This is an pre-opublication draft of what eventually was published in revised form, with contributions from Wendy Ager and the staff of the Antares Foundation, as "Managing Stress in Humanitarian Work: A Systems Approach to Risk Reduction" (©Antares Foundation) The final version is available at
Managing Stress in Humanitarian Aid Workers:
The Risks of Humanitarian Work
Humanitarian aid work is intrinsically stressful. Staff often live and work in physically demanding and/or unpleasant conditions, characterized by heavy work loads, long hours and chronic fatigue, and lack of privacy and personal space. They are often separated from their family for extended periods. They may complain of inadequate time, resources, and support to do the job asked of them and of inadequate recognition for the job they do. They may experience conflict with local authorities and moral anguish over the choices they often have to make (Who to help and who not? Deal with corrupt or vicious warlords or militias or not be permitted to provide aid at all?). They face chronic danger or are repeatedly exposed to tales of traumatization and personal tragedy or to gruesome scenes and they may, themselves, have horrific experiences.
Although many of the stresses facing humanitarian aid workers are due to the intrinsic nature of humanitarian work, it is common for humanitarian workers to report that the greatest amount of stress comes not from the demands of their work itself, but from poorly designed organizational policies and practices. Excessive bureaucratic demands or unclear work roles, from unsupportive management or poor leadership practices, or conflictual relationships within their work team, created or intensified by prolonged close proximity and intimate interdependence, may be potent sources of distress.
National staff experience most of the same stressors as international staff. They may also experience additional sources of stress. Often they or their family have directly experienced the traumatic events that led to the need for humanitarian intervention in the first place. They may live in a community that is still experiencing the on-going effects of these events, compounded with the on-going impact of lack of economic development. Compared to international staff, they experience higher levels of job insecurity, inequality with respect to pay, benefits, job security, career opportunities, and potentially unequal treatment in event of evacuation or program termination. Cross cultural misunderstandings, possibly exacerbated by racial or ethnic issues or by historically based issues such as a history of national staff coming from a country formerly colonized by the country the international staff come from, add to their stress.
The Toll of Stress on Humanitarian Workers
While stress can be a source of growth and although many humanitarian aid workers withstand the rigors of their work without adverse effects, many others do not. Both anecdotal reports and several recent empirical studies have abundantly documented the negative emotional consequences of humanitarian aid work on staff members. As many as one third or more of recently returned expatriate staff of humanitarian aid organizations show clinically significant signs of emotional distress. In one study, for instance, approximately 10% of recently returned international aid workers employed by faith-based agencies could be diagnosed with Post Traumatic Stress Disorder and an additional 19 % reported clinically significant PTSD symptoms. Almost 50% of another group of returned international staff were described as being at moderate or high risk of burnout; 15% showed a clinically significant level of symptoms of depression; and 46% showed a high or moderate level of symptoms of PTSD. In yet another study, one-fifth of returned expatriate staff reported high levels of emotional exhaustion, 30% reported moderate to high levels of depression, and almost described half moderate or high levels of PTSD symptoms. Similar levels of distress have been found among national staff of international and local humanitarian aid organizations and among human rights workers. For example, national staff members who had worked in Kosovo showed high levels of depression, anxiety, post-traumatic stress disorder symptoms, and alcohol use.
The adverse emotional effects of work in the humanitarian aid field may include post-traumatic stress syndromes (resulting from direct exposure to or witnessing traumatizing experiences), “vicarious” or “secondary” traumatization (resulting from repeated exposure to the stories and witnessing the suffering of direct victims of trauma), depression, pathological grief reactions, anxiety, multiple psychosomatic complaints, and “burnout.” Some staff members turn towards self destructive behaviors such as excessive drinking or dangerous driving. Others report increases in interpersonal conflict with co-workers or with family members.
The Costs to the Agency of Staff Stress
The consequences of adverse responses to stress on the part of humanitarian workers go far beyond the distress experienced by the staff members themselves. Stress adversely affects the ability of aid workers to carry out the humanitarian aid agency’s goals of providing services to those directly impacted by a disaster or other humanitarian emergency
Although there is only anecdotal evidence for this from the humanitarian aid world itself, there is an abundance of evidence from other industries (including both commercial sectors such as manufacturing and transportation and not-for-profit service sectors such as education and health care). The evidence indicates that, regardless of industry, chronic stress and burnout have significantly negative impacts on the ability of the employing agency to carry out its purposes.
The cost to the agency of increased turnover is high. It leads to increased hiring and training costs; difficulty staffing field positions with qualified, experienced workers; excessive workloads for the remaining staff; delays in projects; and a loss of local expertise and of institutional memory. One large international NGO estimated that the total cost of recruiting and training a new Program manager is ₤5000-₤6000 (about $10,000-12,000). The International Committee of the Red Cross found that recruiting and training a new delegate costs approximately ₤15000 (about $30,000).
The Potential for Risk Reduction
It would be easy to conclude that, although humanitarian aid worker stress is unfortunate, it is inevitable. “If you go out in the rain, you expect to get wet.” However, a systematic program of risk reduction, operating at the level of the individual staff member, the team, and the agency as a whole, can significantly reduce the adverse burden of stress. Perhaps a better slogan would be, “If you go out in the rain, don’t forget to take your umbrella”!
Stress management is both an individual responsibility, a team responsibility, and an agency-wide responsibility. In each case, the basic strategies for reducing stress are:
Individual stress workers can be trained to act in ways that reduce the stress they experience and to cope better with stress. Agencies can provide staff with training in stress management before the staff member is deployed. Field managers can encourage their staff to engage in “stress-sensible” practices and can themselves monitor the stress experienced by the staff they supervise and provide assistance for staff experiencing adverse effects of stress. Agencies can arrange for direct support services for individual staff members who are experiencing adverse effects from stress (especially in the wake of severe or “critical incident” stress). Finally, staff can be debriefed at the end of an assignment (or periodically) with respect to their experience of stress and those who are still experiencing adverse affects of stress several months after the end of their assignment can be guided to follow-up services.
But stress reduction cannot be left to individuals, alone. The most cost-effective ways of reducing the burden of stress on the agency come from actions taken at the team and agency level. Even after highly traumatic experiences, personal capacities and activities account for much less of the psychological outcome than factors within the control of the organization, such as leadership and social (team) support.
First, the agency itself plays a major role in determining the levels of stress experienced by staff members. Poor management practices, inept managers, and frictions within the work team may be the greatest sources of stress for humanitarian workers. Other agency policies and practices can also create stress and agency policies and practices can hinder staff members in their individual efforts to deal with stress. Conversely, agency policies and practices can help reduce staff stress and support staff members in their own efforts to manage stress. Studies in a variety of settings have found that a “consultative” leadership style (i.e., a leadership style characterized by leading by example; objective, fair, just, and reasonable responses to team members; personal knowledge of staff member’s needs and performance; a willingness to place staff needs ahead of the leader’s needs; and credibility as a source of information) also plays a major role in increasing staff resilience in the face of stress. 
Second, social support – specifically team cohesion -- is the single most important source of protection for individuals against the ravages of stress. Even in the extremely stressful situation represented by war, one study found that social support accounted for 33% of the variability in whether or not a Vietnam veteran developed Post Traumatic Stress Disorder, while each soldier’s level of exposure to horrific events accounted for only 15-20%. While an individual aid worker may (and should) have many sources of social support, including family, friends, professional associations, church groups, and community or recreational organizations, his or her work team is of special importance. The members of the work team share a common goal, work and often live in close proximity to each other, and share hardships, dangers, successes and failures. At its best, the team provides an enormously powerful level of protection against the stresses of humanitarian work. At its worst, when there is serious conflict within the team, it can itself be a major source of stress.
Conversely, in industries that have been studied directly, expenditures to reduce stress and increase employee well being are cost effective. For example, a review of seventy-three published studies of workplace health promotion (including mental health promotion) showed an average savings of $3.50 in reduced absenteeism and reduced health care costs for every $1.00 spent. Another review of forty-two published studies of worksite health promotion programs showed on average a 28% reduction in sick leave absenteeism, a 26% reduction in health costs, and a 30% reduction in workers’ compensation and disability management claims costs. One example: A program at one large firm, in which work teams met to discuss sources of job-related stress, led to the company saving over $1.4 million over four years due to reduced absences.  One-time stress management programs appear to have relatively little effect, but a more comprehensive, organization-wide program can have more substantial effects.
Humanitarian aid agencies have a dual responsibility with respect to reducing staff stress. They must effectively carry out their primary mission and, at the same time, they must protect the well being of their own employees. These responsibilities are not in conflict with one another. From a purely utilitarian perspective, staff stress and burnout have an adverse impact on the ability of the humanitarian aid agency to provide services to the recipients of its work.
The humanitarian community has increasingly realized that programs to reduce the risk of adverse responses to stress are both appropriate extensions of the humanitarian agencies mission to its own workers and make good “business sense.” This is reflected in the development of the Antares Foundation’s Guidelines for Good Practice: Managing Stress in Humanitarian Workers and in the The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings.
 On sources of stress for aid workers, see, among others, Sharing the Front Lines and the Back Hills, ed. Y. Danielli (Amityville, NY: Baywood Publishing, 2002); and Stress and Trauma Handbook, ed. J. Fawcett (Monrovia, CA: World Vision International, 2003), Chapters 4,6; Britt T.W. & Adler, A.B. (1999). Stress and health during medical humanitarian assistance missions. Military Medicine,. 164 (4), 275-279; Fawcett, J. (2002). Preventing broken hearts, healing broken minds. In Y. Danieli (Ed.). Sharing the front line and the back hills: International protectors and providers: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 223-232). Amityville, NY: Baywood Publishing. Pp.,.; McFarlane, C.A. (2004). Risks associated with the psychological adjustment of humanitarian aid workers. The Australasian Journal of Disaster and Studies (accessed on line at http://www.massey.ac.nz/~trauma/issues/2004-1/mcfarlane.htm). Smith, A. (2000). Lessons from Western Kosovo for the documentation of war crimes. Psychiatry, Psychology & Law. 7(2) 235-240. Many additional references on a wide variety of humanitarian workers can be found in . Fawcett, Stress and trauma handbook. Monrovia, CA: World Vision International, pp. 252-272. .
 G. Fawcett (2003) , “Preventing trauma in traumatic environments,” in J. Fawcett (ed)., Stress and Trauma Handbook, (Monrovia, CA: World Vision International, pp. 40-67; G.Fawcett, paper presented at Save the Children training ]workshop, Istanbul, September 18, 2006.
 Presentations at Antares conferences(2002, 2003)
 Eriksson, c. (2002). Stress in humanitarian aid workers.Paper presented at conference on “Managing Stress in Humanitarian Aid Workers,” Sept. 26, Antares Foundation(Amsterdam).
Eriksson, Van de Kemp, Hendrika, Hoke, & Foy, 2001 Eriksson, Cynthia B; Vande Kemp, Hendrika; Gorsuch, Richard; Hoke, Stephen; Foy, David W. (2001). Trauma exposure and PTSD symptoms in international relief and development personnel. Journal of Traumatic Stress,14,(1), pp. 205-212.
 Eriksson, C.B., Bjorck, J., & Abernethy, A (2003). Occupational stress, trauma and adjustment in expatriate humanitarian aid workers. In J. Fawcett, Stress and trauma handbook ( pp. 68-100). Monrovia, CA: World Vision International.
 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: International protectors and providers: Peacekeepers, humanitarian aid workers and the media in the midst of crisis (pp. 242-255). Amityville, NY: Baywood Publishing.
 D. Loquencio et al, “Understanding and addressing staff turnover in humanitarian agencies. HPN Network Paper #55. Humanitarian Practice Network, 2006
.On organizational commitment and turnover in other industries, see, among others, J.E. Mathieu & D.M. Zajac, “A Review and Meta-Analysis of the Antecedents, Correlates, and Consequences of Organizational Commitment,” Psychological Bulletin 108 (1990), 171; J.P.Meyer et al, “Organizational Commitment and Job Performance,” Journal of Applied Psychology, 74 (1989), 152; V. Lee & M. Henderson, “Occupational Stress and Organizational Commitment in Nurse Administrators,” Journal of Nursing Administration, 26 (1996), 21; P.C. Mishra & S. Srivasta, “Job stress as a moderator variable of the organizational commitment and job satisfaction relationship,” Journal of The Indian Academy of Applied Psychology, 27 (2001), 45; C.A. Gaither, “Career Commitment: a Mediator of the Effects of Job Stress on Pharmacists’ Work-Related Attitudes, Journal of the American Pharmacological Association, 39 (1999), 353.
 Loquencio, op cit.
 Perkins, A. (1994). Saving money by reducing stress. Harvard Business Review. 72(6):12.; Sauter, S.L.; Murphy, L.R.; and Hurrell, Jr., J.J. (1990) Prevention of work-related psychological disorders. American Psychologist. 45(10):1146-1153; Farrell, F. (1994) The demoralized zone: Healing the downsizing survivors. Executive Directions. September/October: 37-43; Jacobson et al (1996) American Journal of Health Promotion, 11(1), all cited in American Insittue of Stress, Job Stress, on line at http://www.stress.org/job.htm.and.in Human Nature @ Work, online athttp://www.humannatureatwork.com/serious.htm
 On stress and productivity, see, among others, I. Donald et al, “Work Environments, Stress, and Productivity: An Examination using ASSET,” International Journal of Stress Management, 12 (2005), 409; J. Singh, “Performance Productivity And Quality Of Frontline Employees In Service Organizations,” Journal of Marketing 64 (2000), 15; J. Singh et al, “Behavioral and Psychological Consequences of Boundary Spanning Burnout for Customer Service Representatives;” Journal of Marketing Research 31 (1994), 558; P.E. Greenberg, “The Economic Burden of Anxiety Disorders in the 1990s,” Journal of Clinical Psychiatry 60 (1999), 427; B.Y. Yeh et al, “Subjective Stress and Productivity in Real Estate Sales People,” Psychological Reports 58, 981; M. Jamal & V.V. Baba, “Stressful Jobs and Employee Productivity: Results from Studies on Managers, Blue Collar Workers, and Nurses,” International Journal of Management 9 (1992), 62; T.A. Wright & B.M. Staw, “Affect and Favourable Work Outcomes: Two Longitudinal Tests of the Happy-Productive Worker Thesis,” Journal of Organizational Behavior, 20 (1999), 1; National Business Group on Health, 2005/2006 Staying@Work Survey, summarized at http://www.businessgrouphealth.org/pressrelease.cfm?ID=55; S. Aldana & N. Pronk, “Health Promotion Programs, Modifiable Health Risks, and Employee Absenteeism,” Journal of Occupational & Environmental Medicine 43 (2001), 36-46; L. Chapman.” Meta-evaluation of worksite health promotion economic return studies”. The Art of Health Promotion. 6 (2003), 1-16. (For a recent review of the negative impact of burnout on work performance, see Maslach, Schaufeli, & Leiter, 2000; more severe forms of reaction to stress are even more disabling). (
 National Business Group on Health, 2005/2006 Staying at Work Survey, summarized at http://www.businerssgrouphealth.org/pressrelease.cfm?ID=55
 On organizational citizenship, see Kruse,B.G. (1995). Affective and cognitive mediation of the relationship between situational constraints and organizational citizenship behaviors. Unpublished masters thesis, Central Michigan University, cited in S.M. Jex, Stress and Job Performance. Thousand Oaks, CA: Sage Publications, p. 54.
Resources are available to help individual aid workers manage stress (and to help agencies organize programs to assist staff members). include J. Ehrenreich, The Humanitarian Companion: A Guide for Humanitarian Aid, Human rights, and Development Workers (Warwickshire, U.K.: ITDG Publishing, 2005), especially Chapter 4; J. Ehrenreich, “Caring for Others, Caring for Ourselves” (http://www. mhwwb.org/disasters.htm); and J. Fawcett, J. Stress and Trauma Handbook. (Monrovia CA : World Vision International, 2003), especially Chapters 6-8. Internet resources include a website developed by Idealist.com/Action Without Borders, http:// www.psychosocial.org, which provides numerous links on individual stress management, and the website of the Headington Institute, http:// www.headington-institute.org, which provides additional resources and links to resources. The Geneva-based Centre for Humanitarian Psychology (http://www.humanitarian-psy.org) has developed a CD-ROM based self-study course, “Stress Management in Insecure Environments,” on managing stress in humanitarian workers.
 On the importanc e of consultative leadership, see, inter alia, Gal, R., & Mangelsdorff, A.D.eds., (1991). Handbook of Military Psychology ( CHichester: John Wiley), cited in G. Fawcett, “Preventing trauma in traumatic environments,” in J. Fawcett (ed)., Stress and Trauma Handbook, (Monrovia, CA: World Vision International, 2003Harris, A., Day, C., & Hadfield, M. (2003). Teachers' perspectives on effective school leadership. Teachers & Teaching: Theory & Practice, 9(1), 67-77.; Langner, D.E. (2002). Burnout and leadership styles in residential mental health workers. Dissertation Abstracts International: Section B: The Sciences and Engineering, 62 (8-B).; Lubofsky, D.J. (2002). Supervisor leadership style and counselor’s burnout. Dissertation Abstracts International: Section B: The Sciences and Engineering, 63 (3-B). Remy, M.N. (1999). The relationship of principal leadership styles and school-site conditions to stress levels of elementary school teachers. Dissertation Abstracts International: Section A: Humanities and social sciences, 60 (5-A); Rome, K.P. (2000). The palliative effect of leadership agents on reactions to workplace stressors .Dissertation Abstracts International: Section A: Humanities and social sciences, 60 (11A), cited in S.M. Jex, Stress and Job Performance. Thousand Oaks, CA: Sage Publications, p. 54.
 Barrett, T.W., & Mizes, J.S. (1988). “Combat level and social support in the development of PTSD in Vietnam Veterans. Behavior Modification 12, 100-115, cited in G. Fawcett, “Preventing trauma in traumatic environments,” in J. Fawcett (ed)., Stress and Trauma Handbook, (Monrovia, CA: World Vision International, 2003); G. Fawcett, paper presented at Save the Children training ]workshop, Istanbul, September 18, 2006. Cf. Lynda A. King and Daniel W. King, John A. Fairbank, Terence M. Keane, Gary A. Adams (1998 ) Resilience-Recovery Factors in Post-Traumatic Stress Disorder Among Female and Male Vietnam Veterans: Hardiness, Postwar Social Support, and Additional Stressful Life Events . Journal of Personality and Social Psychology, Vol. 74, No. 2, 420-434
 Aldana, S.G. (2001). Financial impact of health promotin programs: A comprehensive eview of the literature. American Journal of Health Promotion 15 (5).
 L. Chapman, “Meta-evaluation of worksite health promotion economic return studies, Art of Health Promotion Newsletter 6(6), Jan-Feb 2003.
 Mamberto, c. (2007). Companies aim to combat job-related stress. Wall Street Journal, August 13, 2007, p. B6.
 Interagency Standing Committee (2007). Guidelines on mentalhealth and psaychosocial support in emergency settings. Online at http://www.humanitarianinfo.org/iasc/content/products/docs/Guidelines%20IASC%20Mental%20Health%20Psychosocial.pdf.