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Adjustment Risks of
Humanitarian Aid Workers

The Australasian Journal of Disaster
and Trauma Studies
ISSN:  1174-4707
Volume : 2004-1

Risks Associated with the
Psychological Adjustment of Humanitarian Aid Workers

Colleen A. McFarlane, Department of Psychological Medicine, Monash University, Victoria, Australia. Email: collmac@alphalink.com.au
Keywords: Humanitarian aid workers, traumatic stress, mental health, risk factors, wellbeing

Colleen A. McFarlane

Department of Psychological Medicine,
Monash University,
Victoria, Australia


Contemporary humanitarian aid personnel increasingly work in complex environments where problems related to prolonged civil conflicts, poverty and disaster are rife. These conditions place humanitarian staff at risk of experiencing traumatic and daily cumulative stress. As this field of inquiry is relatively young, this paper aims to provide a conceptual overview of common themes that have begun to emerge from recent works. Eleven areas of situational and individual risk are proposed that are likely to have applicability across different contexts, countries and people. Psychological adjustment, medical health and staff security are discussed in relation to each of these factors and ways of promoting safety and wellbeing outlined.

Risks Associated with the
Psychological Adjustment of Humanitarian Aid Workers

It was one of the hardest, in terms of having to cope with your emotions. Yeah, a refugee camp probably would be one of the most difficult situations that you could find yourself in, because it’s so dramatic in terms of you know, you’ve got these thousands of people or whatever, their dying and kids are watching their mums die and you're left with all the orphans and they all cling to you and you know you go through an incredible emotive thing. You go back home, you walk into a supermarket and you turn around and walk out because you can’t cope with all the food.

It is commonly acknowledged that humanitarian aid efforts are increasingly associated with a rising number of civil conflicts and with countries suffering from prolonged poverty and disaster (International Federation of Red Cross and Red Crescent Societies, 1998; Minear & Weiss, 1995). During these complex emergencies, humanitarian staff are at risk of experiencing acute potentially traumatic stressors and ongoing cumulative daily stresses.

Academic research and clinical knowledge about the wellbeing of humanitarian aid workers remains in its infancy. Due to early stage of development of this field, this paper aims to provide a conceptual overview of common patterns that have begun to emerge from recent works. This article incorporates themes that have emerged from my research with humanitarian staff in Cambodia and literature drawn from research, clinical and anecdotal sources. This overview, acknowledging that the majority of humanitarian staff are nationals working for predominantly Western aid agencies, proposes several risk factors commonly associated with humanitarianism. Although, discussion about the wellbeing of national humanitarian staff in this context is limited by a paucity of literature. Nonetheless, the aim is to set forth a preliminary examination of areas that are likely to carry risks for the psychological adjustment of international and national humanitarian staff, that have applicability across different contexts, countries and people.

Health Consequences of Humanitarian Aid Work

The health consequences associated with humanitarian aid work include death, physical illness and psychological distress. The risk factors outlined below can be related to more than one of these domains and so an overview of all three is provided.

Loss of Life

There has been a documented rise in mortality rates of humanitarian aid workers over the past decade, which has indicated the serious risks humanitarian staff face (Sheik et al., 2000). Intentional violence related to the use of weaponry (Sheik et al., 2000), infectious disease (Peytremann, Baduraux, O'Donovan, & Loutan, 2001) and accidents (Hurlburt, 2002; Schouten & Borgdorff, 1995) have accounted for the majority of reported deaths in samples of international and national humanitarian staff. The proportion of deaths in nationals has been estimated to be as much as three times higher than international staff deaths (Peytremann et al., 2001; Sheik et al., 2000).

Physical Illness

Physical illnesses experienced by humanitarian staff can have serious consequences in countries where the availability of health services may be limited. Preventable infectious diseases and accidents have been reported as the main medical problems and account for the majority of medical evacuations (Lange, Frankenfield, & Frame, 1994; Peytremann et al., 2001; Sharp, DeFraites, Thornton, Burans, & Wallace, 1995; Simmonds, Gilbert-Miguet, Siem, Carballo, & Zeric, 1998). Peytremann et al. (2001) included nationals in their study sample and they found that fatalities related to infectious disease, particularly HIV, were noticeable, reflecting the burden of disease in these parts of the world.

Psychological Comorbidity

International staff.
Increasing evidence has suggested that international humanitarian staff are at risk of developing significant mental health problems. Eriksson, Vande Kemp, Gorusch, Hoke, & Foy (2001) found that 10% of their sample of returned American relief workers had developed post-traumatic stress disorder (PTSD) after three years at home, a rate comparable to levels of distress amongst humanitarian peacekeepers (Weerts et al., 2002). Lifetime prevalence rates in civilian populations have been estimated at approximately 10% (Breslau, Davis, Andreski, & Peterson, 1991; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995) suggesting there is a higher than average rate of this condition amongst international relief personnel. Cardozo & Salama (2002) also reported high levels of depression (15%), anxiety (10%) and alcohol abuse (15%) in international aid workers. Reports from multiple sources have repeatedly documented the related distress, culture shock and burnout that humanitarian staff experience (Agger, 1995; Barron, 1999; Danieli, 2002; Harrell-Bond, 1985; Lovell, 1997; MacLachlan, 1993; Salama, 1999; Saner, 1990; Sangster, 1996; Slim, 1995; Smith, Agger, Danieli, & Weisaeth, 1996; Stearns, 1993).

National staff.
Few studies have examined the wellbeing of national staff, however preliminary evidence suggests that nationals are also at increased risk of psychological distress. Holtz, Salama, Lopes Cardozo, & Gotway (2002) suggested that human rights workers in Kosovo experienced elevated levels of depression and anxiety associated with longer duration of employment. Ahmad (2002) outlined a unique range of personal and professional difficulties that national staff faced, including problems with accommodation, finances, safety, job security and family dislocation. Research with refugees and internally displaced persons, which might be extrapolated to similarly displaced national staff, has suggested that these groups experience high levels of distress (e.g., Ahearn, 2000; Kinzie et al., 1990; Mollica, Wyshak, & Lavelle, 1987). Note however, that the interpretation of these studies is compounded by a shortage of culturally validated research that considers the social, cultural, political and historical contexts for researchers and participants alike. The discourse between de Vries (1997) and Summerfield (1997a, 1997b) exemplifies the importance of carefully reflecting on Western models of psychosocial healing and constructions of suffering and trauma in different contexts. In this respect, the psychosocial difficulties of national staff are less well represented in Western literature than those of their international counterparts.

Situational Risk Factors Associated with Psychological Distress

Seven areas of situational risk for psychological distress associated with the unique nature of humanitarian work have emerged from my research and other relevant findings. These areas include the timing of employment, organisational preparation, violence and threat to life, cultural and geographical context, organisational support, systemic role conflicts and interpersonal relations. Where these factors are thought to carry risk for death and illness, relevant discussion is included.


There are critical points in each phase of work for humanitarian staff that carry increased risk of death, ill health and distress. For international staff, these critical points occur prior to departure (discussed under Organisational Preparation), during the first overseas assignment, upon arrival at any new country of assignment, termination of the assignment and upon return home (see Table 1; McFarlane, 2003a). National staff have critical periods during the first job with non-governmental organisations (NGOs) and for the beginning of subsequent jobs thereafter (see Table 2; McFarlane, 2003b). At these times staff have reported increased psychological distress and physical health complaints.

For all staff members, the beginning of a new assignment and completion of multiple stressful assignments may be particularly critical times because of the increased psychological distress and security problems that have been reported. Sheik et al. (2000) reported that a third of all deaths occurred within the first three months of arrival and were unrelated to previous experience. Cardozo & Salama (2002) recommended the use of a formal mentoring system to support newcomers under such conditions. Cardozo & Salama (2002) also noted that experienced personnel who had completed multiple assignments were at risk of increased exposure to more traumatic experiences. My own work supports these suggestions that both upon arrival and after multiple stressful assignments, humanitarian staff are likely to experience greater psychological distress (McFarlane, 2003b). Recreational breaks between assignments may be important for mediating the effects of traumatic stress (Eriksson, 1997; McFarlane, 2003b) allowing staff to ease their stress, rejuvenate and readjust.

For international humanitarian staff, homecoming has also been identified as a risk period for psychological adjustment difficulties (Eriksson et al., 2001; McFarlane, 2003a; Sangster, 1996). In the past decade, organisational support that recognises the difficulties of the overseas sojourn and adjustment to life upon return home, has been limited (Danieli, 2002; Macnair, 1995; McCall & Salama, 1999; Moresky, Eliades, Bhimani, Bunney, & VanRooyen, 2001). Over the past three years however, there are positive signs that the importance of psychosocial care programs is gaining recognition and they are being tailored to the specific needs of returned staff (e.g., Danieli, 2002).

Organisational Preparation

The role of the organisation in preparing international staff for overseas aid work is outlined because of the potential role it can play in mitigating or preventing psychological distress. Preliminary results from Cardozo & Salama (2002) suggest, "there is a relationship between organizational support policies and mental health outcomes in humanitarian aid workers". Studies of organisational practices have shown that pre-departure training in stress-management, conflict resolution, media handling, working cross-culturally and team building have been neglected aspects of training (Macnair, 1995; McCall & Salama, 1999). Simmonds et al. (1998) reported that many staff were not systematically briefed or covered by comprehensive medical examinations. Moresky et al. (2001) noted that manuals were the predominant method used to teach personnel about security, medical and psychological health. It is likely that relying on instructional manuals alone is inadequate as it has been shown that effective training methods need to be tailored to take into account the specific skill or task to be taught, situational and individual variables (Arthur, Bennett, Edens, & Bell, 2003). For example, cross cultural skills training is likely to require an interpersonal approach while some technical tasks may benefit from manualised training. International and national staff require a range of technical, administrative and interpersonal skills that are most likely to benefit from a multi-pronged training approach.

Lack of organisational preparation for international staff may compound high levels of uncertainty about the proposed host country and role ambiguity (Table 1.). Humanitarian staff who are not well connected to other aid workers or in good communication with the aid organisation have limited access to formal and informal knowledge bases, which may further compound their anxiety and uncertainty. I have found that high uncertainty and role ambiguity are associated with elevated levels of anticipatory anxiety and distress in international staff prior to departure (McFarlane, 2003b). These findings are supported by clinical reports (Barron, 1999) and research with expatriate multinational business personnel for whom role ambiguity has been found to be a predictor of negative adjustment (Hechanova, Beehr, & Christiansen, 2003).

For international staff, comprehensive training about the country, security, medical care, psychological stress management, team building and cultural differences of the host country are likely to curb the potential for psychological distress. Peer briefings are likely to assist orientation but they must balance alarming information with support mechanisms and procedures (Cardozo & Salama, 2002; McFarlane, 2003b). Informed pre-departure training methods such as these may allow aid organisations to play a critical role in preparing individuals for and preventing the effects of illness, security problems, chronic and traumatic stress. In turn, these procedures may assist in retaining staff and reducing the expensive organisational costs associated with locating new staff overseas.

Violence and Threat to Life

Violence and the perceived threat to one's life constitute important risk factors in the wellbeing of both international and local staff (see Table 1 and 2). Threats of violence are reflected in the following; the general state of the host society and its phase of conflict and development, threats of violence targeted at particular groups (i.e. foreigners, women, ethnic groups) and threats of violence targeted at particular individuals. They include bombings, shootings, assaults, kidnappings, rape and accidents. In humanitarian work, ongoing concerns about personal safety to oneself, colleagues, family and friends are common (Cardozo & Salama, 2002; Eriksson et al., 2001; McFarlane, 2003b). Eriksson (1997) found that the severity of exposure and high frequency of these occurrences were associated with higher levels of distress upon return home. Moreover in their meta analysis, Ozer, Best, Lipsey, & Weiss (2003) reported that civilian interpersonal violence, the kind that humanitarian staff commonly experience, was likely to carry greater risk for PTSD than other traumatic events.

Awareness of these dangers is rising as civilians are increasingly targeted. However, the lack of legal and military protection for humanitarian staff exacerbates the problems of violence. Peacekeepers are often not mandated to protect aid workers and international law has limited ability to apprehend those who challenge it (Smith, 2002). Unfortunately national staff may be more at risk because they are often not evacuated from countries in extreme danger, are not afforded the special status of Western aid workers while in-country and have limited access to resources. In a recent survey of fifty-three American organisations Moresky et al. (2001) found that only half the organisations they surveyed provided security training. Not only does this place the lives of humanitarian staff in danger, but is also likely to detract from their sense of safety and increase the likelihood of psychological distress. While it is unlikely that encounters with violence and threatening situations can be easily prevented, well-planned security procedures and psychological support that encourage individual health and security-promoting behaviours are indicated.

Cultural and Physical Context

International staff.
For international staff, social, cultural and geographical isolation are often an inherent part of the overseas experience. Expatriates are likely to be socially isolated from other Westerners, distanced from cultural familiarities and, if living in remote or inaccessible regions, geographically isolated. A combination of social, cultural and geographical isolation can evoke feelings of abandonment, despair and fear (Table 1; McFarlane, 2003b). Isolation necessarily reduces the opportunity for social support, a factor commonly associated with the amelioration of stressful or traumatic experiences (Davidson, Hughes, Blazer, & George, 1991; Flannery, 1990). Moreover isolation is compounded by placement in countries where cultural differences are greatest. Where greater cultural differences arise, lower levels of cultural adaptation and job failure have been demonstrated in international student and multinational business personnel groups (Hullett & Witte, 2001; van Oudenhoven, van der Zee, & van Kooten, 2001). These authors recommended cultural training methods to improve cultural empathy, interpersonal problem-solving techniques and reinforcement of self-efficacious behaviours. Increasing access to electronic communication technology and the ability of international staff to integrate with local people are examples of ways in which feelings of loneliness and isolation may be ameliorated (Hullett & Witte, 2001; McFarlane, 2003b).

National staff.
National staff may also find themselves working with minority, disadvantaged and/or community groups where they are considered outsiders. These groups may be culturally and linguistically different, thus posing difficulties with intercultural communication and trust for national staff (see Table 2; McFarlane, 2003b). It is likely that national staff can similarly benefit from intercultural training programs.

Organisational Support

Clinicians have suggested that there is a culture of denial among some aid organisations as well as a legitimate lack of organisational capacity to cope with the psychosocial challenges their staff face (Ager, Flapper, van Pietersom, & Simon, 2002). Moresky et al. (2001), Macnair (1995) and Simmonds et al. (1998) all reported an overall lack of training resources available for personnel, particularly nationals, while in the field.

International staff.
Conflict with the aid organisation, or staff members therein, role ambiguity, the remoteness of the Western office to the in-country office and the functional capacity of the NGO all increase the risk that humanitarian staff will feel unsupported organisationally (McFarlane, 2003b). I found that difficulties were particularly evident during critical incidents in which staff were faced with acute stressors and when direct requests for assistance were not met with constructive responses (Table 1). International humanitarian staff retained feelings of annoyance and anger and distanced themselves from the aid organisation when faced with such situations (McFarlane, 2003b). Communication difficulties across the geographical divide of field and national offices may be an important mediator in these matters. Unfortunately, distancing between parties carried the potential to reduce responsiveness by one or more parties and compromised more pressing matters such as security.

National staff.
It is likely that there are different stresses for nationals associated with working for a Western-based aid organisation. These stresses arise in relation to the added burdens of cultural difference with the Western organisational style, language and communication barriers, an increased sense of insecurity about job loss, socioeconomic differences and enhanced power differentials (Ahmad, 2002; Carr, McAuliffe, & MacLachlan, 1998; McFarlane, 2003b). Ahmad (2002) claimed that national staff were discontented with the amount of training they received by the organisation. Similar difficulties arise for nationals when they see foreigners enjoying higher salaries and additional lifestyle benefits (Carr et al., 1998; McFarlane, 2003b). I have found that in relation to the need for survival and financial security, some national staff have taken risks and tolerated poor working conditions in order to keep their job. Consequently, they have experienced related negative changes in health and wellbeing (Table 2; McFarlane, 2003b). To compound these difficulties, in different societies, the role of the organisation as a means of support may not be recognised by national staff. Additionally, the organisational assistance offered to national staff may be coloured by Western constructions of mental health, faith and healing that have limited applicability to the host culture. Careful culturally based research needs to address these important parameters in order for the wellbeing of national staff to be effectively addressed.

Systemic Role Conflicts

Humanitarian staff often experience ongoing conflicts between their professional goals and those of external players such as beneficiaries, local and international governments and other associated bodies. Humanitarian staff working towards rebuilding peace, security and national dignity can work in antithesis to governments that may be noticeably corrupt, factional or dictatorial, beneficiaries that sometimes appear to make superficial or self-interested funding decisions and at worst, the very act of war. I have found that aid workers experience frustration, despair and anger at the difficulty of conducting effective work within these contexts (Tables 1 and 2; McFarlane, 2003b). Assessing and reality-orienting staff expectations prior to their work, as well as allowing ventilation, encouragement and support while on the job, will assist in safeguarding the wellbeing of humanitarian staff. Peer support and job satisfaction are likely to have protective effects for these difficulties.

Interpersonal Relations

International staff.
The interpersonal relationships of international staff can experience change and disruption when they work overseas, increasing the potential for stress. Relations with significant others at home and living abroad are affected by the change to overseas work. Smith (2002) noted that people who are stressed, “form unwise relationships and get into protracted problems with colleagues. Staff conflict disrupts programs and can compromise security” (p.174). Furthermore, international aid workers may leave others at home (spouse, children, elderly parents) that create worry because of the distance and difficulties of attending to their concerns (Hurlburt, 2002; McFarlane, 2003a). Those at home may have difficulties understanding what the aid worker is going through. Being single while overseas may give rise to despair and distress if the individual is working in isolation from other expatriates and limited by cultural norms of the host country about sexual relations (McFarlane, 2003b). Adequate compassion leave for travel (Hurlburt, 2002) and involvement of family members in training programs (Hechanova et al., 2003; van Oudenhoven et al., 2001) are recommended to ameliorate the socially and psychologically disruptive effects of working away from loved ones.

Likewise, the relationships of expatriates with nationals may be complicated by cultural differences and recent life events of nationals in their home country (see Table 1). The clinical experiences of van Gelder & van den Berkhof (2002) suggest that aid workers who worked with traumatised local groups tended to burn out faster (as in vicarious trauma). Rejection by the local population has also been noted to place international staff at risk for distress (Danieli, 2002). Moreover difficulties with intercultural communication, conflict and adjustment have been reported for expatriate business personnel that are likely to be similar for international humanitarian workers (Hechanova et al., 2003).

National staff.
Similarly, national staff face intercultural relationship difficulties with expatriate humanitarian staff. They can experience frustration and conflict with Westerners who appear not to understand their culture and which can be compounded by power differentials (see Table 2). Interpersonal conflict may also be exacerbated by different cultural norms regarding the expression of conflict and negative emotions (McFarlane, 2003b). These situations have the potential to impact work performance, security and wellbeing.

National staff may also face separate relational difficulties in their personal lives. Ahmad (2002) noted that family dislocation related to the work was prevalent. It is likely that some national staff have been internally displaced and may suffer from alcoholism, domestic violence, depression, anxiety and so forth in relation to recent civil conflicts (see de Jong, 2002).

In summary, seven situational risk factors have been outlined that identify areas in which humanitarian aid workers are likely to experience psychological adjustment difficulties. Humanitarian staff who encounter accumulated situational risk factors may be most at risk of psychological distress. By considering individual risk factors such as those outlined below in combination with these types of situational factors, the negative effects of humanitarian aid work may better anticipated. I do not claim to offer an exhaustive list but these emergent factors are worthy of further examination.

Table 1: Qualitative Data Supporting Risk Factors for International Humanitarian Staff 1

Risk factor
Data from international humanitarian staff
"So there was no money for the project to get off the ground, so that just fell in a heap. So that was fairly stressful. You know arriving (laughing) as this fresh face from the airport walking into an incredibly politicised situation and then yeah seeing the whole thing just fall apart."  
Organisational Preparation
"I was the only person going to that country in that departure and they couldn’t find someone to tell me about it, a returned staff member. They did eventually, but they brought a woman who'd left after two or three months. She’d hated it and she’d hated the people and the country. She had a complete crisis of culture shock so she spent the time reciting the difficulties that she’d had and told me that I was insane and ‘Good luck’ and laughed and that was it. So I thought ‘Oh, shit, I'm in trouble’. On top of that they were sending me to do something I hadn’t applied to do at all. I didn’t know anything about it, so I was a bit nervous generally. … But the others finished talking to people just come back from Toogaloo or Fiji or something and they were rapt they couldn’t wait to get there and I was shit-scared."  
Violence and Threat to Life
"It was stress related to living and working in a community that is more violent, that is, anti-women, rape is a very real possibility. I haven’t lived in a community where rape has hindered my, or the potential of physical attack I should say hindered my ability to feel comfortable walking around the streets. But it did in that country. I also had some very hard experiences there and saw more than most people in terms of the violence so while I didn’t let that make me lose my objectivity but it has to colour how you feel about a community".  
Cultural and Physical Isolation
"I think it was that but ah, it’s very isolated, there's nowhere to get out. You know in the previous country you can go to the capital city, you can find a hotel. There is nowhere in this country to go so the best you can hope for is to stay in your house, keeping the world outside….What it has is that you have a very, you develop local expectations, which is not necessarily appropriate for someone who is not a local.”  
Organisational Support
"So I found, the stress that I had there was really organisational processes and communication."  
Systemic Role Conflicts
"… and so development work usually takes a long time, it should be processed oriented, you should go sit under a tree and listen to the people, what do they want? But the system does not generally allow us to do that. So we get our funding, we’ve got to put in our reports, we’ve got to have our achievable objectives, what’s the outcome option plan, what’s your tasks for this next three weeks, da, da, da, da, da.”  
Interpersonal Relations
"A refugee camp probably would be one of the most difficult situations that you could find yourself in, because it’s so dramatic in terms of you know, you’ve got these thousands of people or whatever, their dying and kids are watching their mums die and you're left with all the orphans and they all cling to you and you know you go through an incredible emotive thing.”  

1 Qualitative data from McFarlane (2003b)

Table 2 : Qualitative Data Supporting Risk Factors for National Humanitarian Staff 2

Risk factor
Data from national humanitarian staff  
"Yeah, the first time I did not work directly with that kind of person, but I work with all children and all youth. And the first time I feel very sad about their living standard. They are live in the very poor, poor that I have never seen. At first I has just live in Phnom Penh, I go to study and I live in Phnom Penh. I don't know what the difficult is. And after I get there, the first month I feel very sad and very stressed".  
Violence and Threat to Life
"You know that day, the violence almost broke out … The people very angry you know…They very angry, their face show their anger. They don’t say anything, they just come, we call them to meeting, we call them for meeting. They come from their house with the face very angry face and violent face. Even we have not meet yet and after we met, even we try to explain them what so ever we can do to explain them, their face is the same. Today I think if we don’t disperse the loan as what they want we cannot stay today, that maybe they have a violent.
… And the people about one hundred people you know (laughing). I am very afraid for that."  
Cultural and Physical Context
"When I went the first time to a remote region I feel that very difficult. Like the road they cannot go easy, to communicate, they cannot make easy communication to the place and another one we have difficult understand the culture. The living condition there, very difficult."  
Organisational Support
A young man came to live in a refugee camp after the Pol Pot regime in Cambodia collapsed and he had been displaced from his family and land. He worked in the refugee camp because as a man he was not entitled to a food ration, and he was responsible for his brother. In that program one of his tasks had been to collect mosquitoes in test tubes on his arm to carry out tests for malaria. He was worried for his health. He said, "I think that we have no choice but this is our best choice."  
Systemic Role Conflicts
A middle aged Cambodian man expressed the desire to work to rebuild his nation after many years of civil war. He wanted to work for a Cambodian NGO and restore the pride of his nation. But he didn’t like they way they handled their financial affairs and he returned to an international NGO. He expressed disappointment that he was dependent on an organisation from another country.  
Interpersonal Relations
"He is from a better country and he is well educate, and he want to push everything to be the same as the country. I say that "could not". He say that we learn something from another country to be adapted in our own country, we have to fit together. We could not take some … from a whole other country to push, to ask one country to do as you do it. I think I can not. Sometime he, ah,. sometime also he hate me."  

2 Qualitative data from McFarlane (2003b)

Individual Risk Factors Associated with Psychological Distress

A preliminary discussion about individual factors that are likely to place aid workers at increased risk of psychological distress, physical ill health and security problems is now provided. Data that relates predominantly to international humanitarian staff is discussed due to the lack of information germane to national staff.

Prior Psychological Adjustment

For both national and international staff prior psychological adjustment may carry risk for later distress, illness or loss of life. I have found preliminary evidence to suggest that prior psychological adjustment may influence adjustment to humanitarian work (McFarlane 2003b). In their meta analysis, Ozer et al. (2003) claimed that prior psychological adjustment and prior trauma carried significant risk for the development of PTSD following later traumatic stressors. Further research is warranted that examines prior psychological adjustment as a predictor of distress in humanitarian staff.

Expectations of Humanitarianism

International staff in my study recounted expectations of their role and the host culture that were related to levels of later distress. For example expectations about the ideals of humanitarianism and the conduct of colleagues were often met with disappointment (McFarlane, 2003b). Clinical authors have suggested that these expectations may be important forerunners to later wellbeing (Barron, 1999). Inexperienced aid workers wanting simply to help can become targets for anger and rejection. This challenge to their value system may come at a time when their professional confidence to deal with the situation is most needed (Barron, 1999).

National Cambodian staff in my study often reported that they began work with an international aid organisation for their own survival. Many staff in Cambodia had been displaced by years of civil war and first worked for an aid organisation while they were living in refugee camps. There, they worked for food rather than money and so their entry into humanitarian work was predicated by different circumstances to international staff. Their need to survive sometimes outweighed decisions about how to live and they subsequently endured stressful working environments in order to do so (McFarlane, 2003b).

Risk Taking and Judgement

Risk taking behaviour has been reported as prevalent among humanitarian staff (Smith, 2002). Smith reported frequent risk-taking behaviours amongst expatriate staff such as venturing out into lines of fire for pizza, or refusing to give food to hungry, drunken men at checkpoints. Other researchers have also noted sexual risk-taking behaviours among Peace Corp volunteers (Moore, Beeker, Harrison, Eng, & Doll, 1995). Sheik et al. (2000) reported that workers who were parents were significantly less likely to die from unintentional violence (accidents), implying that individuals without such responsibilities were more likely to engage in risk-taking behaviours. Host countries may have a lack of infrastructure and regulation that, along with differences in prevailing norms about risk-taking behaviour, may contribute to the development of risk-taking behaviours (McFarlane, 2003b).

The Practice of Self-Care

Psychological needs for dependence and emotional care may be difficult for aid workers to express in the face of overwhelming demands to give. Several authors have reported that despite being briefed, aid workers did not follow preventive measures for their health (Blacque-Belair, 2002; Lange et al., 1994; Sharp et al., 1995). Sharp et al. (1995) and Blacque-Belair (2002) both reported that some relief workers felt uncomfortable utilizing medical prevention strategies that were not available to the local population. Clinically, Barron (1999) also noted that staff could feel emotionally isolated because "worker-victims typically do not feel entitled to attend to or have others attend to their own needs. Ignoring or burying their own needs can become second nature or may even have drawn them to relief work in the first place." (p. 156). Education around "permission" to be vulnerable needs to be incorporated into every stage of employment.

A Comment on Resilience

Generally, humanitarian staff are able to adapt to the acute and chronic stressors of their work. Overall as a group they demonstrate considerable resilience and reap many personal rewards from their work such as job satisfaction, personal meaning and improved wellbeing (McFarlane, 2003a). Indeed the active and constructive pursuit of rebuilding communities and nations may be protective for their wellbeing. However, acknowledgement, awareness and support for the potential difficulties they face is imperative in order to preserve such resilience.


This article has outlined a number of situational and individual risk factors that can further advance the field of humanitarian aid towards a health promoting model of active support for staff. Difficulties in providing support for aid workers are intimately connected to the geographical and cultural distances between aid organisations and their employees that make this a complex task. Clinical and research programs must take into account the specific cultural and situational factors of each country in order to be effective. The prevailing forces of civil unrest and globalisation amongst people, means that there is an imperative to advance timely, appropriate and coordinated academic and applied activities. Moreover, because this is a relatively new field, we have the opportunity to ensure such work is done effectively.


Ager, A., Flapper, E., van Pietersom, T., & Simon, W. (2002). Supporting and equipping national and international humanitarian non-governmental organizations and their workers. In Y. Danieli (Ed.), Sharing the front line and the back hills: Peacekeepers, humanitarian aid workers and the media in the midst of crisis. (pp. 194-200). Amityville, NY: Baywood.

Agger, I. (1995). A longing for Sarajevo: Understanding the trauma of aid workers. In I. Agger, S. Vuk & J. Mimica (Eds.), Theory and practice of psychosocial projects under war conditions in Bosnia-Herzegovina and Croatia (pp. 27-33). Zagreb: European Community Humanitarian Office.

Ahearn, F. L. (2000). Psychosocial wellness of refugees: Issues in qualitative and quantitative research methods. Oxford, UK: Berghahn Books.

Ahmad, M. M. (2002). Who cares? The personal and professional problems of NGO fieldworkers in Bangladesh. Development in Practice, 12(2), 2002.

Arthur, W., Bennett, W., Edens, P. S., & Bell, T. (2003). Effectiveness of training in organizations: A meta-analysis of design and evaluation features. Journal of Applied Psychology, 88(2), 234-243.

Barron, R. A. (1999). Psychological trauma and relief workers. In J. Leaning, S. M. Briggs & L. C. Chen (Eds.), Humanitarian crises: the medical and public health response (pp. 143-175). Cambridge, MA: Harvard University Press.

Blacque-Belair, M. (2002). Being knowledgeable can help enormously. In Y. Danieli (Ed.), Sharing the front line and the back hills: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 201-202). Amityville, NY: Baywood.

Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216-222.

Cardozo, B. L., & Salama, P. (2002). Mental health of humanitarian aid workers in complex emergencies. In Y. Danieli (Ed.), Sharing the front line and the back hills: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 242-257). Amityville, NY: Baywood.

Carr, S., McAuliffe, E., & MacLachlan, M. (1998). Psychology of aid. London, UK: Routledge.

Danieli, Y. (Ed.). (2002). Sharing the front line and the back hills: international protectors and providers: peacekeepers, humanitarian aid workers and the media in the midst of crisis. Amityville, NY: Baywood.

Davidson, J. R. T., Hughes, D., Blazer, D. G., & George, L. K. (1991). Post-traumatic stress disorder in the community: An epidemiological study. Psychological Medicine, 21, 713-721.

de Jong, J. (2002). Trauma, war, and violence: Public mental health in socio-cultural context. New York, NY: Kluwer Academic.

de Vries, M. (1997). To make a drama out of trauma is fully justified. The Lancet, 351(9115), 1579-1580.

Eriksson, C. B. (1997). Traumatic exposure and reentry symptomatology in international relief and development personnel (Doctoral dissertation, Fuller Theological Seminary, 1997). Dissertation Abstracts International, 58(04B).

Eriksson, C. B., Vande Kemp, H., Gorusch, R., Hoke, S., & Foy, D. W. (2001). Trauma exposure and PTSD symptoms in international relief and development personnel. Journal of Traumatic Stress, 14(1), 205-212.

Flannery, R. B. (1990). Social support and psychological trauma: A methodological review. Journal of Traumatic Stress, 3, 593-611.

Harrell-Bond, B. (1985). Humanitarianism in a straightjacket. African Affairs, 334, 3-13.

Hechanova, R., Beehr, T. A., & Christiansen, N. D. (2003). Antecedents and consequences of employees' adjustment to overseas assignment: A meta-analytic review. Applied Psychology: An International Review, 52(2), 213-236.

Holtz, T. H., Salama, P., Lopes Cardozo, B., & Gotway, C. A. (2002). Mental health status of human rights workers, Kosovo, June 2000. Journal of Traumatic Stress, 15(5), 389-395.

Hullett, C. R., & Witte, K. (2001). Predicting intercultural adaptation and isolation: Using the extended parallel process model to test anxiety/uncertainty management theory. International Journal of Intercultural Relations, 25, 125-139.

Hurlburt, K. (2002). Precious lives honored to serve. In Y. Danieli (Ed.), Sharing the front line and the back hills: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 161-169). Amityville, NY: Baywood.

International Federation of Red Cross and Red Crescent Societies. (1998). World Disasters Report. Oxford, England: Oxford University Press.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.

Kinzie, J. D., Boehnlein, J. K., Leung, P. K., Moore, L. J., Riley, C., & Smith, D. (1990). The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. American Journal of Psychiatry, 147, 913-917.

Lange, W. R., Frankenfield, D. L., & Frame, J. D. (1994). Morbidity among refugee relief workers. Journal of Travel Medicine, 1(2), 111-112.

Lovell, D. M. (1997). Psychological adjustment amongst returned overseas aid workers. Unpublished D.Clin.Psy. thesis, University of Wales, Bangor.

MacLachlan, M. (1993). Splitting the difference: how do refugee workers survive? Changes: International Journal of Psychology and Psychotherapy, 11, 155-157.

Macnair, R. (1995). Room for improvement: The management and support of relief and development workers (Relief and Rehabilitation Network No. Network Paper 10.). London, UK: Overseas Development Institute.

McCall, M., & Salama, P. (1999). Selection, training, and support of relief workers: an occupational health issue. British Medical Journal, 318, 113-116.

McFarlane, C. (2003a). The balance of trauma, stress and resilience by international aid workers: A longitudinal qualitative investigation. Paper presented at the 10th Annual Conference of The Australasian Society for Traumatic Stress Studies, Hobart, Australia.

McFarlane, C. (2003b). (McFarlane, 2003b). Unpublished raw data.

Minear, L., & Weiss, T. G. (1995). Humanitarian Politics. New York, NY: Foreign Policy Association.

Mollica, R. F., Wyshak, G., & Lavelle, J. (1987). The psychosocial impact of war trauma and torture on Southeast Asian refugees. The American Journal of Psychiatry, 144(12), 1567-1572.

Moore, J., Beeker, C., Harrison, J. S., Eng, T. R., & Doll, L. S. (1995). HIV risk behavior among Peace Corps Volunteers. Aids, 9(7), 795-799.

Moresky, R. T., Eliades, M. J., Bhimani, M. A., Bunney, E. B., & VanRooyen, M. J. (2001). Preparing international relief workers for health care in the field: An evaluation of organizational practices. Prehospital and Disaster Medicine, 16(4), 257-262.

Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129(1), 52-73.

Peytremann, I., Baduraux, M., O'Donovan, S., & Loutan, L. (2001). Medical evacuations and fatalities of United Nations High Commissioner for Refugees field employees. Journal of Travel Medicine, 8(3), 117-121.

Salama, P. (1999). The psychological health of relief workers: Some practical suggestions. Relief and Rehabilitation Network Newsletter, 15, 12-14.

Saner, R. (1990). Manifestation of Stress and Its Impact on the Humanitarian Work of the ICRC delegate. Political Psychology, 11(4), 757-765.

Sangster, K. (1996). The role of aid workers in the refugee camp and refugee mass situation. Unpublished masters thesis, LaTrobe University, Melbourne, Victoria, Australia.

Schouten, E. J., & Borgdorff, M. W. (1995). Increased mortality among Dutch development workers. British Medical Journal, 311(7016), 1343-1344.

Sharp, T. W., DeFraites, R. F., Thornton, S. A., Burans, J. P., & Wallace, M. R. (1995). Illness in journalists and relief workers involved in international humanitarian assistance efforts in Somalia, 1992-1993. Journal of Travel Medicine, 2(2), 70-76.

Sheik, M., Gutierrez, M. I., Bolton, P., Spiegel, P., Thieren, M., & Burnham, G. (2000). Deaths among humanitarian workers. British Medical Journal, 321, 166-168.

Simmonds, S., Gilbert-Miguet, P., Siem, H., Carballo, M., & Zeric, D. (1998). Occupational health of field personnel in complex emergencies: Report of a pilot study. Geneva: World Health Organization.

Slim, H. (1995). The continuing metamorphosis of the humanitarian practitioner: Some new colours for an endangered chameleon. Disasters, 19(2), 110-126.

Smith, B. (2002). The dangers of aid work. In Y. Danieli (Ed.), Sharing the front line and the back hills: peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 171-176). Amityville, NY: Baywood.

Smith, B., Agger, I., Danieli, Y., & Weisaeth, L. (1996). Health activities across traumatised populations: emotional responses of international humanitarian aid workers. In D. Danieli, Rodley, N.S. & Weisaeth, L. (Ed.), International Responses to Traumatic Stress: Humanitarian, Human Rights, Justice, Peace and Developmental Contributions, Collaborative Actions and Future Initiatives (pp. 397-423). Amityville, NY: Baywood.

Stearns, S. D. (1993, September). Psychological distress and relief work: Who helps the helpers? Refugee Participation Network, 15, 3-8.

Summerfield, D. A. (1997a). Legacy of war: Beyond "trauma" to the social fabric. The Lancet, 349(9065), 1568.

Summerfield, D. A. (1997b). "Trauma" and the experience of war: A reply. The Lancet, 351(9115), 1580-1581.

van Gelder, P., & van den Berkhof, R. (2002). Psychosocial care for humanitarian aid workers: The Medecins Sans Frontieres Holland Experience. In Y. Danieli (Ed.), Sharing the front line and the back hills: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 179-185). Amityville, NY: Baywood.

van Oudenhoven, J. P., van der Zee, K. I., & van Kooten, M. (2001). Successful adaptation strategies according expatriates. International Journal of Intercultural Relations, 25, 467-482.

Weerts, J. M. P., White, W., Adler, A. B., Castro, C. A., Algra, G., Bramsen, I., et al. (2002). Studies on military peacekeepers. In Y. Danieli (Ed.), Sharing the front line and the back hills: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 31-48). Amityville, NY: Baywood.

Author Note

Acknowledgements: This work could not have been carried out without the support of Dr. Peg Levine, Dr. Jocelyn Dunphy-Blomfield, the Department of Psychological Medicine (Monash University), Community Aid Abroad (Oxfam, Australia) and The Ministry of Health, The Royal Kingdom of Cambodia. Special thanks goes to those people who generously participated in the author's doctoral research.

Correspondence concerning this article should be addressed to Colleen McFarlane, Department of Psychological Medicine, Monash University, 246 Clayton Road, Clayton, Victoria, 3168, Australia. Email: collmac@alphalink.com.au



Colleen A. McFarlane © 2004. The author assigns to the Australasian Journal of Disaster and Trauma Studies at Massey University a non-exclusive licence to use this document for personal use and in courses of instruction provided that the article is used in full and this copyright statement is reproduced. The authors also grant a non-exclusive licence to Massey University to publish this document in full on the World Wide Web and for the document to be published on mirrors on the World Wide Web. Any other usage is prohibited without the express permission of the author.

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