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Table of Contents
Year : 2019  |  Volume : 17  |  Issue : 1  |  Page : 50-58

Humanitarian well-being: Addressing the intimate partner to promote humanitarian well-being, a literature review

Psy.D, Doctor of Clinical Psychology, River Rock Connections, Denver, Colorado, United States

Date of Web Publication28-Jun-2019

Correspondence Address:
Katie Spencer
River Rock Connections, Denver, Colorado
United States
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_43_18

Rights and Permissions

Humanitarians are critical players in alleviating suffering worldwide. As a result of their willingness to put themselves in challenging, often dangerous environments, humanitarians are at high risk for negative mental health outcomes. Addressing humanitarian mental health effectively must consider the well-being of the intimate partner. The paper reviews the literature on humanitarian mental health, the protective nature of social support, the relevance of the intimate partner as a provider of social support, and outcome research on interventions that increase social support through the inclusion of the intimate partner. This paper draws comparisons between military and humanitarian intimate partners and provides information on the military’s research and programming as a model for humanitarian organisations to consider. One of the most effective ways to improve humanitarian mental health is to increase the well-being of the intimate partner and intimate relationship.

Key implications for practice

  • The humanitarian context can lead to high levels of poor mental health outcomes.
  • Humanitarian distress and attrition has a negative impact on an organization's mission effectiveness and bottom-line.
  • One of the most effective ways to improve humanitarian mental health is to increase the well-being of the intimate partner and intimate relationship.

Keywords: Humanitarian well-being, intimate partner, social support

How to cite this article:
Spencer K. Humanitarian well-being: Addressing the intimate partner to promote humanitarian well-being, a literature review. Intervention 2019;17:50-8

How to cite this URL:
Spencer K. Humanitarian well-being: Addressing the intimate partner to promote humanitarian well-being, a literature review. Intervention [serial online] 2019 [cited 2023 Jun 3];17:50-8. Available from: http://www.interventionjournal.org//text.asp?2019/17/1/50/240650

  Introduction Top

The challenging and complex environments within which humanitarians operate increase their risk for developing negative mental health outcomes (Cardozo & Salama, 2002; Cardozo et al., 2005; Cardozo et al., 2012; Chan & Huak, 2004; Ehring, Razik, & Emmelkamp, 2011; Eriksson et al., 2001Eriksson, Kemp, Gorsuch, Hoke, & Foy, 2001; McFarlane, 2004; Musa & Hamid, 2008; Ursano, Fullerton, Vance, & Kao, 1999; Welton-Mitchell, 2013). Humanitarians are civilians and professionals who voluntarily respond to the ‘human costs of disasters such as wars, floods, earthquakes, famines, or refugee crises, or respond to longer term issues such as poverty, hunger, and disease’ (Antares Foundation, 2012, p. 7). Though the humanitarian workforce consists of both international (or ‘expatriate’) and national (or ‘local’) staff, this paper focuses primarily on the former.

Humanitarians are often considered to be well-intentioned, compassionate individuals. These qualities serve not only to motivate the pursuit of this difficult career, but also to increase one’s vulnerability in the absence of support. Humanitarians often deploy to settings too dangerous for their intimate partners (romantic partners who may or may not be a legal spouse) to accompany them. As a result, humanitarians who have intimate partners are often separated from this critical source of social support that typically increases their capacity to cope with stress (Cohen, 2004; Johnson et al., 1997). In addition to job stressors, intimate partner and relationship distress can create or maintain mental health challenges for the humanitarian. Humanitarian organisations that seek to address the mental health needs of its staff will be most effective if they also address the well-being of intimate partners.

The literature on the impact of humanitarian aid deployment on intimate partners is sparse. To demonstrate the relevance of intimate partner and relationship well-being to the mental health of humanitarians, this paper draws from distinct bodies of literature. Research on humanitarian well-being provides an understanding of the challenging context and proven risk for negative mental health outcomes among this population. Research on social support as a protective factor against negative mental health outcomes in non-humanitarian populations supplements the data specific to humanitarians. Social support research is highlighted to show the importance of the humanitarian’s social system, specifically the intimate partner and relationship, in preventing and alleviating distress. Data on the interrelated nature of relationship distress and individual psychopathology are pulled from non-humanitarian populations to support the argument that interventions focused on an individual’s social system, at the level of the intimate partner, are effective in supporting the targeted individual as well. The final portion of this paper examines United States military research on, and programmes for, military intimate partners; and makes programmatic recommendations for humanitarian organisations to implement to address staff well-being.

  Why should humanitarian organisations care about mental health? Top

This section demonstrates the impact of humanitarian distress and attrition on an organisation’s mission effectiveness and bottom line. Understanding this reality should motivate organisations to seek evidence-based interventions to increase employee retention and well-being. The remainder of the paper will argue that systemic treatment models that address the intimate partner and relationship may produce optimal employee outcomes. First, however, one must understand the organisational impact of high levels of distress.

When humanitarian well-being is not addressed, it can lead to poor work outcomes. Research demonstrates that humanitarian distress negatively impacts work efficiency and efficacy (Antares Foundation, 2012; Cardozo et al., 2012; Fawcett, 2001). In Welton-Mitchell (2013) study on United Nations High Commissioner for Refugees (UNHCR), 42% of participants (n = 1341) indicated that mental health symptoms interfered with their ability to do their job. Staff stress interferes with productivity, leads to poor decision-making, and contributes to staff putting themselves and others in risky situations (Antares Foundation, 2012). Accidents and illness that can occur as a result of distress decrease levels of commitment to the organisation’s work (Antares Foundation, 2012).

Accidents and illness due to staff distress also contribute to high levels of absenteeism and attrition. In 2012, psychiatric conditions were the number one cause for missing work globally among UNCHR staff, accounting for 18% of total sick leave days lost for the organisation that year (Welton-Mitchell, 2013). A study by De Paul and Bikos (2015) showed that 53% of humanitarians did not plan on returning to their home organisation after their assignment. This is a notably higher attrition rate than corporate expatriates (44%) (De Paul & Bikos, 2015). In addition to the impact of turnover on efficacy in the field, high attrition increases an organisation’s expenditures on recruiting, training, and deploying new staff. Turnover results in loss of expertise and employees have a slower productivity rate, which is a cost that is difficult to quantify. Boushey and Glynn (2012) reviewed 27 studies on the cost of employee turnover and found that the median cost of turnover was 21% of an employee’s annual salary.

Recognition of the connection among staff distress, poor work outcomes, high attrition rates, and significant costs has led some humanitarian organisations to take action. Though limited, some organisations have introduced individualised mental health interventions aimed at improving functioning at work and in relationships. These approaches include individual counselling and, in the case of UNHCR, peer support systems (Welton-Mitchell, 2013). This paper, however, supports a systems theory approach to intervention. To improve mental health and resilience at the individual level intervention must address systemic issues, including issues within the family unit and with the intimate partner (Sippel, Pietrzak, Charney, Mayes, & Southwick, 2015). If the well-being of the intimate partner and relationship is addressed, the humanitarian is more likely to receive social support from this source, which can prevent or alleviate distress.

  Humanitarian work and mental health risk Top

To grasp the critical role of intimate partner social support, and the detrimental impact of its unavailability, it is important to understand the humanitarian context and existing data on humanitarian well-being. An expanding body of research demonstrates how the humanitarian context can lead to negative mental health outcomes including depression, anxiety, post-traumatic stress disorder (PTSD), decreased life satisfaction, substance abuse, and burnout (Cardozo & Salama, 2002; Cardozo et al., 2005; Cardozo et al., 2012; Connorton, Perry, Hemenway, & Miller, 2011; Curling & Simmons, 2010; Ditzler, Hoeh, & Hastings, 2015; Eriksson et al., 2001).

Acute and chronic stressors characterise the humanitarian workplace and expose staff to many mental health risk factors. Humanitarians arrive to a context of extreme environmental stressors in their deployment destination. Ditzler et al. (2015) describe this context as one of ‘civil strife, limited or depleted natural resources, endemic disease, meagre or absent health care, unsafe transportation, inadequate public health assets including water and sanitation, and other critical infrastructure’ (p. 20). Authors found that ‘persistent exposure to the suffering and deprivation of others’ was the main source of stress for humanitarians, which can lead to secondary or ‘vicarious’ traumatisation (Ditzler et al., 2015, p. 23).

Targeted violence is one way in which humanitarians are at high risk of direct trauma exposure (Connorton et al., 2011; Eriksson et al., 2001). The line between humanitarian and military intervention has blurred in recent decades. The humanitarian ‘workplace’, wrote McCormack and Joseph (2013), ‘is increasingly characterised by the complexities of global politics, military goals, terrorist threats, and overwhelming international human crises’ (p.148). Partially as a result of overlapping military and humanitarian agendas, targeted violence against humanitarians has increased (Antares Foundation, 2012; Barnett, 2005; Blanchetiere, 2006; Sheik, 2000; Wilson & Lindy, 1994). In 2012, there were 167 incidents of major violence against humanitarians resulting in the death, kidnapping, or serious wounding of 274 individuals (USAID, 2013). In 2014, 329 humanitarians were victims of ‘major attacks’ (USAID, 2014). Humanitarians also report relatively frequent exposure to ‘gunfire nearby, being chased by a group or individual, being caught in a riot, having one’s home broken into, life-threatening illness and a lack of access to medical care, and the unexpected or premature death of a colleague’ (Antares Foundation, 2012, p.10).

Environmental and organisational factors can also lead to chronic stress (Cardozo & Salama, 2002; Connorton et al., 2011; Ditzler et al., 2015). Curling and Simmons (2010) found that 74% of humanitarians surveyed reported that they were ‘moderately’ to ‘extremely’ stressed at their job. The authors compared this to 45% among the general population in the United Kingdom. Chronic stressors include, but are not limited to: restricted movement due to security concerns, housing problems, conflicts with team members, lack of direction from management, excessive workload, physically demanding work, different languages and working through translators, unusual foods, lack of privacy, different social customs (especially concerning gender roles), harsh climate, lack of accustomed comforts, and separation from family and friends (Antares Foundation, 2012; Ditzler et al., 2015).

Many humanitarians experience the challenge of separation from family and intimate partners. Deployments vary in length, as do the conditions on site. There are short-term international assignments. There are also international duty stations where family members can live and, from this location, the humanitarian may deploy to an insecure setting for short or medium-length periods of time. While safer than the deployment destination, the location where family members reside may also be challenging. Finally, there are long-term deployments to non-family duty stations, which can last multiple years. In the latter situation, a humanitarian will only see family and friends during leave/vacation and ’rest and recuperation’.

Welton-Mitchell’s findings (2013) highlight the impact of the humanitarian’s personal relationships on his or her well-being. The second largest source of stress (following ‘implementation problems’) among UNHCR staff surveyed included ‘disruptions to home life including rotation requirement’ and ‘family concerns’ (p. 31). Family concerns were reported by 29% of the participants and ‘personal/family related issues’ were the third highest reason for seeking counselling among UNHCR staff in 2011 (p. 32). Forty-nine percent of participants reported that their job interfered with their ability to ‘maintain relationships with [their] family, friends, or colleagues’ (p. 56).

Intimate partners of humanitarians experience challenges inherent to their relationship and context that can contribute to negative mental health outcomes. Separation can contribute to anxiety and depression, particularly when the humanitarian operates in a dangerous setting with minimal access to means of communication. McFarlane, one of the few authors, who touches on the experience of humanitarian family members, describes how the humanitarian may not be able to attend to family members’ concerns, creating worry and difficulty in the relationship (2004). Humanitarian intimate partners may have similar experiences to military spouses who struggle not only with personal worries and relationship challenges, but also the challenges of single parenting (Verdeli et al., 2011).

The challenge of being the partner at home can lead to intimate partner distress and relationship discord. While there is no data on the mental health of intimate partners, there is a growing body of research on humanitarian mental health.

  Humanitarian mental health data Top

Cardozo et al. (2012) completed the first longitudinal study on expatriate humanitarian mental health, which showed high rates of anxiety, depression, low satisfaction with life, and burnout (subcategories: emotional exhaustion and depersonalisation). The authors collected data at pre-deployment (n = 212), immediately post-deployment (n = 169), and follow-up between 3 and 6 months post-deployment (n = 154). Immediately post-deployment, 12% of humanitarians reported clinically significant anxiety symptoms. Level of anxiety symptoms fell at follow-up, but not to pre-deployment levels. Burnout depersonalisation also increased immediately post-deployment and diminished at follow-up. High levels of depression and emotional exhaustion immediately post-deployment were maintained 3–6 months post-deployment. Twenty percent of participants were still depressed 3–6 months post-deployment. Life satisfaction was also significantly lower at follow-up than it had been at pre- and immediately post-deployment (Cardozo et al., 2012).

The aforementioned longitudinal study corroborates earlier and more recent findings that reveal high rates of burnout, substance abuse, PTSD, and depression. Eriksson et al. (2009) found that 40% of participants (n = 111) scored in a range of high risk for burnout. A pilot study of UNHCR staff (2001) showed that 29% of participants were emotionally exhausted (Welton-Mitchell, 2013).

Given the risk for trauma exposure, PTSD is a relevant mental health disorder among the humanitarian community. In one study, 10% of returned expatriate humanitarians (n = 113) met full diagnostic criteria for PTSD and 19% reported symptoms that could be considered partial PTSD (Eriksson et al., 2001, p. 209). Research findings on expatriate humanitarians assisting after natural disasters have also shown high rates of PTSD. Though the sample size (n = 33) was small, Armagan, Engindeniz, Devay, Erdur, and Ozcakir (2006) found that 24.2% of expatriate humanitarians who responded after the 2004 Asia tsunami met diagnostic criteria for PTSD and 63.6% had at least one PTSD symptom. Chan and Huak (2004) looked at the mental health of expatriate staff (n = 22) responding to the 2004 tsunami 1 week after their return to Singapore. The authors found that 40% of participants were experiencing symptoms of acute stress, which is predictive of PTSD 7–13 months later (Chan and Huak, 2004). 9.1% met criteria for PTSD (Chan and Huak, 2004).

Sometimes co-morbid with PTSD, depression is also prevalent among humanitarians. In Welton-Mitchell (2013) study 60% of UNHCR staff reported feelings of sadness, unhappiness, or ’emptiness’, and 6% reported frequent suicidal ideation (p. 56). In a study of former humanitarians, 15% had clinically significant levels of depression and 15% struggled with alcohol abuse (Cardozo & Salama, 2002). Cardozo et al. (2005) found that 1.1% of expatriate and 6.2% of national staff working in Kosovo met diagnostic criteria for PTSD, but that 17.2 and 16.9% respectively could be diagnosed as depressed. Regarding Cardozo et al.’s study (2005), Musa and Hamid (2008) comment that the authors used significantly higher cut-off scores (eight and nine) on the General Health Questionnaire than the usual cut-off score of four. This suggests that the rates of diagnosis in the expatriate and national samples would have been even higher if they had used the standard cut-off score. Using the cut-off score of four, Musa and Hamid (2008) found that, among a sample of 54 expatriate and national staff, 50% ‘could be classified as nonpsychotic psychiatric cases’ (p. 413). Rates of distress were higher among national staff than expatriates, though distress was significant in both groups.

Cardozo et al. (2005) highlight some of the differences between expatriate and national humanitarians with regard to mental health outcomes. Because national humanitarians are more likely to identify with victims or have direct experience of the related events, their risk for developing PTSD or other stress symptoms is higher than their expatriate counterparts (Ehring et al., 2011; McFarlane, 2004; Musa & Hamid, 2008; Ursano et al., 1999). Interestingly, national staff in this study had lower levels of non-specific psychiatric morbidity than expatriates, which, the authors comment, could be explained by their access to social support (Cardozo & Salama, 2002; Cardozo et al., 2005). This hypothesis highlights the important role of social support in humanitarian well-being.

  Social support as a protective factor Top

Research on humanitarian mental health offers evidence that the presence of social support protects against negative mental health outcomes and the absence of social support is a risk factor. It will be critical to consider this in the design of efficacious interventions. Unlike risk factors that cannot be addressed, such as a history of mental illness or direct trauma exposure (Cardozo et al., 2005; Cardozo et al., 2012; Eriksson et al., 2013), bolstering or facilitating access to social support is a direct method of protecting humanitarians from negative mental health outcomes.

Lack of social support has a detrimental impact on the humanitarian. Studies show that lack of social support due to separation from family, contributes to depression among humanitarians (Cardozo et al., 2005; Cardozo et al., 2012). Cardozo et al. (2005) found a highly significant relationship between non-specific psychiatric morbidity and the inability to communicate with family members. In a phenomenological study, participants reported they felt their host organisation could have better facilitated communication with family at home (Hearns & Deeny, 2007). In addition, ‘a combination of social, cultural and geographical isolation can evoke feelings of abandonment, despair and fear’ (McFarlane, 2004).

Low social support upon return home also increases the risk for negative mental health outcomes among humanitarians. McFarlane (2004) highlights how the humanitarian’s friends and family may not understand his or her experience. McCormack and Joseph (2013) wrote that, ‘when family and friends show little willingness to listen, or when stories are so horrific the returnee believes no one will understand, a sense of rejection, invalidation and isolation on return is likely’ (p. 149). Reintegration challenges can lead a humanitarian who is already struggling to redeploy prematurely to avoid difficulty at home. This can become a pattern that contributes to the potential for long-term negative mental health outcomes (McCormack & Joseph, 2013).

The presence of social support stands out as a critical protective factor for humanitarians, serving as a buffer between trauma exposure and trauma reactions (Eriksson et al., 2001; Kaspersen, Matthiesen, & Gotestam, 2003). One study (n = 214) showed that perceived social support was a buffer for both PTSD and depression among expatriate humanitarians (Eriksson et al., 2013). De Paul and Bikos (2015) demonstrated that a humanitarian’s perception of social support from the host organisation was associated with psychological well-being and intention to complete their international assignment. Humanitarians with strong social support networks have been found to have higher levels of life satisfaction throughout their deployment (Cardozo et al., 2012; Eriksson et al., 2001). It was found that social (supportive relationships) and organisational (policies and procedures) support were both protective against burnout emotional exhaustion and perceived social support from social relationships increased the humanitarian’s sense of personal accomplishment (Eriksson et al., 2009). McCormack, Joseph, and Hagger (2009) suggest that humanitarian organisations that include ‘family members and/or intimate others’ in reintegration programming may have ‘better outcomes in the field and staff retention as a consequence’ (p. 110).

The intimate partner and quality of the intimate relationship have repercussions for the humanitarian. In one study, humanitarians who were married had higher levels of life satisfaction, but were also at higher risk for psychological distress (Cardozo et al., 2012). This suggests that the intimate partner can be an important form of support and satisfaction, but that being married ‘comes with certain responsibilities which could cause worries and stress during deployment’ (Cardozo et al., 2012, p. 11). Deployment related stress can impact both members of the relationship, and affect the ability of each of them to give and receive social support. The demonstrated negative impact of separation from (and benefit of connection with) family and/or intimate partners suggests they play a critical role in humanitarian well-being.

  Including the intimate partner in interventions Top

To support the humanitarian, treatment must also address the intimate partner and relationship. For many people the relationship they have with their intimate partner will be the most important interpersonal relationship they develop in their lifetime (Whisman & Baucom, 2012). Thus, it is a relationship from which the most social support can be provided and received. Distressed intimate partners and relationships can decrease the availability of social support within the relationship, which may eliminate a critical protective factor for the humanitarian. Thus, addressing the mental health of the humanitarian may necessitate interventions that focus on the intimate partner and relationship. Systems theory suggests an interrelated relationship between the health of an individual and those who make up their social system. Improved relationship functioning is the foundation for improved individual functioning (Fraenkel, 1997).

Due to the fact that research on humanitarian intimate partners is sparse, this section draws from general literature on intimate partner psychology to illustrate how the mental health of the intimate partner and the quality of the intimate relationship may affect the humanitarian. Research on non-humanitarian populations demonstrates that social support from one’s intimate partner has a significant impact on well-being, including at the neurological level. Coan Schaefer, and Davidson (2006) demonstrated that ‘women’s neural responses to threat of electric shock were more greatly attenuated when they held the hand of their husbands relative to the hand of an anonymous male experimenter’ (p. 1032). In other studies, social support from an intimate partner enhanced the ability to cope with social and economic stressors (Conger & Conger, 2002; Van Doesum, Hosman, & Riksen-Walraven, 2005). While social support from others, including family and friends, is important, the quality of the relationship with one’s spouse has the greatest impact on mental health (Whisman, Sheldon, & Goering, 2000).

If the humanitarian or intimate partner develops a mental health disorder, then this can lead to relationship distress and/or psychopathology in the other partner. Research on non-humanitarian populations reveals that individual psychopathology often leads to intimate partner and relationship distress. For example, studies show that the presence of PTSD in one partner leads to psychological distress in the other (see Calhoun, Beckham, & Bosworth, 2002; Dekel and Solomon, 2005; Dirkzwager, Bramsen, Adèr, & van der Ploeg, 2005; Jordan et al., 1992; Lambert, Engh, Hasbun, & Holzer, 2012 for meta-analysis; Manguno-Mire et al., 2007; Waysman, Mikulincer, Solomon, & Weisenberg, 1993; Westerink & Giarratano, 1999) as well as relationship discord and intimate partner aggression (Galovski & Lyons, 2004; Monson, Fredman, & Dekel, 2010).

The origin of distress may be within the relationship itself, which increases the likelihood that either partner will develop negative mental health outcomes. Studies of non-humanitarian populations reveal the significant correlation between relationship discord and individual psychopathology. Whisman and Uebelacker (2006) found that relationship discord is associated with ‘greater social role impairment in relationships with relatives and friends, greater work role impairment, greater general distress, poorer perceived health, and greater likelihood of suicidal ideation’ (p. 373).

Research on non-humanitarian populations shows a correlation between relationship distress and mental health disorders. For example, relationship distress can lead to anxiety (Overbeek et al., 2006), PTSD (Taft, Watkins, Stafford, Street, & Monson, 2011; Tarrier and Sommerfield, 1999), substance abuse (Fals-Stewart, Birchler, & O’Farrell, 1996; Whisman et al., 2006; Whisman, 2007; Whisman & Baucom, 2012), binge eating disorder (Whisman, Johnson, Be, & Li, 2012), agoraphobia (Dewey & Hunsley, 1990), and personality disorders (Daley, Burge, & Hammen, 2000).

One of the most well researched correlations is between relationship discord and depression (Whisman & Uebelacker, 2009). For example, population-based studies in the United States and the Netherlands show that relational distress increases the risk for developing depression (Overbeek et al., 2006; Whisman & Bruce, 1999). Relationship satisfaction and depressive symptoms are shown to change concurrently (Davila, Karney, Hall, & Bradbury, 2003; Kouros, Papp, & Cummings, 2008; Vento & Cobb, 2001; Whitton, Stanley, Markman, & Baucom, 2008), which highlights the importance of interventions that treat the system and not just the individual.

Not only can individuals develop mental health disorders as a result of relationship distress, but also they are less likely to respond to individual treatment if they continue to experience relationship discord (Whisman & Baucom, 2012). A growing body of research suggests that couples therapy or including the intimate partner in individually targeted treatment may be the most effective intervention, because it addresses the needs of both individuals and the relationship.

Recent research reveals that improvement within a relationship, which increases social support within the dyad, may precede improved individual functioning, particularly for men. Knobloch-Fedders, Pinsof, and Haase (2015) studied 125 heterosexual couples over the first eight sessions of conjoint couples therapy. Results showed that relationship adjustment and individual functioning were significantly correlated for both genders across time with rapid improvement over the first four sessions. For men, conjoint treatment with improved relationship functioning was a precursor for improved individual psychopathology. These findings supported studies by Christensen et al. demonstrating that individual functioning improved only as a relationship distress improved (Christensen et al., 2004 as cited in Knobloch-Fedders et al., 2015).

Research on cognitive behavioural couples therapy (CBCT) for PTSD supports the inclusion of the intimate partner in treatment for the identified patient. When one receives individual treatment for PTSD, relationship functioning does not improve concurrently (Monson, Macdonald, Schnurr, Resick, & Friedman, 2006). However, when PTSD treatment includes the intimate partner, PTSD symptoms decrease and relationship satisfaction increases (Monson et al., 2012). Further, it was demonstrated that intimate partners with clinical levels of distress prior to CBCT show ‘reliable and clinically significant improvements’ post-treatment (Shnaider, Pukay-Martin, Fredman, Macdonald, & Monson, 2014, p. 129). This research is promising for other disorders such as depression, which also show minimal improvement in individual treatment when the person remains in a distressed relationship (Whisman, 2001).

From both individualistic and systemic perspectives addressing the well-being of the intimate partner and the relationship may improve humanitarian mental health outcomes. From the individualistic point of view, addressing the mental health needs and concerns of the intimate partner may improve the quality of the relationship and presence of social support. From a systemic perspective, the quality of the intimate relationship directly impacts each individual’s psychopathology.

  Lessons learned from the U.S. military Top

The military has acknowledged the interdependence of family, specifically that of the intimate partner, and service members’ well-being (Sippel et al., 2015). In response, the military has conducted research and launched programmes to support the intimate partner and family members. While the overall efficacy of these programmes is not strong (Clark, Jordan, & Clark, 2013), the military’s initiatives are an improvement compared to humanitarian organisations. This section briefly highlights the military’s recognition of and research on the intimate partner, and programmes designed to address their needs.

In 1983 General Wickman stated that, ’taking care of our families enhances both retention and readiness’ (Clark et al., 2013, p. 112). When the intimate partner is unwell it can have a negative long-term effect on his or her mental health, ‘the well-being of the children, and the service member’s system of support during deployment and reintegration into the family unit and civilian life following the return home’ (Verdeli et al., 2011, p. 488). The repercussions of intimate partner well-being are large, as the negatively affected elements underlie the efficacy of individual service members and that of the broader military. A growing body of research has improved understanding of the effects of distress among these individuals.

Research on the mental health of military intimate partners shows high levels of distress, in some cases on par with that of their active duty partners. Deployment stress can either trigger or exacerbate mental health problems for the intimate partner (Mansfield et al., 2010). A cross-sectional study (n = 163) found significantly elevated levels of depression and anxiety among active army and marine spouses (Lester et al., 2010). A study of 940 Operation Iraqi Freedom and Operation Enduring Freedom spouses (51% participation) found that 17.4 and 12.1% met diagnostic criteria for generalised anxiety and major depressive episodes, respectively (Eaton et al., 2008). These rates were comparable with those of combat soldiers (Hoge et al., 2004) and double that of the general population (Kessler et al., 2003).

The military has created programmes designed to address the needs of intimate partners and family members. For example, the Army’s Family Readiness Group (FRG) provides information and support to families, particularly in preparation for deployment and separation, and helps them to solve problems and use resources efficiently (Clark et al., 2013). This service is now also available virtually in an effort to reach more family members. Capitalising on the ways in which technology can increase access, the army created the Comprehensive Soldier and Family Fitness programme, which provides online resiliency training for soldiers and their families. Increasing organisational connection and support, the Army Family Action Plan was designed to increase family engagement with and connection to the highest levels of army leadership. The Military OneSource programme consolidated access to family services across branches of the military and created a 24-h access programming (Clark et al., 2013).The military conducted a longitudinal study on military spouses (the Military Family Life Project) to understand the need for and utilisation of family and spouse specific services. Results showed that there was a high need for the services and significant underutilisation of them (Clark et al., 2013). Clark et al. (2013) argued that services are underutilised due to the ‘coercive nature of the military for service members’ (p. 115). The study showed that there is ample room for improvement in ensuring that services are accessed. However, the research and programme development is a positive step demonstrating the organisations recognition of the importance of caring for military spouses to support service members.

  Recommendations Top

Humanitarian organisations should recognise the role of intimate partner social support in the promotion of humanitarian resilience and retention rates. The following recommendations may assist organisations in providing better care for staff.

  Research Top

To implement efficacious programming that includes the intimate partner research should be conducted to better understand the needs and concerns of this population. Humanitarian organisations should review the existing body of research on humanitarian well-being as well as support and participate in future efforts to expand knowledge on this topic.
  1. Conduct research on the well-being of humanitarian intimate partners. The Military Family Life Project (Military OneSource, 2010) may be a useful research model for humanitarian organisations to consider. Organisations may wish to hire outside researchers. Graduates of the International Disaster Psychology programme at the University of Denver may be a useful resource. Contacting the authors of the studies referenced in this paper (e.g. Welton-Mitchell, 2013) is another possible avenue for finding appropriate research support. SalusWorld.org is an organisation that may also be able to assist in research projects on this topic.
  2. Consider hiring organisational psychology consultants to assess the needs and concerns of humanitarians and intimate partners to receive specific guidance on programmes and interventions that will increase staff well-being and retention. Consultants should have a background in organisational psychology, mental health research, and, ideally have knowledge of the humanitarian field. Google searches for ‘organisational psychology consultants’ reveals multiple resources to begin this process.

  Intervention Top

As humanitarian organisations begin to introduce mental health interventions, treatments that include the intimate partner will have a greater impact on humanitarian outcomes than interventions that only treat the individual.
  1. Facilitate frequent and quality access to communication enabling humanitarian partners and intimate partners to be in contact more regularly, which may allow them to address problems, alleviate concerns, and understand that their loved one is safe.
  2. Consider CBCT for PTSD as a treatment model (Monson & Fredman, 2012) as an evidence-based treatment utilising the intimate partner and relationship for addressing individual psychopathology.
  3. Provide a minimum of eight sessions of couples therapy. This is in line with research demonstrating that improvement in both relationship as well as individual functioning occurs within the first four sessions and stabilises in the fifth–eighth sessions (Knobloch-Fedders et al., 2015).
  4. Ensure that employee benefits include both couples therapy as well as individual therapy for both the humanitarian and the intimate partner.
  5. Provide pre-departure and reintegration programmes to prepare couples and families for the realities of humanitarian deployments and to support the reintegration process upon return.

  Conclusions Top

It is understood that humanitarians experience high levels of negative mental health outcomes and that social support is protective. Focusing on the systemic and interrelated nature of individual health with intimate partner and relationship health it becomes clear that interventions designed to support each level of this system will have the most effective and sustainable outcome. The humanitarian exposed to difficult and possibly traumatic stimuli could become more resilient with increased access to social support from their intimate partner. In addition to the value of increasing the wellness of individuals, a happier and healthier humanitarian workforce will contribute to staff retention, lower costs, increased organisational efficacy, and ultimately greater mission success.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Antares Foundation. (2012). Managing stress in humanitarian workers. Guidelines for good practice (4th ed.). Netherlands: Author. Retrieved from https://www.antaresfoundation.org/guidelines  Back to cited text no. 1
Armagan E., Engindeniz Z., Devay A., Erdur B., Ozcakir A. (2006). Frequency of post-traumatic stress disorder among relief force workers after the tsunami in Asia: Do rescuers become victims? Prehospital And Disaster Medicine, 21 (3), 168-172.  Back to cited text no. 2
Barnett M. (2005). Humanitarianism transformed. Perspectives on Politics, 3 (4), 723-40.  Back to cited text no. 3
Boushey H., Glynn S. J. (2012, November 16). There are significant business costs to replacing employees. Retrieved from https://www.americanprogress.org/issues/labor/report/2012/11/16/44464/there-are-significant-business-costs-to-replacing-employees/  Back to cited text no. 4
Calhoun P., Beckham J., Bosworth H. (2002). Caregiver burden and psychological distress in partners of veterans with chronic posttraumatic stress disorder. Journal of Traumatic Stress, 15 (3), 205-212.  Back to cited text no. 5
Cardozo B. L., Salama P. (2002). Mental health of humanitarian aid workers in complex emergencies. In Danieli Y. (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. Amityville, NY: Baywood Publishing. 242-255.  Back to cited text no. 6
Cardozo B. L., Crawford C. G., Eriksson C., Zhu J., Sabin M., Ager A., Simon W. (2012). Psychological distress, depression, anxiety, and burnout among international humanitarian aid workers: A longitudinal study. PLoS One, 7(9), e44948.  Back to cited text no. 7
Cardozo B., Holtz T., Kaiser R., Gotway C., Ghitis F., Toomey E., Salama P. (2005). The mental health of expatriate and Kosovar Albanian humanitarian aid workers. Disasters, 29 (2), 152-170.  Back to cited text no. 8
Chan A., Huak C. (2004). Emotional impact of 2004 Asian tsunami on Singapore medical relief workers. International Journal of Disaster Medicine, 2 (4), 152-156.  Back to cited text no. 9
Clark M., Jordan J., Clark K. (2013). Motivating military families to thrive. Family and Consumer Sciences Research Journal, 42 (2), 110-123.  Back to cited text no. 10
Coan J., Schaefer H., Davidson R. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological Science, 17 (12), 1032-1039.  Back to cited text no. 11
Cohen S. (2004). Social relationships and health. American Psychologist, 59, 676-684.  Back to cited text no. 12
Conger R. D., Conger K. J. (2002). Resilience in Midwestern families: Selected findings from the first decade of a prospective, longitudinal study. Journal of Marriage and Family, 64, 361-373.  Back to cited text no. 13
Connorton E., Perry M., Hemenway D., Miller M. (2011). Humanitarian relief workers and trauma-related mental illness. Epidemiologic Reviews, 34 (1), 145-155.  Back to cited text no. 14
Curling P., Simmons K. (2010). Stress and staff support strategies for international aid work. Intervention, 8 (2), 93-105.  Back to cited text no. 15
Daley S. E., Burge D., Hammen C. (2000). Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: Addressing issues of specificity. Journal of Abnormal Psychology, 109, 451-460.  Back to cited text no. 16
Davila J., Karney B. R., Hall T. W., Bradbury T. N. (2003). Depressive symptoms and marital satisfaction: Within-subject associations and the moderating effects of gender and neuroticism. Journal of Family Psychology, 17, 557-570.  Back to cited text no. 17
Dekel R., Solomon Z., Bleich A. (2005). Emotional distress and marital adjustment of caregivers: Contribution of level of impairment and appraised burden. Anxiety, Stress, and Coping, 18, 71-82.  Back to cited text no. 18
De Paul N. F., Bikos L. H. (2015). Perceived organizational support: A meaningful contributor to expatriate development professionals’ psychological well-being. International Journal of Intercultural Relations, 49, 25-32.  Back to cited text no. 19
Dewey D., Hunsley J. (1990). The effects of marital adjustment and spouse involvement on the behavioral treatment of agoraphobia: A meta-analytic review. Anxiety Research, 2, 69-83.  Back to cited text no. 20
Dirkzwager A. J. E., Bramsen I., Adèr H., van der Ploeg H. M. (2005). Secondary traumatization in partners and parents of Dutch peacekeeping soldiers. Journal of Family Psychology, 19, 217-226.  Back to cited text no. 21
Ditzler T. F., Hoeh A. D., Hastings P. R. (2015). Human security workers deployed in austere environments: A brief guide to self-care, sustainment, and productivity. Journal of Human Security, 11 (1), 19-25.  Back to cited text no. 22
Eaton K. M., Hoge C. W., Messer S. C., Whitt A. A., Cabrera O. A., McGurk D., Castro C. A. (2008). Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Military Medicine, 173, 1051-1056.  Back to cited text no. 23
Ehring T., Razik S., Emmelkamp P. M. (2011). Prevalence and predictors of posttraumatic stress disorder, anxiety, depression, and burnout in Pakistani earthquake recovery workers. Psychiatry Research, 185 (1-2), 161-166.  Back to cited text no. 24
Eriksson C. B., Kemp H. V., Gorsuch 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.  Back to cited text no. 25
Eriksson C. B., Bjorck J. P., Larson L. C., Walling S. M., Trice G. A., Fawcett J., Foy D. W. (2009). Social support, organisational support, and religious support in relation to burnout in expatriate humanitarian aid workers. Mental Health, Religion & Culture, 12 (7), 671-686.  Back to cited text no. 26
Eriksson C. B., Cardozo B. L., Foy D. W., Sabin M., Ager A., Snider L., Simon W. (2013). Predeployment mental health and trauma exposure of expatriate humanitarian aid workers: Risk and resilience factors. Traumatology, 19 (1), 41-48.  Back to cited text no. 27
Fals-Stewart W., Birchler G. R., O’Farrell T. J. (1996). Behavioral couples therapy for male substance-abusing patients: Effects on relationship adjustment and drug-using behavior. Journal of Consulting and Clinical Psychology, 64, 959-972.  Back to cited text no. 28
Fawcett J. (2001). Cost analysis: Continuity, quality, efficiency. Paper presented at the first working conference on Managing Stress in the Humanitarian Aid Worker: Towards an Integrated Approach, Amsterdam, The Netherlands.  Back to cited text no. 29
Fraenkel P. (1997). Systems approaches to couple therapy. In Halford W., Markman H. (Eds.), Clinical handbook of marital and couples interventions. New York, NY: John Wiley & Sons. 379-413.  Back to cited text no. 30
Galovski T. E., Lyons J. (2004). The psychological sequelae of exposure to combat violence: A review of the impact on the veteran’s family. Aggression and Violent Behavior: A Review Journal, 9, 477–501.  Back to cited text no. 31
Hearns A., Deeny P. (2007). The value of support for aid workers in complex emergencies: A phenomenological study. Disaster Manage Response, 5 (2), 28-35.  Back to cited text no. 32
Hoge C. W., Castro C. A., Messer S. C., McGurk D., Cotting D. I., Koffman R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351, 13-22.  Back to cited text no. 33
Johnson D. R., Lubin H., Rosenheck R., Fontana A., Sonthwick S., Charney D. (1997). The impact of the homecoming reception on the development of posttraumatic stress disorder: The West Haven Homecoming Stress Scale (WHHSS). Journal of Traumatic Stress, 10 (2), 259-277.  Back to cited text no. 34
Jordan B. K., Marmar C. R., Fairbank J. A., Schlenger W. E., Kulka R. A., Hough R. L., Weiss D. S. (1992). Problems in families of male Vietnam veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 60, 916-926.  Back to cited text no. 35
Kaspersen M., Matthiesen S. B., Gotestam K. G. (2003). Social network as a moderator in the relation between trauma exposure and trauma reaction: A survey among UN soldiers and relief workers. Scandinavian Journal of Psychology, 44 (5), 415-423.  Back to cited text no. 36
Kessler R. C., Berglund P., Demler O., Jin R., Koretz D., Merikangas K. R., Wang P. S. (2003). The epidemiology of major depressive disorder: Results from the national Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association, 289, 3095-3105.  Back to cited text no. 37
Knobloch-Fedders L. M., Pinsof W. M., Haase C. M. (2015). Treatment response in couple therapy: Relationship adjustment and individual functioning change processes. Journal of Family Psychology, 29 (5), 657-666.  Back to cited text no. 38
Kouros C. D., Papp L. M., Cummings E. M. (2008). Interrelations and moderators of longitudinal links between marital satisfaction and depressive symptoms among couples in established relationships. Journal of Family Psychology, 22, 667-677.  Back to cited text no. 39
Lambert J. E., Engh R., Hasbun A., Holzer J. (2012). Impact of posttraumatic stress disorder on the relationship quality and psychological distress of intimate partners: A meta-analytic review. Journal of Family Psychology, 26, 729-737.  Back to cited text no. 40
Lester P., Peterson K., Reeves J., Knauss L., Glover D., Mogil C., Beardslee W. (2010). The long war and parental combat deployment: Effects on military children and at-home spouses. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 310-320.  Back to cited text no. 41
Manguno-Mire G., Sautter F., Lyons J., Myers L., Perry D., Sherman M., Sullivan G. (2007). Psychological distress and burden among female partners of combat veterans with PTSD. Journal of Nervous and Mental Disease, 195, 144-151.  Back to cited text no. 42
Mansfield A. J., Kaufman J. S., Marshall S. W., Gaynes B. N., Morrissey J. P., Engel C. C. (2010). Deployment and the use of mental health services among U.S. Army wives. The New England Journal of Medicine, 362, 101-109.  Back to cited text no. 43
McCormack L., Joseph S. (2013). Psychological growth in humanitarian aid personnel: Reintegrating with family and community following exposure to war and genocide. Community, Work & Family, 16 (2), 147-163.  Back to cited text no. 44
McCormack L., Joseph S., Hagger M. S. (2009). Sustaining a positive altruistic identity in humanitarian aid work: A qualitative case study. Traumatology, 15 (2), 109-118.  Back to cited text no. 45
McFarlane C. A. (2004). Risk associated with the psychological adjustment of humanitarian aid workers. Austalasian Journal of Disaster and Trauma Studies, 2004(1), XX-XX.  Back to cited text no. 46
Military OneSource. (2010). The military family life project. Retrieved at http://www.militaryonesource.mil/MilFamStudy  Back to cited text no. 47
Monson C. M., Fredman S. J. (2012). Cognitive-behavioral conjoint therapy for PTSD: Harnessing the healing power of relationships. New York, NY: Guilford.  Back to cited text no. 48
Monson C. M., Fredman S. J., Dekel R. (2010). Posttraumatic stress disorder in an interpersonal context. In Beck J. G. (Ed.), Interpersonal processes in the anxiety disorders. Washington, DC: American Psychological Association.  Back to cited text no. 49
Monson C. M., Macdonald A., Schnurr P. P., Resick P. A., Friedman M. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898-907.  Back to cited text no. 50
Monson C. M., Fredman S. J., Macdonald A., Pukay-Martin N. D., Resick P. A., Schnurr P. P. (2012). Effect of cognitive-behavioral couple therapy for PTSD: A randomized controlled trial. Journal of the American Medical Association, 308 (7), 700-709.  Back to cited text no. 51
Musa S. A., Hamid A. A. (2008). Psychological problems among aid workers operating in Darfur. Social Behavior and Personality: An International Journal, 36 (3), 407-416.  Back to cited text no. 52
Overbeek G., Vollebergh W., de Graaf R., Scholte R., de Kemp R., Engels R. (2006). Longitudinal associations of marital quality and marital dissolution with the incidence of DSM-III-R disorders. Journal of Family Psychology, 20, 284-291.  Back to cited text no. 53
Sheik M. (2000). Deaths among humanitarian workers. British Medical Journal, 321 (7254), 166-168.  Back to cited text no. 54
Shnaider P., Pukay-Martin N. D., Fredman S. J., Macdonald A., Monson C. M. (2014). Effects of cognitive-behavioral conjoint therapy for PTSD on partners’ psychological functioning. Journal of Traumatic Stress, 27 (2), 129-136.  Back to cited text no. 55
Sippel L. M., Pietrzak R. H., Charney D., Mayes L., Southwick S. (2015). How does social support enhance resilience in the trauma-exposed individual? Ecology and Society, 20 (4), 10.  Back to cited text no. 56
Taft C. T., Watkins L. E., Stafford J., Street A. E., Monson C. M. (2011). Posttraumatic stress disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79, 22-33.  Back to cited text no. 57
Tarrier N., Sommerfield C., Pilgrim H. (1999). Relatives’ expressed emotion (EE) and PTSD treatment outcome. Psychological Medicine, 29 (4), 801-811.  Back to cited text no. 58
Ursano R. J., Fullerton C. S., Vance K., Kao T. C. (1999). Post-traumatic stress disorder and identification in disaster s. American Journal of Psychiatry, 156, 353-359.  Back to cited text no. 59
USAID Aid Security Database. (2013). The new normal: Coping with the kidnapping threat. Retrieved from https://aidsecurity.org/sites/default/files/AidSecurityReport_2013_web.pdf  Back to cited text no. 60
USAID Aid Security Database. (2014). Unsafe passage: Road attacks and their impact on humanitarian operations. Retrieved from https://aidsecurity.org/sites/default/files/Aid%20%20Security%20Report%202014.pdf  Back to cited text no. 61
Van Doesum K. T. M., Hosman C. M. H., Riksen-Walraven J. M. (2005). A model-based intervention for depressed mothers and their infants. Infant Mental Health Journal, 26, 157-176.  Back to cited text no. 62
Vento P. W., Cobb R. J. (2011). Chronic stress as a moderator of the association between depressive symptoms and marital satisfaction. Journal of Social and Clinical Psychology, 30 (9), 905-936.  Back to cited text no. 63
Verdeli H., Baily C., Vousoura E., Belser A., Singla D., Manos G. (2011). The case for treating depression in military spouses. Journal of Family Psychology, 25 (4), 488-496.  Back to cited text no. 64
Waysman M., Mikulincer M., Solomon Z., Weisenberg M. (1993). Secondary traumatization among wives of posttraumatic combat veterans: A family typology. Journal of Family Psychology, 7, 104-118.  Back to cited text no. 65
Welton-Mitchell C. (2013). Mental health and psychosocial services for UNHCR staff: A global review. A paper presented at Policy Development and Evaluation Service, UNHCR HQ, Geneva.  Back to cited text no. 66
Westerink J., Giarratano L. (1999). The impact of posttraumatic stress disorder on partners and children of Australian Vietnam veterans. Australian and New Zealand Journal of Psychiatry, 33, 841-847.  Back to cited text no. 67
Whisman M. A. (2001). The association between depression and marital dissatisfaction. In Beach S. R. (Ed.), Marital and family processes in depression: A scientific foundation for clinical practice. Washington, DC: American Psychological Association. 3-24  Back to cited text no. 68
Whisman M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal Psychology, 116, 638-643.  Back to cited text no. 69
Whisman M. A., Baucom D. H. (2012). Intimate relationships and psychopathology. Clinical Child and Family Psychology Review, 15, 4-13.  Back to cited text no. 70
Whisman M. A., Uebelacker L. A. (2006). Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults. Journal of Family Psychology, 20, 369-377.  Back to cited text no. 71
Whisman M. A., Uebelacker L. A. (2009). Prospective associations between marital discord and depressive symptoms in middle-aged and older adults. Psychology and Aging, 24, 184-189.  Back to cited text no. 72
Whisman M. A., Sheldo C. T., Goering P. (2000). Psychiatric disorders and dissatisfaction with social relationships: Does type of relationship matter? Journal of Abnormal Psychology, 109, 803-808.  Back to cited text no. 73
Whisman M. A., Uebelacker L. A., Bruce M. L. (2006). Longitudinal association between marital dissatisfaction and alcohol use disorders in a community sample. Journal of Family Psychology, 20 (1), 164-167.  Back to cited text no. 74
Whisman M. A., Johnson D. P., Be D., Li A. (2012). Couple-based interventions for depression. Couple and Family Psychology: Research and Practice, 1, 185-198.  Back to cited text no. 75
Whitton S. W., Stanley S. M., Markman H. J., Baucom B. R. (2008). Women’s weekly relationship functioning and depressive symptoms. Personal Relationships, 15, 533-550.  Back to cited text no. 76
Wilson J. P., Lindy J. D. (1994). Empathic strain and countertransference. In Wilson J. P., Lindy J. D. (Eds.), Countertransference in the treatment of PTSD . New York, NY: Guilford. 5-30.  Back to cited text no. 77


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