The psychological impact of humanitarian crises on humanitarian staff

Daniela Ana-Maria RADU

Lumina –The University of South East Europe

“At times their deeds are heroic. The certainty is that their hands are drained with mud and they most of the times risk their lives in honor of their profession They are like knights without an armor for they fight dangers with more and more complex technical methods. At times, cruelly, facing the atrocities of death and war, they emotionally break down and end on having the inner strength of protecting their minds and their vulnerability reaches extremities”[i]

“The politics of humanity need to be understood and shared”[ii].

Abstract: This paper will analyze the way in which armed conflicts and widespread violence (as variables of humanitarian crises) establish themselves as external traumatizing factors which can trigger a post-traumatic stress symptom in humanitarian personnel. We intend to outline a method of integrative intervention for the humanitarian personnel affected by post-traumatic stress symptom, using to this purpose the multi-level model of intervention.

Keywords: humanitarian crises, humanitarian personnel, post-traumatic stress symptom, multi-level model of intervention, integrative psychoterapy.

1.       INTRODUCTION

R. Brauman stated that from a historical viewpoint, the humanitarian context may be seen as follows: arbitrary violence and behaviors can be spotted one side of the surface, for on the other side there might be seen a strain of civil pain and suffering, standing for the victims of armed troupes and predators.[iii] Professional activity in the humanitarian field is a logical connection to stress. If for some of these professionals stress may be a sustainable source in their work, there also is another category, which gives in to orders and things shown on the field of work.[iv]

The psychological support program had been launched in 1993 by the International Red Cross federation, when a part of staff came back home suffering from psychological traumas after having viewed the genocide of the Tutsi population in Rwanda. The project psychological support aim is helping the helpers to manage their stress.[v]

There is an observable lack in clearly structured statistics, consolidated data basis and reports concerning the risk which humanitarian staff face. An set of as such statistics under the work of the Centre for Refugees and Answer to Disasters from Baltimore, in the Johns Hopkins Blumberg School of Public Health Baltimore shows the fact that in recent years, a considerable number in humanitarian staff was killed out of intended actions. Deliberated violence, armed attacks, ambuscades and rapes cause up to 60% of the deaths, 71% of the causes of violence by will do not relate to stealing while 56% of the violent cases had ended with deaths, the usage of small weaponry had been declared at least in fifty 56% of the signaled cases.[vi]

Intended violent manifestations on humanitarian staff had been more evident especially after the Cold war, a moment which marked an active participation as well as a huger exposure, all in order to help the suffering. The aftermath of these changes on humanitarian staff are multiple: experimenting a high grade of violence and frustration, of having stopped from aiding those who survived the crises.[vii]

The actual crises inter combine civil conflicts with varied forms of war and have political dimensions as well as military, social and humanitarian ones. Therefore they generate a unique form of stress and indicate a high violence risk. An element of instability for individual personality structures of humanitarian workers in humanitarian crisis areas is revealed by the lack of respect towards traditional and formal rules. In the past twenty years wars had been taken without any respected rules, the humanitarian professionals as well as civil being obedient to the closed circle of major risks.[viii]

2. VARIABLES OF HUMANITARIAN CRISES, SOURCES OF INDIVIDUAL TRAUMAS

Humanitarian catastrophes are disorders in the continuous course of individual or continuous existence standing for unhappy events, which interfere suddenly, and in an unexpected way. As a meaning, crises cover complex situations, hard to manage, having important consequences, long lasting and hostile. The elements[ix] which signal a general structure of the crisis with humanitarian references are: a significant deterioration of individual and collective security; the event (bumming, epidemics) or its consequences (lack of drinkable water, of medicine or shelter); the number of victims (dead wounded, homeless and sickly); the singularity and amplitude of a disaster determines within the affected population physical and emotional fragility (strong emotional suffering risks, as well as long lasting effects, medical issues, hunger, the transportation to a safer zone  the event had provoked important destructions of places such as habitats, schools, institutions, hospitals, infrastructures).

Humanitarian crises reflect their consequences on population activity. They threaten the continuous flow of social activity as a cause of the disintegration of social organizational structures without which the normal functioning of collectivity cannot exist. Institutional responsible find themselves unable to solve the upcoming issues and to give first aid measures to the affected populations. In humanitarian crises, individual traumatisms are multiple: physical aggressions (stealing, kidnappings, physical threat or violence, rapes, domestic violence, torture), moral aggressions (forcefully breaking taboos or communitarian values, permanent personal threats or threats towards close people), moral and physical aggressions (torture and sexual abuse).

Armed conflicts may determine a complex series of traumatisms, both for civil populations as well as for humanitarian staff. A series of traumatizing factors may interfere isolated or in a cumulative way: city bombings, experimenting a victim or witness status of physical or moral violence belonging to the enemy, committing traumatizing facts under enemy pressure and by enemy request. Thus, we may remind: suffering or being witness to an act of rape, suffering or being a witness to an act of torture, making the object of arbitrary arrests, being sentenced to prison, suffering or being the witness of interrogatories along with violent acts, taking part in hostage taking, seeing one’s own house either on fire or destroyed, suffering from hunger, thirst, heat, cold or lack of sleep.

Population exodus stands as a source itself for inducing trauma both for the refugee populations as well as for humanitarian staff. Of traumatizing factors we may mention: the need to live one’s home without keeping their goods, the need to go on long distances, death threats and harassment, parting from the rest of the family deprivation of personal belongings or ID papers, visualizing corpses on the way to new refugee camps, psychological isolation and the lack of affective protection, rejection or malfeasance at border pass, hostility upon arrival in a foreign land.[x]  While a massive exodus takes place, the crisis is collective because of the discomposure of the social and familial tissue. 

Population exodus, most of the time, favorites an export of political, religious and ethnical tensions. Social structural changes may lead to the forceful creation of new social organizing methods, as the social rules in the refugee camps as well as those applying to persons abroad may determine a modifying in lifestyle, the latter facing new types of authority and cohabitation. These conditions influence the mental balance of the group as well as the individual psychological structures. A series of other traumatizing factors may be associated to the ones already mentioned: a new life environment, overpopulated, unhygienic, with limited access to food and water, a new way of living which does not allow the accomplishing of usual activities, the risk of other traumatizing events such as rapes, rebel aggressions which often devastate the camps, the hostilities of hosting communities.

Chronically violence stands as another variable of the humanitarian crises, which determine trauma on a level of individual psychological structures. The areas which find themselves in a continuous state of war, of social disorder, as a result of terrorist acts offer a ”normal realm” where violence is a part of the collective as well as the individual consciousness. This situation may lead to simplifying the risks and may induce to the persons an adapting process, which in time may become an illness: adapting to a risky social environment by daytime, with a suicidal potential during the night. Humanitarian staff activity is developed in social contexts marked by extreme violence, violence which in most cases stands as a main cause for the death of staff willing to offer help. In spite their humanity which they show and their will to help, humanitarian workers are threatened and voluntary violence is turned towards them.

Humanitarian professionals, in the aftermath of confronting a situation of extreme violence may find themselves unable to manage their psychological traumas. This incapability of managing traumas is caused by emotional overwhelms which is the main feature of the burn out syndrome. In repeated missions of the humanitarian staff, cumulative stress amplifies, becoming a chronically illness. Through visible signs of the burn-out state we may find: chronically sleep disorders, soma disorders and states of overwhelming incapacities, deterioration of mental capacities, loss of memory and action efficiency, loss of self esteem, feeling down, profound delusions, rejection of values which lead individual actions and in some situations there may also be observed an appearance of panic as in paranoid attacks and severe depressions.[xi]

Thus there is a need to distinguish between the traumas defined by the DSM and the daily unavoidable ones, which may bring in various contexts disorders to the personal status. Some emotional disturbing experiences may be also provoked by ethical stress thought to be any experience which contributes to the change of an individual scale of values, which blocks ideals, the meaning of life or a perspective on humanity.[xii] Amongst these experiences we may include violence, cruelty, corruption or unethical behaviors. Humanitarian professionals are often idealists for whom unethical or non-moral behaviors may be thought unlinked to their set of values. Experiencing such states may contribute to accumulating stress and it may lead to a burn out state of feeling. A humanitarian staff professional testimony is thus concluding. ”I feel betrayed, let down; I feel like a priest who lost his religion. You come here because you care and you can only survive if you don’t care.  When the ethics of an organization are disregarded by the very guardians, it is disillusioning.”[xiii]

Thus, in the sphere of negative consequences coming in the aftermath of being unable to manage individual traumas by humanitarian staff, there may be pointed out some manifestations such as excessive implication and mostly identifying with the suffering populations ore moreover, apathy towards beneficiaries, auto-destructive behavior, inner and family related conflicts, with work comrades as well as post traumatic stress disorder.  

3. POST TRAUMATIC STRESS DISORDER (PTSD)

According to DSM IV[xiv], Posttraumatic stress disorder (PTSD) stands as a disorder resulted from a traumatizing event, which psychologically releases fear, sadness and horror. This disorder appears as a persisting re-experiencing of the traumatizing event, avoiding behavior associated to the traumatism and a stage of neuro-vegetative hyper activity. Thus the Posttraumatic stress disorder stands as a major anxious issue different from other anxieties because this one shows exposure to a traumatizing situation. The Posttraumatic stress disorder follows the traumatizing event on a psychological frame inducing intense fear, the feeling of lack of reactions and unwillingness. PTSD is a defensive psychological strategy, a kind of mental and emotional anesthesia, in order to create a protective environment regarding disturbing memories, which brought over the fear, the panic as well as feelings such as terror and sadness.

An insidious aspect of this clinical picture is represented by the fact that the event, which provoked the disturbance, may pass from an intensity point over the limits of expectancy and bare ability of the person living this trauma. The individual affected by PTSD may himself be the victim of the event, may be the witness in an accident within one’s communitarian activity or of a humanitarian catastrophe, which ended with a considerable number of victims. These events do not affect only their central subjects, but also the secondary ones, otherwise mentioned, any person exposed to an intensely stressful agent.

Genetically and biological factors

Research does not offer solid arguments regarding the influence of genetically and biological factors in the ongoing disorder.[xv] Within the category of risky factors[xvi] there may be mentioned: the female sex, the age of trauma, malfeasance over childhood, other psychiatrically disorders, other psychiatrically family disorders, and lack in education.

Evolution

 According to personality structure, the evolution may differ. Under a direct impact in shock the body adapts, thus the feeling of hyper vigilance and hyper reactivity on a psychological way turns on active just like a protective system, preventing other future and potential dangers. According to each personal history as well as the subjective manner of understanding trauma, the risks of reaching a state of PTSD are not the same for everyone and not identical in various moments in an individual s life. A series of factors considered as intense and long lasting influences of the post traumatic stress state could be: previous traumatism, predisposed to depression, fragile personality, insecure affective environment, family psychiatrically issues, various biological factors.

Appearance and evolution process

In a first degree, when the state of vigilance is not permanent we may observe that an individual has no manifestation particularities and that one could find the self in the normal state of reaction. Another degree, which integrates yet, another response to PTSD shows an everlasting individual state of tension when the subject reacts as if there were the risk of living once again the horror and the powerlessness felt in the moment of the traumatizing event. Over this period, the individual is upset, aggressive, and anxious suffering from sleep disorder and looked at avoiding everything, which could reactivate trauma. These reactions last for a few weeks and may fade progressively. The third degree is the lengthening of a stressful state, which thus becomes posttraumatic. The period separating the moment in which trauma occurs, from the one of psychological modifications may vary from a few weeks to a few months or more. 

The symptoms

In case of lasting symptoms for more than one month we may mention PTSD. We must keep in mind the fact that the gathering of symptoms often starts a few weeks later from the event and the lasting in manifestation may be from a few months to more years. Almost in half of the cases, complete healing may be noticed in three months whereas other people have symptoms lasting for more than twelve months after the trauma. The general state of PTSD imposes treatment as, a series of statistics prove that: for 30% of the persons with PTSD there is a risk of upcoming depression, 25% of the subjects who have PTSD find themselves with anxiety disorders (panic attacks, obsessive compulsive disorders, general anxiety, phobias), 50% take alcohol, medicine or drugs[xvii]. In 20% of cases, the victim’s behavior is organized and dominated by reliving the traumatic experience.[xviii] Various uncontrollable flashbacks intimidate the subject’s life. The latter imaginarily lives in a state of trance or sleep, the memory of a traumatic event in its slightest details (images, odors).

When an individual is suffering from PTSD the symptoms are long lasting and the rate of spontaneous remissions is little. Also other symptoms may continue showing as nightmares. Thus, statistics show that 50 % of the women who faced a sexual abuse keep on showing symptoms even ten years later, that 15% of cardiac and liver transplants are due to the intervention itself as the risk of rejection is considerably more important and linked to PTSD. One year after a traffic accident 20 % of individuals manifest on PTSD 37% come up with depressions, phobias and nutritional disorders.[xix] To these ones there might also be added a series of physical psychosomatically and behavioral symptoms more or less affecting such as sleep disorders, nutritional disorders, raised heartbeat, depression, constant sensation of lack of air, sickness, disgust, dizziness, fear of losing self control and of sliding into a state of illness, panic disorders, phobias, fear of dying, sensations of numbness and pinches, irascibility, avoiding behavior, repeated nightmares, digestive disorders, panic, feeling tired and unable to concentrate. Moreover, PTSD induces an alteration of social functioning as well as professional and brings in serious difficulties in the marital and familial status. Because of the fear of becoming an understood burden the individuals suffering from PTSD refuse to communicate which makes the close ones finding it difficult to approach the victims by empathy. In such situations verbal communication is difficult for the emotions and the reactions following are very intense.

Diagnosis

According to DSM (IV) there are six criteria, which allow the conventional diagnosis. First, the individual had been exposed to a traumatizing event in which two criteria had been noticed: the subject lived, was the witness or the direct combatant of various events in which others had died or been severely wounded as well as death threatened, the reaction of the subject towards the event had been translated by induced fear, a feeling of horror and powerlessness. If the PTSD subjects are children, an unorganized or agitated behavior can be a substitute for such manifestations. The second condition is the constant reconstitution of the traumatizing event under various features such as: repetitive and intrusive memories of the event which may lead to a feeling of sadness and which contain images, thoughts or perceptions, repeated worrying dreams of the event which induce a deep sad feeling, the constant feeling that the event may occur again including the feelings of once again going through the event with illusions hallucinations and dissociated feelings, deep sadness and emptiness towards internal or external stimuli re bringing or reminding of the trauma, psychological reactivity to exposure of internal or external stimuli which bring back the traumatic feeling. The third condition asks for a persisting avoiding of stimuli associated to trauma and a low level of general reactivity: making efforts to avoid the thoughts, feelings or conversations associated with the trauma, efforts to avoid the activities, environments or people which revive the trauma activities, incapability to remember the real aspects of the trauma, reducing interest of taking part in important activities, feeling of being detached to others till up rooted, a reduced level of affectivity, incapability of showing tender feelings, feeling that the future is senseless, that all personal and professional projects cannot come true. On the forth aspect it is to be considered if the persisting presence of feelings produces a neurovegetative state as if the subject would show: sleep disorders, interrupted sleep and irascible states or fury outbursts (concentration disorders, hypervigilence, exaggerated tension reactions). The fifth element in the diagnosis imposes the finding out of a personality disorder for the symptoms subscribed to the second third and forth criteria last for more than one month. For the sixth indicator there is to be observed if the disturbance above mentioned is part of a significant clinical suffering or a deterioration in the social professional or other important field functions. 

Acute Stress is different from PTSD because the confronting with the traumatic event had taken part less than four weeks before manifesting. In order to differentiate PTSD from the obsessive compulsive disorder it is to be attentively analyzed the content of intrusive thoughts, which imposes to be directly correlated with traumatic events. All contain of repeated flashbacks makes the difference between PTSD and a psychotic disorder. The therapist will attentively analyze while establishing the diagnosis and the possibility for the subject who claims to have PTSD may induce a self-state in this way the Multiphase Personality Inventory of Minnesota applies (IMPM) - as an imposed method.

Associated elements and disorders

Studies show that a significant number (at times up to 100%) of the subjects diagnosed as suffering from PTSD, follow the criteria for at least one more disorder of the first axe, DSM. In this category the most seen are depression and consuming substances as well as panic attacks, agoraphobia, obsessive-compulsive disorder and social phobia. Also, there may be seen as associated with PTSD some personality disorders axe II (DSM): borderline, antisocial behavior, paranoid manifestations that may also be schizoid and obsessive compulsive. The attitude revealed by a PTSD individual. Often, the individuals with PTSD experience a state of guilt, shame, catalogued as normal according to some specialists such as N. Prieto and F. Lebigot who think that ”this self guilt immediately shown must be understood as a sometimes desperate or painful but always possible attempt of retaking control, but also as a trial to be, to become a direct actor in the event and not to be depersonalized completely obedient to the chaotic course of happenings”[xx].

Research made at the Psychiatrically Yale Clinic by Lazrove in 1995, have indicated that in a group of individuals facing the same traumatizing event part of them are immune to these stimuli, while the rest are victims of PTSD.[xxi] Some personal variables such as unhappy childhood experiences, behavioral features or preexisting mental disorders, may contribute in some cases to the subject developing PTSD. Still the most important factor is the calamity of the experience.

4. A POSSIBLE MODEL OF INTERVENTION

Accuse: D. Male 38 years old, not married. He lives with his partner in Geneva and has been living here for five years. Three months ago he returned from Chad from his second mission and he is feeling sleep disorder, irascibility, difficulties in concentration, nightmares, anxiety, couple and work relational problems.

Trauma Historical Facts: As six months ago he was on a field mission together with three former soldier children, a female and a male colleague, their car had been attacked by rebels. His female comrade had been deadly shot, and the children (former soldier children in the counseling and resocialization program) got their limbs cut and he had been wounded and carried by his other comrade to the nearest location for care: the hotel close to the airport.

Feelings and Dysfunctions

After the traumatizing event he continued his mission for only one month then asked to return home following another mission in Burundi, which he did not take part in, because of the fact that for two months his mental state had deteriorated and he is once more living the scenes that happened in Chad. He stopped painting in his spare time, he feels constantly hyper vigilant and agitated, he refuses communication with his partner or other friends whom he had neglected over the past two months. His relations with colleagues are tense finding himself at his second letter of complaint from his superior over the past month. He shows furious and strongly anxious states, he would rather stay isolated without sharing his state with anyone. 

Current Symptom Analysis

Two months ago, finding himself in an European capital city, at a reunion in a conference hall in a hotel close to the Airport, he found himself caught in a strong feeling of fear, general anxiety, dizziness, sensation of suffocation. The sequences in Chad in which he could see both his female comrade who got killed as well as the severed children started obsessively coming to mind.

We shall propose a set of objectives and possible technique according to the dimensions of the integrative multi level model. The multi level integrative model[xxii] of evaluation and intervention integrates various spheres thought as relevant both in personal development as well as in the interventional strategy. The dimensions, which after the interaction could produce and express mental disorders, both physical and psychosomatic are: life context, cognitive dimension as well as emotional, somatic, behavioral and spiritual[xxiii].

At a life context level, the therapist will concentrate on the life history of his customer, on the traumatizing experiences (in case of PTSD) which contributed to the structuring of various cognitive and behavioral patterns which may be noticed in the current life of a customer as main schemes of filtering the information which one gets from the external environment. The cognitive dimension integrated in this model, will guide the attention of the therapist to the informational conscious processing as well as the unconscious ones but also on their content (relevant in PTSD). After the conscious mental processing, the customer may verbally communicate the mental content of informational processing. In relation to PTSD, the therapist will pay attention to the content and the way it is delivered, as there may also be a possible acting on behalf of the customer. On the other hand, unconscious mental processing do not allow a verbal expression of their own accord. In terms of PTSD this incapability to communicate is frequent because of the fact that the subject is not aware of their existence, as the defensive action is present usually manifesting shame and anxiety. The emotional level includes a multitude of the experiences of the subject, the manner in which the latter describes his own states. The therapist will try and decipher the content of the emotions behind verbal labels of his customer in order to find out about the emotional state neutral, positive or negative. The physiological and biological level stands as a component of this model where we may find the somatic scheme of a trauma. These soma features may be seen both on the path of anatomy as well as physiology. It is important to keep in mind that the intensity of these somatic traumas, the modifications that occur in the vegetative neurological system influence an emotional balance. This is the cause for which there has to be imposed a holistic view, thus capturing the hidden links between the structures forming the whole and its integral evolution.

The behavioral level will orientate the therapist’s attention on the known motor behaviors as well as operational either voluntarily controlled: reactions, manifestation attitudes or otherwise expressed. In the case of PTSD the therapist has to find the operational behaviors as an aftermath of a defensive reaction to the traumatic stimulus versus the attitude of the subject in inappropriate environments.

The spiritual level stands as an image of meaning, values, and cultural objectives of the collective unconsciousness. The therapist will evaluate the manner in which the subject orientates the cognitive resources as well as emotional according to proper values, as the subject tries to involve in the scale of values of the social structure which has managed his personality and how much does this dialogue with the environment possibly affect inner scales of values.

Life context 

Projected objectives:

O1.Trying a positioning of the client alongside the most important people in his life;

O2. Trying to position the client alongside the most important things and events in his life;

O3. Trying to position the client alongside the traumatic event.

Helpful techniques to fulfill the objectives:

a. A letter to the parents, where the patient is asked to write what he feels and what he thinks he could not tell them. Later, the content of the letter is to be discussed.

b. Genograma technique which could offer functional information regarding the family of origin, the manifestation of family members, in various moments of life which the patient regards as important. This technique could be useful in order to recover abusive behaviors as well as dependent of critical events, of traumas, of accidents or of family resources. As a parallel to the genograma of the original family, he could also draw the genograma of the own family (couple relationship)

c. Anamnesis may apply in order to create an inner link between the events which happened six months ago and feelings of the present. The therapist will try to establish some links between these events and the feelings shown and moreover, they will follow to find out the significance of the symptoms in the patient and his life contest

Level of cognition

In order to mark the objectives, the therapist will look at the cognitive distortions specific to SSPT meaning over generalizing, dichotomy (all or nothing) and personalizing.

Projected objectives

O1. Inclusion in the manner of life overview of the idea of reality recognition just as it shows (some events that are highly negative may unexpectedly occur and people are not always capable of managing them);

O2: Balancing the interpretation scale of the patient regarding self-image;

O3: Clarification regarding the proper situation according to event tracking, eliminating the intention of personalizing the events that took part in his life; 

O4: Identifying new centers of interest for the patient’s life.

Techniques which could accomplish these objective

a. Techniques which manage cognition disorders linked to trauma

An example of cognition disorder: “there is no place on Earth where there is no violence”.

We propose the following way to work: What experiences did he gain from such an environment, what beautiful things are there around him, what did he like to do before, how much is he wasting as he cannot draw near the things which he used to do creating a state of wellbeing, what is the list of current risks for patients? What risks does one have when at home? What about on a mission? What kind of safety measures does one have?

Example of cognition disorder: “I could have saved my companion from death. I could have avoided the children remaining without hands. I feel responsible for this”. May it be step by step specified how could he have done those things as the rebels were armed and extremely angry for the fact that part of the children who they were using as warriors, as weapon carriers, have stopped working for them and started following the counseling programmed, there can be talk about someone responsible (from his place of work) for the death of the female comrade as well as the tortures applied on the children?, How can responsibility be divided ?, He may be asked : if your friend were facing the same situation, would you accuse him for not having done enough exercising forgiveness. Example of cognitive disorder: “I cannot see the meaning. Everything is senseless”. We propose the following way of working with this issue: Projecting a list with preferred activities taken before the traumatic event, the ongoing of a daily schedule and concentrating on sense full events for the patient, knowing the fact that sense or meaning also attracts the idea of death and loss of loved ones, changing the system of values and valuing the fact that he is alive, that he has a partner in life, and that he has a role in the formed couple.

Example of cognitive disorder: “My partner does not understand me”. We shall propose intervention as follows: creating a list with the problems stated by the patient that are not understood by his partner, clearly establishing a timescale since the partner can no longer understand him. 

b. Technique of Information

The patient will fill in a list of traumatizing stimuli, the Questionnaire of post traumatic stress (QPTSD), the post traumatic stress scale regarding criminal events, (SSPT-EC), created by Saunders, Arata and Kilpatrick. He will get familiar to other information regarding PTSD. These test batteries and informational sources could help the client to clarify some details regarding the ongoing of events and appearance of symptoms. 

The emotional level

Projected Objectives

O1: Reducing, parting the state of shame, guilt and sadness; 

O2: Experiencing new affective states regarding self and in the couple relationship;

O3: Reducing the state of anxiety.

Techniques that could be used in order to reach the objectives

a. Exposure. Exposing in an imaginary plan and In Vivo to the  “traumatic memory” and to the avoided situations. Imaginary exposure aims to bring back the traumatic scene to the patient, whom after applying a relaxation technique will be asked to relate about the way he lived the traumatic event. The narration of the patient, guided by the therapist (questions which activate some memories or images) and organized by the latter in more parts, in case the situation asks for it (intense and multiple traumas), thus the experience will repeat in order to reduce the anxiety of the patient. The first exposure shall be registered in order to, if there be a future appointment, the patient may see his own narration and after viewing it he may “once more live the event”. This chain of ”re- living ” shall take place in other future appointments until the level of anxiety is reduced. The results of the appointments shall be registered in the imaginary exposure file.

When the patient shows a diminished level of anxiety, the therapist may suggest for the In vivo exposure to the avoided situations. In the current situation, two suggestions could be prescribed: to go to the family of his deceased comrade (whom he knows and had been visiting before) and to spend more time together with them or along with his couple partner to spend a weekend in the hotel next to the airport where the crises reactivated. The results of the exercises to In Vivo exposure shall be registered in a work file. 

b. The Role play Technique: the patient, interpreting a role, has to be attributed a new behavioral model, which can at many times be the premise to more complex changes in personality. If he and his partner shall agree they will be suggested to practice the role play technique also known as role reverse, in order to see himself through the eyes of his partner whom he had completely neglected over the past two months.

Behavioral Level 

Projected Objectives

O1: Encouraging the patient into taking risk, into new future projects,

O2: Stimulating and developing functional behaviors

O3: Stimulating into undergoing daily activities and into making efforts for a better life in the couple

O4: Eliminating auto destructive behaviors of hostile attitude towards the partner and workmates. 

Techniques in order to reach the objectives

a. Ericksonian Hypnosis. Being non-directive, stimulating creativity and having flexible features it could be a useful technique in order to evaluate unconscious resources unused by the patient, moreover if the later shows a permanent state of vigilance.

b. The Empty Seat Technique

The patient is asked to imagine that his ex comrade were on the empty seat. Verbalizing a set of emotions and thoughts might help him reduce the guilty feeling which he is intensely experiencing.

c. The Role technique- the patient is asked to enter the role in which he feels the safest as well as the role which makes him feel the least safe and self confident. If the latter agrees, his partner and one of his close workfellows may be invited to the sessions. If the patient agrees, his life partner will take part in the therapy session where he may play the father figure. 

d. Re-Learning Ability Technique: 

Along with the patient a list of activities shall be established according to his wishes to take part in and which he cannot act on because of his physical degradation over the past months. A schedule shall be made, under the shape of homework. Homework examples: he shall go out to the theatre with his partner, he shall invite his mates to a dinner made by him and his partner, he shall not insult the colleague who sent him on a mission in Ciad (even if our case study subject asked to be sent), etc.

Somatic Level

Projected Objectives

O1. Recommending to go to physicians or other specialists in order to fulfill psychotherapy along with some medicine;

O2: diminishing the general state of well-being, the dysfunctions in couple life and proposing a change in lifestyle;

Techniques to help reaching the objectives

a. Relaxation techniques for breath control, in order to clear away headaches and impulsive actions;

b. Techniques related to nutritional changes and practicing sports;

c. Projective techniques (in his spare time the patient used to paint. Over the past two months he gave up on painting).

Spiritual level

Projected Objectives

O1: Centering on present values, on having new roles in personal as well as in couple life;

O2: Helping the client from the shadows to propose a soul project (creating an exhibition with the theme of giving and sacrifice), being a father, etc).

Techniques which help in reaching the objectives

a. The technique of centered dialogue on various themes such as the meaning of life, freedom, creation and orienting discussions towards the future, to one own capacity of showing his potential.

b. The technique of analyzing the meaning of life in the style of a dialogue with one s self along with the others so as to gain access to inner resources and to reconstruct for the aim of new projects. 

5. CONCLUSIONS

The work started with our intention of approaching two research areas (humanitarian domain and integrative psychotherapy), re implementing a possible dialogue between these two, a dialogue which may be useful in practice. Our researches in the past years have concentrated on humanitarian crises, on interventions in situations of a crisis and on protecting the vulnerable people, victims of armed conflicts and extreme violence. The proposed model of intervention aims to stand as an argument in favor of the idea that integrative Psychotherapy could offer true models of psycho therapeutically intervention for humanitarian staff who develop PTSD.

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