Zena Awad (right) is a psychosocial delegate with the Swedish Red Cross, seconded to the International Federation of Red Cross and Red Crescent Societies’ Ebola emergency response operation in Sierra Leone. Her role is to mentor the Sierra Leone Red Cross Society psychosocial officer and develop a programme and strategy to support three key groups: Red Cross volunteers, Ebola survivors and their families, and orphans and other vulnerable children.

What is psychological first aid?

Psychological first aid is looking at the psychological needs of the person and then trying to assist them to get the support, security, safety, and help they need while they are in a crisis or immediately after an emergency event. It’s basically first aid at the psychological level and would mean assessing someone’s (or your own) immediate needs and addressing them or referring them to the services that they need. The ability to confront your emotions and process them in a constructive and positive way helps people to deal with trauma or stress encountered in a crisis.

How can stress manifest itself in an individual working in an emergency like the Ebola response?

Side effects can be loss of appetite, difficulties sleeping, panic attacks, aggression and becoming withdrawn or having difficulty expressing oneself coherently in a conversation. Individuals can start engaging in risky behaviours caused by frustration and isolation. There are different signs and levels of stress, such as the normal day-to-day stress which people can normally cope with, but there are severe stress levels where people need assistance and this is when psychological first aid can be very useful.

Why do members of the safe and dignified burial (SDB) teams need psychological first aid?

Members of the SDB teams need psychological first aid because they are still in the middle of an emergency operation. Despite the fact that the majority of burials are not Ebola-related deaths, the teams still have to follow the same standard operating procedures, and so they are still under the same level of challenge and stress. Challenges such as entering into unknown communities, and the daily emotional toll of facing family members who have lost loved ones are compounded by the risk of being infected by Ebola should the corpse be positive. Because of working in this context, they need the skills to address the psychological needs of the community that they enter, and the needs of their colleagues, as well as their own.

What difficulties have members of the SDB shared with you?

All of them have memories of dead bodies, some of which were in a severely decomposed state after having been left out on the street or abandoned in the home at the start of the outbreak. Some are really feeling the effects of working in an Ebola response operation through the rejection of family and community members who fear that they may become infected with Ebola. The SDB volunteers have been trying to process these memories and deal with these feelings of isolation. It is not easy for them to witness these events and come to terms with them, so memories really do linger. Moreover, they have had to find new support networks because of stigma. Some people have chosen to reject them through fear and lack of understanding of what Ebola is, or marginalize our SDB volunteers because they are in direct contact with dead bodies. As a result, many of our volunteers have been isolated and stigmatized which adds to the psychological impact of what they witness on a daily basis.

What techniques are you teaching the volunteers?

We are training the volunteers to assess their own needs in terms of what tasks they carry out in the operation and then identify their own positive mechanisms to cope. They learn about different levels of vulnerabilities, how people react in a crisis, and approaches to assess needs and give support. Many people design their own strategies to cope, but they may not necessarily be healthy, for example they may engage in negative practices such as substance abuse. On the other side, a positive mechanism we teach can be the ability to identify someone who you could turn to when you need support, rather than turning to alcohol. It’s about being able to express yourself in a constructive way instead of repressing the memories and trying to escape from those memories through drinking or harming yourself or others around you.

How will these skills benefit others?

We are teaching people skills to assess their needs and to address them in a positive way, but at the same time these people participating in the workshops have been trained to be trainers. We are training the trainers, so that they can then go and stage their own workshops for their own colleagues. This would mean all our volunteers are equipped with these skills and are able to be psychosocially considerate of the needs of the communities where they are working. These skills help strengthen the support that the volunteers give each other.

How is psychological first aid different from assistance for Post Traumatic Stress Disorder? (PTSD)

PTSD means that you have a mental disorder which we don’t diagnose people with in the middle of an emergency because it is a condition that arises after an emergency or crisis. It is too early to talk about SDB volunteers suffering from PTSD because they are still at the center of the response. If six months after the crisis has passed and these symptoms of aggression, isolation etc. presented themselves simultaneously, we would then look towards assistance for PTSD. We can see some of the symptoms now such as loss of appetite, isolation and not sleeping well, but this is what we call normal reactions to abnormal situations. It would be wrong to diagnose and label people with PTSD or even look for those signs from that aspect because at the moment the volunteers need ways of coping through positive behaviour mechanisms for the present situation - such as relaxation exercises to help them sleep better.

Do you think SDB volunteers are at risk of PTSD?

SDB volunteers can be at risk of PTSD, however the risk is mitigated through psychological first aid. Through learning to address their needs and deal with them in a positive way, the volunteers are better equipped in the long term to cope with the after effects. After the outbreak, extra support should be given once the volunteers are reintegrated back into their communities through follow-up psychosocial assistance

What support is the Red Cross offering to its staff and volunteers during the Ebola response?

The Red Cross offers its volunteers and staff psychosocial support and assistance to reintegrate back into communities by helping to re-establish relationships. After the burial teams have been disbanded, livelihoods support will be given to the volunteers. This is one of the main concerns of the SDB volunteers in particular: they ask what will I do post-Ebola? How will I go back to my normal life? They don’t see this happening very easily. We have to look at these needs and how to address them, given that some of the volunteers will not receive the required support from their families.

Why is psychosocial support such an important aspect in the Ebola response?

Psychosocial support is an aspect that is integrated in everything we do because the way that we do our activities is so important, for example the approach to a community to conduct a safe and dignified burial. We strive to carry out our activities in a way that will not cause tension, conflict or harm. Mental health is a complex issue and needs to be thought of in the long-term.