencies carry greater sig-ni¢cance. Among these are the awareness


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of our ownwork and beliefs, heightened sen-sitivity to the issues of our own safety, cogni-sance of the balance between power andcontrol, e¡ects of trauma work on self-esteem and reliance on personal resilienceas a key to overcoming compassion fatigue.In their work, global MH specialists faceunique external, professional, and personalchallenges. Physical and moral hardship,safety and health related risks and exposureto mass trauma and severe su¡ering can allbe personally overwhelming. External chal-lenges can include: security, politics, fund-ing, insu⁄cient resources, and the in£uenceof organisations that impose their rules,regulations, and values.Other challenges include:

� F

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acingacompromised referral systemandlack of professional supports

� S
erving multicultural populations � B eing part of a multidisciplinary and
multicultural team
� D ealing with the potentially con£icting
valuesof individual focusedmental healthversus population focused public healthapproaches

� M
anaging the potential con£ict betweenchoosing to respond to immediate MHneeds of survivors versus communitydevelopment and capacity building
� H
aving to make professional decisionsunder duress
� F
acing morally ambiguous situations andunique ethical conundrums
Themain goal of professional codes of ethicsis the welfare and protection of the clients.As the American Psychological Association(APA) Ethics Code (2002/2010) states, ethicsare intendedtoprovide guidance for psychol-ogists and standards of professional conductto cover most situations encountered by psy-chologists. Behnke (1997) described theapproach to the ethical practice of psychol-ogy as being mindful of the values thatinform our clinical work, especially whenthose values compete with one another,

© War Trauma Foundation. Unautho

where an ethical dilemma is understood asa complex situation that often involves anapparent mental con£ict between moralimperatives that if one would obey it wouldresult in transgressing another. In simplerterms, ethics help to navigate morallyambiguous situations.International context takes professionals outof their comfort zones and painstakinglyscrutinises the preconceived notions thatthey have been trained to rely onwithin rou-tinework. Exposure to the incomprehensiblefailure of humanity forces a person to re-examine their belief systems and to questionmoral convictions which, in turn, o¡ers anopportunity for profound existential discov-eries about the world, and themselves. Thisauthor would argue that in morally ambigu-ous situations with no good solutions, hu-manitarian values provide solid guidancefor sound ethical decisions. Figure 1 illus-trates the relation of professional ethics tothe values of humanitarianism. The centraloverlapping part signi¢es the ethics for glo-bal mental health work that encompassesboth professional and multidisciplinaryagendas. Other interconnectedparts includethe fundamental principles of humanitarianassistance, the strategic guidelines for psy-chosocial interventions and the safety andself-care imperative.Do these values carry the same importancein planning psychosocial interventions anddevelopingaprogramme? This author o¡ersa blueprint for hierarchy of values comingfrom di¡erent approaches and disciplinesvalues where the values are envisioned as aset of four concentric (or nesting) circles(see Figure 2). The more central placementof values re£ects their precedence and literalunderstanding, while the values placed onthe periphery serve as strategic guidancethat allows broader interpretations. Let’slook at these levels starting with the centreand moving outward. Figure 2 points outthe prioritised importance of the safetyimperative in any operational decisions, fol-lowed by a professional code of ethics,


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Professional code of ethics

Strategicguidelines forpsychosocialinterventions

Safety and self-careimperative

Fundamentalprinciples ofhumanitarian

assistance

Figure 1: Ethics for global mental health work within a system of humanitarian values.

Cherepanov

strategic guidelines for psychosocial inter-ventions, and ¢nally, the fundamental prin-ciples of humanitarian assistance. Thevalues of A and B levels (safety, self-care,and professional code of ethics) are binding.The values of the C and D level are similarlyimportant; however, they are aspirationaland meant to provide the framework ofvalues, vector and operational guidance.Historically, these values themselves havebeen adjudicated along with the evolvingunderstanding of humanitarianism.Imagine a mental health specialist whodesigned a programme for trauma survivorsandwantedtomake surethatthisprogrammewas consistent with humanitarian values.What should the tactic be? For this, wecheck this proposal against the values in anoutward direction starting from A (Safety).If a proposal doesn’t meet the standards onanyof the levels, it needs tobe reviewed.Afterrisks are carefully evaluated and safety andsecurity are assured, the next step would beto check whether the proposed intervention


has the potential to violate the professionalcode of ethics, if they re£ect the guidelinesfor psychosocial interventions, and ¢nally,whether they are in agreement with funda-mentalprinciples of humanitarianassistance.In the next part, the author will furtherelaborate on D) Fundamental principles, C)Strategic guidelines, and A) Safety impera-tive, as they apply to global mental healthwork. Section B) Professional codes of ethicswill not be discussed in this paper. For thesake of establishing the continuity betweenthe di¡erent levels of values, the author willfurther elaborate on these principles in theoutward direction starting from theoreticalpostulatestowardtheirpracticalimplications.

Humanitarian values: brief historyand current stateWhile hardly anyone has questioned theoverall importance of contemporary hu-manitarianism, its principles are oftenchallenged and continue to be augmentedin response to precedents set in the ¢eld.


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(D) Fundamentalprinciples ofhumanitarianassistance

(C) Strategic guidelinesfor psychosocial

interventions

(B) Professional codeof ethics

(A) Safety and self-careimperative

Figure 2: Hierarchyof themultidisciplinaryvalues inplanningthepsychosocial interventions.



The Sphere Project (2004, p.10) outlined thecurrent trends in humanitarian relief:

� H

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umanitarianism has widened from apurely charitable ‘philanthropy’ to includerights based and professional approaches

� A
dvocacy with governments has beenmore common in recent times
� T
here is an increasing need to accept thatcon£icts are chronic in some developingcountries
� P
rinciples are needed to keep humanitar-ian work separate from the militaryand politics
� D
isasters are increasingly complex � T here is an increasingdiversitywithinthe
humanitarian community
� T here is an increasing complexity of
organisations involved in operating withdi¡erent measures of success

The framework of humanitarian assistancelays out the ground principles shared by var-ious international humanitarian relief work


actors. They are aspirational by natureand, in addition to the professional codes ofethics, o¡er guidelines in three domains:fundamental principles of humanitarianresponse, guidelines for psychosocial inter-ventions and the safety and self-careimperative.The need for shared values and consistencyof actions within humanitarian assistance¢rst became apparent duringWorldWar IIand led to the proclamation of the UniversalDeclaration of Human Rights (UnitedNations, 1948). The 1965 Fundamental Prin-ciples of the International Red Cross andRed Crescent Movement (www.ifrc.org/en/publications-and-reports) was developed tocoordinate agendas and create consistencyin humanitarian response and has becomea major milestone in the evolution of hu-manitarianism. The growing body of evi-dence has questioned the universality ofhumanitarian principles and also empha-sised the importance of standards of work.Some principles have received additional


http://www.ifrc.org/en/publications-and-reports


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clari¢cation following these precedents. Forinstance, the principle prohibiting takingadvantage of survivors was introduced inthe wake of the ‘aid for sex’ scandal amid theallegations of sexual abuse of refugee chil-dren by peacekeepers and aid workers inWest Africa in 2002. Another example isthe1990s situation in post-genocide Rwandathat polarisedhumanitarianactors andchal-lenged some of the ground principles ofhumanitarian response, such as whether toprovide humanitarian aid to those whoparticipated in genocide.This led to reneweddiscussions about limits, values and prin-ciples of humanitarian actions. In responseto the criticism, the UNand NGOs initiateda number of initiatives and collaborativepartnerships designed to improve hu-manitarian assistance and accountability,out of which emerged the Sphere Project(1997) and the IASC project (2007). Thefocus of the Sphere Project has been thedevelopment of minimum standards in coreareas of humanitarian assistance, whileIASC has issued guidelines for psychosocialsupport in emergency settings. Table 1 sum-marises the development of humanitarianvalues relevant to international mentalhealth work, as re£ected in the Sphere pro-ject training manual (www.sphereproject.org) with added highlights from theWorldHumanitarian Summit (World Humanitar-ian Summit, 2016).

Fundamental principles ofhumanitarian assistance:aspirational guidanceAlthough some fundamental principlesof humanitarian response continue to beadjusted to the ever changing, global hu-manitarian landscape, they are de¢ningcharacteristics for a multidisciplinaryresponse that also includes global MH work.These values re£ect the ¢eld experience ofvarious agencies engaged in humanitarianresponse and de¢ne the values governinghumanitarian work. In con£ict situations,


their breachmaydrastically a¡ect the abilityof agencies to respond to survivors’ needs,and also put the safety of personnel at risk.Organisations such as military forces andcommercial companies, which are not con-sidered humanitarian agencies, are notobliged to base their responses on these prin-ciples.Workingwith suchorganisationsplacesmore responsibility on an MH specialist inclarifying their professional role andorganis-ational values prior to deployment.While thewording of principles can slightly vary acrossNGOs, theywerebuiltuponandclosely relateto the International Federation of the RedCrossandRedCrescent’s (www.ifrc.org)Fun-damental Principles of theMovement, whichwere¢rst formulated in 1965. Initially, these wereprinciplesofhumanity, impartiality, indepen-denceandneutrality.Later,principlesagainstproselytism and unethical behaviours wereaddedtothehumanitariansetofvalues.Belowis a formulationof theseprinciples taken fromTheCode of Conduct for the InternationalRedCross

and Red CrescentMovement andNGOs inDisaster

Relief (www.ifrc.org), with the author’sremarks (in italics) on some questions theseprinciples may pose for an MH specialist.These discussion points (below) weresuggested by participants in the training onethics of global trauma work at the Inter-national Society for Traumatic StressStudies (ISTSS) conference in November2016 (Cherepanov,2016).

Humanitarian imperativeThe main goal of humanitarian work is toprevent or alleviate su¡ering; nothingshould override this principle. The SphereProject has recognised this as a governingprinciple (Slim,1997).

Howdowe determinewho is ingreater need formen-

tal health assistance?

Humanity and humanitarianaccountabilityThese principles underline the importanceof professional competencies, accountability


http://www.sphereproject.org/


http://www.ifrc.org/


Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.

Table 1. Timeline of developments in humanitarian values

Time points Actors and events Key developments and impact

1948 The United Nations (UN) GeneralAssembly

The Declaration of Human Rightsdeclared ‘universal respect for, andobservance of, human rights and

fundamental freedoms for all without

distinction as to race, sex, language, or

religion’ (www.un.org/en/universal-declaration-human-rights)

1965 The 20th International Conferenceof the Red Cross and RedCrescent

Establishment of fundamentalprinciples of the movement:humanity, impartiality,independence and neutrality(www.ifrc.org)

1971 The Biafran CivilWar (Nigeria) Formation of Me¤ dicins Sans Frontie' res(MSF),MSFdeclared importance ofadvocacy and proposed principle ofsolidarity to replace the principle ofneutrality

1980s Ethiopian famine Global awareness of shortfalls ofhumanitarian action through themassive impact of media exposure(www.sphereproject.org)

1991 United Nations createdThe O⁄cefor Coordination ofHumanitarian A¡airs (OCHA)

OCHA’s mission is to mobilise andcoordinatehumanitarianactionandto promote the humanitariancommunity’s compliance withhumanitarian principles in everyhumanitarian response(www.unocha.org)

1994 The Red Cross and Red CrescentMovement

Principles for the choice of responsesand programme developments indisaster relief. It was agreeduponbyeight of the world’s largest disasterresponse agencies (www.ifrc.org).

1997 The Sphere Project Developeda setofminimum standardsin core areas of humanitarianassistance to enhance theaccountability of the humanitariansystem in disaster response(www.sphereproject.org)

2000s West African scandal NGOs Codes of conduct



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http://www.un.org/en/universal-declaration-human-rights




http://www.unocha.org/



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Time points Actors and events Key developments and impact

2007 The Inter-Agency StandingCommittee (IASC)

The Guidelines onMental Health and

Psychosocial Support in Emergency

Settings (IASC, 2007)May, 2016 TheWorld Humanitarian Summit

(WHS)Prioritised education in humanitarianactionand setupthe‘EducationCannotWait’ fund (UNICEF, 2016)

IntroducedtheCharteronInclusionofPersons

withDisabilities inHumanitarianAction

(Handicap International, 2016).The¢rsteverglobalcompacttoaddressthe needs of youth in crisis settings(World Humanitarian Summit,2016)

Critique by NGOs:�Concerns that adaptinghumanitarian action to di¡erentneeds tailored to gender, age, anddisability was not being given highenough priority (Oxfam, 2016)�Regretfully, the issue of safety andwellbeing of the aid workers ‘did notappear to have gained any prominence’atthe Summit (Maudling, 2016)

Table 1. (Continued)

Cherepanov

and adherence to the principles of hu-manitarian work. The humanity principlemeans that all humankind shall be treatedhumanely and equally in all circumstances,by saving lives and alleviating su¡ering,while ensuring respect for the individual.This is considered the fundamental principleof humanitarian response. Accountabilityhas been de¢ned as balancing the needs ofstakeholders anda commitment to providingassistance, and using power responsibly.This means avoiding unnecessary and costlyredundancies and focusing on sustainabledevelopment and local capacity building,as was later re£ected in the Interagency Stand-ing Committee (IASC) guidelines on psychoso-cial response in emergency settings (IASC,2007).


For an MH specialist, this means providingservices in a professional manner, whichincludes responsibility for the consequencesof helping interventions, both intended andunintended. Howdowe determine the limitsof our responsibility toward the people weserve and the NGOs we work with? Is therea possibility for con£ict of loyalties?

ImpartialityProvision of humanitarian assistance mustbe impartial and not based on nationality,race, religion or political point of view. Itmust be based on need alone.

Howdoes this principle con£ict with another facet of

our professional role, namely advocacy and bearing

witness?


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IndependenceHumanitarian agencies must formulate andimplement their own policies independentof government policies or actions.

The sustainability of the recovery and the safety

of people we serve often depends on building

upon the available infrastructure, as well as colla-

borating with governments and public health estab-

lishments.

NeutralityThis principle discourages MH pro-fessionals from taking sides in a con£ict,or engaging at any time in controversiesof a political, racial, religious, or ideologicalnature.

Somebelieve that theprinciple ofneutralitymaybe in

con£ict with advocacy for survivors, social justice

and political change, which are all important parts

of global MH work.

ProselytismThis principle states that the provision ofaid must not exploit the vulnerability ofvictims, nor be used to further political orreligious creeds.

Even this apparently self-evident principle leads to

many questions: can MH providers always control

how their work, political a⁄liation or faith are used

or misused by a third party? Another question is

whether a provider’s disclosure can inadvertently

in£uence religious or political views of bene¢ciaries.

What ifaproject is funded byafaith based orpolitic-

ally engaged NGO? Where do we draw the line?

Vulnerability: sexual exploitationThis principle proclaims that sexual exploi-tation and abuse by humanitarian workersconstitute acts of gross misconduct. Thisaddendum was developed in response to anumber of reports that identi¢ed the sexualexploitation of refugees in Africa by UNand non-UN personnel. In an emergencywhere victims have lost everything, they


are particularly vulnerable to sexual abuse(Wall, 2016). Humanitarian agencies areresponsible for developing rules of sta¡ con-duct that prevent abuse of the bene¢ciaries.It implies that humanitarian workers arenot to take advantage of the vulnerabilitiesof those a¡ected by war and violence.

Even this seemingly obvious principles of not exploit-

ing people’s vulnerability can easily become a grey

area in ¢eld work, where little is as it seems—except

for sexual exploitation, of course.The awareness of

the dynamics of powerand control inMH¢eld work

helps to minimise the risks of exploiting those we

are trying to help.

Strategic guidelines forhumanitarian interventions:operational guidanceIn 1994, the International Red Cross andRed Crescent Movement developed guide-lines for the choice of humanitarian responseand for programme development for NGOsand personnel involved in disaster relief(www.ifrc.org). At that time, eight of theworld’s largest disaster response agenciesrelied ontheir organisations’experiencewithdevelopment assistance, setting priorities inchoosing interventions and making pro-grammatic decisions. The IASC (2007, pp.7^15) operationalised these principles asthey apply to psychosocial needs, ando¡ered strategic guidelines and practicalrecommendations for tailoring mentalhealth and psychosocial interventions inemergency settings to the di¡erent levels ofneed. The IASC’s guidance in assessing themental and psychosocial needs, along withthe pyramid of psychosocial intervention indisaster response, has become a gold stan-dard for international psychosocial work. Ifuniversal principles of humanitarian assist-ance lay out a system of values, strategicguidelines recommend operational rulesfor e¡ective and ethical psychosocial work(outlined below).



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Human rights and equityHumanitarian actors should promote thehuman rights of all a¡ected persons whileprotecting individuals and groups who areat heightened risk of human rights viola-tions. Humanitarian actors should alsopromote equity and nondiscrimination.

ParticipationHumanitarian action should maximise theparticipation of local a¡ected populationsin humanitarian response. In most emer-gency situations, signi¢cant numbers ofpeople exhibit su⁄cient resilience to be ableto participate in relief and reconstructione¡orts.

Do no harmWork on mental health and psychosocialsupport has the potential to cause harmbecause it deals with highly sensitive issues.Humanitarian actors may reduce the riskof harm in various ways, such as: participat-ing in coordination groups to learn fromothers and to minimise duplication and gapsin response; designing interventions on thebasis of su⁄cient information; committingto evaluation, openness to scrutiny andexternal review; developing cultural sensi-tivity and competence in areas where theyintervene/work; and developing an under-standing of, and consistently re£ecting on,universal human rights, power relationsbetween outsiders and emergency a¡ectedpeople and the value of participatoryapproaches.

Building on available resources andcapacitiesAll a¡ected groups have assets or resourcesthat support mental health and psychosocialwellbeing.Three key principles are: buildinglocal capacities, supporting self-help andstrengthening the resources already present.Externally driven and implemented pro-grammes often lead to inappropriate mentalhealth and psychosocial support and


frequentlyhave limited sustainability.Wherepossible, it is important tobuildboth govern-ment and civil capacities.

Integrated support systemsActivities and programming should be inte-grated as far as possible. The proliferationof standalone services, such as those dealingonly with rape survivors or only with peoplewith a speci¢c diagnosis, can create a highlyfragmented care system.

Multilayered supportsIn emergencies, people are a¡ected in di¡er-ent ways and require di¡erent kinds of sup-port. One key to organising mental healthand psychosocial support is to develop alayered system of complementary supportsthat meet the needs of di¡erent groups. Alllayers are important and should ideally beimplemented concurrently.

Safety and self-care imperativeHigh personal and professional demands, aswell as moral challenges associated withMH ¢eld work make safety and self-carean undisputed priority, and one where burn-out prevention becomes a crucial factor inmaintaining health and safety both forsta¡ and for clients. In July 2015, BrendanMcDonald, a UN aid worker, published anarticle inThe Guardian appealing to humani-tarian agencies to stop failing their sta¡ onmental health and safety. Therein hedescribed the mental health crisis amongaid workers (McDonald, 2015).The justi¢ca-tion for the campaign was supported by the¢ndings of the Antares Foundation (Young,2015), whose research found that 30%of ¢eldworkers reported symptoms of PTSD after¢eld assignments, and that 79% of the 754respondents to the survey on the GuardianGlobal Development Professional Networkstated that they had experienced mentalhealth issues. The overwhelming majority(93%) believed these to have been relatedto their work within the aid industry.


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On 10 December 2015, the United NationsGeneral Assembly recognised the import-ance of this issue (United Nations, 2015).McDonald initiated an online campaign toinclude issues around aid worker mentalhealth and safetyat theWorldHumanitarianSummit, which ‘has yet to be realised’ (Maudl-ing, 2016).

Safety ¢rst!The NGO sector has been responsive togrowing concerns about the safety of aidworkers, and according to Persaud (2014,p.18), is currently in themidst of ‘professionalis-ing’ safety and security protocols, whichincludes increasing calls for common stan-dards and accredited programmes for sta¡development. This is particularly relevantto MH ¢eld work, where even basic pro-fessional expectations about prioritisinghelpers’ safety before attending to the needsof a client can turn into a contentious con£ictof loyalties.One commonexample is the pro-tocol for NGOs in response to a suddendeterioration in a security situation. A per-sonnel evacuation can mean abandoningclients, colleagues and friends, as well asmonths of work. Not surprisingly, this canbecome a very emotionally charged issue:some sta¡ feel responsibility for the safetyof clients andwillwant to remain, or will feelthat their agency is overreacting or actingtoo cautiously. Regardless of this, the ulti-mate decision will be made by the agency’sheadquarters (Bickley, 2010, p. 182). Onecan only imagine the psychological toll thisdecision takes on the mental health person-nel in question.While providing psychologi-cal support to aid workers, Cherepanov(personal communication, 16 March 2016)observed ¢eld sta¡ for whomthis experiencewas extremely discouraging and traumaticas it went against the most deeply seededprofessional, humanistic and moral beliefsconcerning the abandonment of patients orcolleagues. This example illustrates theimportance of pre-deployment training,


understanding the ‘bigger picture’ and NGO¢eld guidelines and follow-up support.Developing awareness of the personal levelof comfort with agency protocols is animportant part of preparing for a ¢eldassignment.

Burnout indicatorsBurnout is an occupational hazard in MHandtraumawork.Thehighphysical, mental,and moral demands of the ¢eld signi¢cantlyincrease potential for burnout. Professionalisolation, emotional drain from empathis-ing, long hours with few resources andambiguous success stronglycontribute to thisburnout. Exposure to mass human su¡eringand unsolvable moral conundrums can betraumatising by itself, and may further leadto compassion fatigue. In ¢eld work, self-awareness and self-care become not onlyethical requirements, but also can be a mat-ter of core professional competency, healthand safety. In addition, according to Chere-panov (1999), ¢eld workers face signi¢cantpsychological di⁄culties during re-entrythat may lead to lingering depression, inter-personal di⁄culties and job loss, whichfurther depletes much needed supports.NGOs are now, more than ever. aware ofthe mental health needs of aid workers andhave been implementing psychological sup-ports in various formats: pre departure psy-cho-education, psychological support in the¢eld (such as debrie¢ngs), and peer supportnetworks to assist coping with trauma, stres-ses, and psychosocial issues during re-entry(MSF Canada, n.d.). Large NGOs nowwidely use external referral systems, such asemployee assistance programmes (EAP),which is made available to personnel in caseof more extensive mental health needs.Many signs of burnout arewell knownacrosshelping professions (Figley, 1995; Pearlman,& Saakvitne, 1995) and include depression,cynicism, isolation, boredom, loss of com-passion, emotional exhaustion, substanceabuse and a reduction in one’s sense of


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personal accomplishment. Internationalwork routines often involve exposure tomasssu¡ering, and this profoundly impacts thesystems of personal meanings and beliefs


Table 2. Burnout indicators in internation

Burnout indicators

Questioning themeaning of work and lifeHopelessnessMisanthropyLoss of faith in humanityLoss of motivation to work

DepressionSelf-neglect.For instance,notbeingableto

eat while others are starvingRecklessness and excessive risk taking

Excessive anger and criticism toward theorganisation

Counter-transference

Violation of personal and professionalboundaries

Illusion of omnipotence and beingirreplaceable

Increased stresses and con£icts at workand in family

Family breakupJob lossCompromised support systemMaking life changing decisions while in

the ¢eldCommitting to the next assignment

without taking enough time to recoverDeclining peer support

about one’s self and the world. This is onereason why humanitarians often pose exis-tential questions as to whether their lifeand work have any meaning, purpose or


al work and precipitating factors

Precipitating factors

Existential despair and fatigue

Loss ofmeaningof e¡orts:‘nothingwillmakeany di¡erence’

Survivor guilt

Feeling that own life is not as importantwhen so many other people die

Re£ection of helplessness and inability tohelp. It diminishes ability to use peersupports.This anger ismisdirectedand,in fact, should be addressed towardinjustice and su¡ering.Theorganizationmaybe imperfect, but it ishere to help

Identi¢cationwith the victim orperpetrator

Rescue fantasies

Di⁄culties switching between emergencyand non-emergencymode at work or inpersonal life, blurring the boundariesbetween personal life and work

Neglecting re-entry

29

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value. While providing psychological sup-port to aid workers, Cherepanov (personalcommunication, 8 September 2016) ident-i¢ed common indicators and contributingmeanings linked to burnout. These burnoutindicators (seeTable 2) are not clinical symp-toms per se, but they can signi¢cantly a¡ectquality of work and life, and may lead tothe development of mental health disorders(such as depression and anxiety) throughthought distortion, maladaptive patterns ofcognitions and coping behaviours, andpsychological isolation.

Burnout prevention and reversalThe author proposes a set of recommen-dations for ¢eld workers on preventing andreversing burnout.These are:

� H

ht30

ave apre-deployment training in recog-nising signs of burnout

� C
reate an inventory of your strengths,support and sources of resilience
� L
earn to accept moral ambiguity � L isten to peers, especially if they express
concerns about your psychological well-being

� U
nderstand the signi¢cance of havingreactions that indicate a possibilityfor burnout
� T
alk to peers � T alk to supervisor or manager � M obilise support and review coping skills
that have helped in the past, such as jour-naling, reading, arts, spirituality

� B
ring a book for personal reading inaddition to professional reference books
� P
lan time for yourself when you can haverelative privacy
� T
ake breaks between assignments � P lan for re-entry � R each out to professional help if symp-
toms persist or worsen

DiscussionThe increasedpublic visibility of globalmen-tal health has underlined the paramount


importance of professional ethics and stan-dards of care amid a high price for ethicallyquestionable practices. It has also exposedquestionable practices such as ‘traumatourism’1, the use of experimental or notvalidated methods, ethnocentrism andimposition of western culture, disregardfor cultural diversity and the survivors’strength and resilience, and failure to carefor self.When MH specialists navigate morally andethically complicated situations, placingglobal MH work ethics within the largercontext of humanitarian values sharedby ot-her humanitarian actors, it provides anadditional point of reference. The universalvalues for humanitarian assistance tracetheir origins to the Universal Declarationof Human Rights and re£ect the positiveand negative experiences of humanitarianrelief agencies. Field work exposes MHspecialists to extreme su¡ering and moralconundrums, where they have to make de-cisions under duress while working in pro-fessional isolation in settings with complexneeds. Ethical guidelines can then helpto set up basic parameters and to make com-petent decisions about the best choice ofinterventions. This assures competent, con-sistent and responsible care for vulnerablepopulations while strengthening actors’professional con¢dence in making di⁄cultdecisions. In professional situations requir-ing complex decision making, the universalhumanitarian values and core humanitarianprinciples, which are aspirational by nature,provide an additional, but very importantpoint of reference for negotiating moraldilemmas. E¡ective collaborative multidis-ciplinary e¡orts that are based on ethicalstandards and shared humanitarian valuesnot only suggest what to do when there areno obvious good solutions, but also to£ag wrongdoings.International work highlights the import-ance of safety, self-care, andburnout preven-tion as ethical requirements. This workexposes MH workers to professionally


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unique situations that force them tore-evaluate everything they thought theyknew about the world and self. This experi-ence leaves profound impacts and specialistsmay question their professional competen-cies, moral beliefs and the meaning andimportance of their work. Unsurprisingly,this greatly increases potential for burnoutand diminishes capacity to provide pro-fessional and quality care for the mostvulnerable populations. While NGOs arenow paying more attention to the psycho-logical needs of aid personnel and are put-ting support systems in place, many issuesremain. It is recommended that NGOsstrengthen the pre, during, and post deploy-ment support for mental health and psycho-social service providers, and include topicson ethics, burnout prevention and its rever-sal within routine training. In the future,research will focus further on the reconcilia-tion of multidisciplinary professional valuesthat are pertinent to humanitarian mentalhealth work; algorithm for solving personaland moral dilemmas, and developmentof the professional training modules onethics for di¡erent areas of global mentalhealth work and other areas of psychosocialactivities.

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1 Trauma tourism doesn’t have a formal de¢-nition, yet its connotation refers to people who£ock to places of destruction in order to feel betteror bene¢t themselves without any considerationfor thewellbeing of local survivors.This phenom-enon was powerfully described by C. L. Moore(September,1946) in her science ¢ction noveletteVintage Season.The script revolves around voyeur-istic time travellers who organise their


entertainment tours to visit the most horrifyingdisaster scenes right before the disasters happen.The travellers must agree to the contractual rulesfor these tours that are to avoidemotional involve-ments andnot totry to changeanything, includinghelping victims because it may change thesequence of historical events.

Elena Cherepanov, PhD, is a psychologist and

Certi¢ed Trauma Specialist. She is director of

the integrated behavioural health services for

refugees and immigrants at Lynn Community

Health Center, faculty at Cambridge College

(School of Psychology and Counselling), as well

as an expert-consultant for UNICEF, working

with traumatized communities nationally and

internationally in Russia, Armenia, Chechnya,

Chernobyl, Kosovo, Ukraine, Liberia and

Abkhazia.

email: [email protected]





https://www.theguardian.com/global-development-professionals-network/2015/nov/23/guardian-research-suggests-mental-health-crisis-among-aid-workers





mailto:[email protected]

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