619

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

Chapter 38

BEHAVIORAL HEALTH ISSUES IN 

HUMANITARIAN AND MILITARY 

RELIEF OPERATIONS: THE SPECIAL 

PROBLEM OF COMPLEX EMERGENCIES

THOMAS F. DITZLER, PhD*

INTRODUCTION

OPERATIONAL Behavioral health IN CONTEXT: THE HUMANITARIAN 

SPACE AND ITS PLAYERS

The International Community

Nongovernmental Organizations

Military Support to Other Players

PRINCIPLES AND PRACTICE OF CIVIL-MILITARY COLLABORATION IN Behavioral health

Security Needs and Information Sharing

Practical Considerations 

SPECIAL Behavioral health CONSIDERATIONS IN COMPLEX HUMANITARIAN ENVIRONMENTS

Factors Influencing Survivor Psychic Distress

Psychic Ground Effects 

Environmental Threats

PRINCIPLES OF Behavioral healthCARE IN HUMANITARIAN ENVIRONMENTS

Acute Phase

Reconsolidation Phase

SUMMARY

*Director of Research, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859
620

Combat and Operational Behavioral Health

INTRODUCTION

The provision of timely, effective, and culturally 

competent disaster behavioral health services is critical 

in all phases of a disaster response. Historically, disaster management and humanitarian assistance planners 

have divided events into three general categories: (1) 

natural, (2) technological, (3) and complex. Natural 

disasters include common geological and meteorological events such as floods, cyclonic storms, earthquakes, 

volcanic eruptions, and tsunamis. For those directly affected, these events can be catastrophic, but they do not 

constitute meaningful political threats for the public 

at large. The same may be said for most technological 

emergencies, such as the Bhopal, India, chemical accident of 1984, or for catastrophic infrastructure failure, 

such as the Chernobyl nuclear reactor meltdown in the 

Soviet Union in 1986. These disasters are often the result of human error, but they do not generally represent 

acts of political intention or willful malice. Local teams 

of trained personnel typically provide the response to 

these events, with regional or national assets deployed 

as required. However, in very large or regional natural 

disasters, such as the December 26, 2004, Indian Ocean 

tsunami, or in complex emergencies involving politically mediated security and logistical problems, such 

as the conflicts in Somalia or the former Yugoslavia, 

the operating environment may require an integrated 

multinational civil-military response.1

A number of recent events have provided opportunities to examine the capacities and limitations of civilmilitary collaboration in disaster response in general,2

and in the provision of behavioral health support in 

particular.3 Because of the organizational and logistical 

burden of large-scale and complex emergencies, civilian and military behavioral health providers must have 

a sound working knowledge of the shared operating 

space and the players who help shape the context of 

services. This chapter will consider (a) the humanitarian 

space and its players, (b) benefits and challenges to effective civil-military collaboration, (c) special behavioral 

health considerations in complex environments, and (d) 

principles with demonstrated utility in helping affected 

populations return to predisaster functioning. 

Operational Behavioral health In Context: The Humanitarian Space and Its Players

Knowledge of the organizational and logistical aspects of integrated disaster response is critical to the 

efficacy of behavioral health services. The working 

environment is often referred to as the “humanitarian space”; it has been described in functional terms 

as an environment with the independence, flexibility, 

and freedom of action necessary to gain access and 

provide assistance to beneficiaries in a humanitarian 

emergency. For many civilian operators, including 

international and nongovernment organizations 

(NGOs), humanitarian space is achieved through acceptance of and adherence to the humanitarian principles of impartiality, neutrality, and independence as 

modeled by the International Committee of the Red 

Cross (ICRC).4

 Specifically, this means that aid is given 

regardless of race, creed, or nationality; aid is not used 

to further a particular political or religious position; 

and humanitarian and relief agencies do not act as 

tools of a state or policy.

Because military organizations responding to disasters are by definition not impartial, neutral, or independent, concern has arisen over the use of the term 

”humanitarian” in reference to military support in 

some contexts. The United Nations (UN) Inter-Agency 

Standing Committee provides useful guidance on this 

issue in a reference paper, Civil-Military Relationship in 

Complex Emergencies.5

 In part, the committee recommends that military efforts should be termed “relief” 

instead of “humanitarian.” The difference in terminology is not just academic: the security and logistical 

support provided by the military can be critical to 

the success of the overall humanitarian effort; however, civilian humanitarians express concern that the 

perception of their affiliation with the military could 

negatively affect their security and ability to access 

vulnerable groups. 

Well-orchestrated civil-military responses can offer 

great benefits, but such efforts take careful planning, 

a clear understanding of roles of civilian and military 

personnel, and effective communication between the 

two groups. This coordination is especially important 

in behavioral health services because of the profound 

effect of sociocultural issues in the acceptability of 

care. A central theme of disaster behavioral healthcare 

is the need for cultural competence in the delivery of 

services. Especially in large-scale disasters, it is critical 

for providers to know the context of services: what 

other agencies and activities are involved, how the 

range of services is coordinated, and what personnel 

and programs are available.

The first task for military personnel is to understand 

the types of organizations and personnel who share the 

environment—the “players.” Personnel arriving on 

site should expect to find the humanitarian operating 

space shared by a range of “actors” (the acceptable 

generic reference in much of the literature in applied 

social and behavior science in political environments, 

such as terrorism, area studies, and complex disas-
621

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

ters, especially when the mix includes a broad range 

of groups—in this case, active belligerents, military 

personnel, civilian agencies, and international organizations) presenting highly diverse organizational 

cultures and roles, as well as the affected population. 

In addition to various host nation assets, the key actors in a large-scale humanitarian response frequently 

include donor governments and agencies, UN operational agencies, NGOs, the International Red Cross 

and Red Crescent Movement, other international and 

regional organizations, and the media. Some of these 

organizations may provide acute behavioral health 

services, but the goal of many is the development of 

long-term, self-sustaining programs as an integrated 

part of capacity building and development. Successful behavioral health service is directly related to the 

physical, social, psychological, and spiritual support 

provided by these programs.

The International Community

Major donors in the international community 

include the European Community Humanitarian 

Office, Japanese International Cooperation Agency, 

Australian Council for International Aid, United 

Kingdom Department for International Development, US Agency for International Development, 

and Canadian International Development Agency. 

UN agencies, funds, and programs are also much 

in evidence. Although no agency has a primary behavioral health mandate, many UN activities make 

meaningful contributions to behavioral healthcare 

through pursuit of physical security, stability, 

sanitation, shelter, child development programs, 

and other essential support. Among these, the UN 

Development Program works in poverty reduction, 

development goals, democratic governance, crisis 

prevention, information and communication technology, human immunodeficiency virus/acquired 

immunodeficiency syndrome (HIV/AIDS) response, 

and landmine action in 166 countries. The UN High 

Commissioner for Refugees (UNHCR) has a mandate 

under international law to protect and assist refugees as specified in the 1951 Refugee Convention.6

Focused on provision of food, shelter, and other basic 

necessities, this support is especially important in 

environments where the affected groups may include 

refugees, internally displaced persons, or migrants, 

a situation that can bring additional distress even 

in stable environments. UNHCR has approximately 

5,000 staff in 120 countries with a current caseload 

of over 20 million people worldwide.

The World Food Program, the largest provider of 

food aid in the UN system, responds to both emergency needs and long-term economic and social development goals. In 2004, the program fed 113 million 

people in 80 countries. Operating in over 140 countries, 

the UN Children’s Fund prioritizes girls’ education, 

early childhood development, immunization, protection from violence and exploitation, HIV/AIDS services, health and nutrition programs for children and 

pregnant women, and children’s rights. In recent years 

the program has also worked for the demobilization 

and reintegration of former child combatants through 

community-based efforts.7

The UN established the World Health Organization 

(WHO) in 1948; its constitutional objective is “the attainment by all peoples of the highest possible level 

of health.” In disasters, WHO provides medical assessments and supplies and trains healthcare workers 

as part of building capacity. WHO is staffed by some 

3,500 health experts, other experts, and support staff 

on fixed-term appointments, working at the Geneva, 

Switzerland, headquarters; in six regional offices; and 

in countries around the world. WHO actively pursues 

relations with NGOs to promote its policies, strategies, 

and activities.

A common feature of complex humanitarian 

emergencies (CHEs) is psychic trauma caused by the 

failure to maintain basic human rights. UNHCR, the 

secretariat for all UN human rights bodies, ensures 

that human rights are “mainstreamed” into all other 

UN activities. In addition to national capacity building, 

UNHCR maintains a field presence of human rights 

monitors and observers. 

International organizations established by treaties 

also work closely with the UN and other actors. The 

International Organization for Migration, established 

in 1951 to assist with the movement of displaced 

persons in Europe, is the leading intergovernmental 

organization in the field of migration and now operates worldwide with 120 member states and offices in 

over 100 countries. This organization works closely 

with governmental, intergovernmental, and nongovernmental partners in managing the movement 

of migrants, resettling refugees to third countries or 

returning them to places of origin, and countering trafficking of people. The International Red Cross and Red 

Crescent Movement is the world’s largest humanitarian network, with a presence and activities in almost 

every country. The Movement has three distinct entities: (1) the Geneva-based ICRC directs and coordinates 

international relief efforts in situations of conflict and 

promotes and strengthens humanitarian law (Geneva 

Conventions) and universal humanitarian principles; 

(2) the International Federation of Red Cross and 

Red Crescent Societies acts as the official representative of the member national societies and directs and 

coordinates the international assistance efforts of the 

individual member societies; and (3) the individual 
622

Combat and Operational Behavioral Health

National Red Cross and Red Crescent Societies provide a range of auxiliary disaster, development, and 

capacity-building services to the national authorities 

in their own countries. Although not officially a part 

of the UN, the Movement has observer status at UN 

headquarters in New York City. 

Nongovernmental Organizations 

The term “NGO” defines a very diverse group 

with respect to size, style of management, and type of 

operations. The World Bank defines NGOs as “private 

organizations that pursue activities to relieve suffering, 

promote the interests of the poor, protect the environment, provide basic social services, or undertake community development.”8

 Tens of thousands of NGOs 

exist; many consult to governments and the UN, and 

some have a meaningful influence in world affairs.

According to Hall-Jones,9 the NGO sector now represents the eighth largest economy in the world. NGOs 

are generally funded by grants or private donations, 

although some receive large donations from governments. The groups may be national (indigenous) 

or international and are typically staffed by skilled 

professionals such as physicians, nurses, logisticians, 

engineers, and lawyers. NGOs are sometimes classified 

by their orientation (religious or secular); mission types 

(operational or advocacy); specific interests (medical 

care, child protection, food distribution); or operating 

area (community based, national, or international). 

Their size varies from small community-based groups 

to very large international organizations with equally 

large budgets. 

Many NGOs have been working in particular locations for many years and have vast knowledge of 

the areas and access to the local population. InterAction is the largest alliance of US-based international 

development and humanitarian NGOs, with more 

than 160 member organizations.10 The largest of these, 

in terms of financial assets, is currently the Bill and 

Melinda Gates Foundation, with an endowment of 

$28.8 billion.9

Military Support to Other Players

In recent years the military forces of many nations 

have deployed in response to humanitarian crises. 

These missions involve various forms of logistical 

and security support to protect civilian aid workers 

and ensure that relief reaches the populations in need. 

Types of military support can be conceptualized as 

belonging to five general service clusters, all of which 

have security as a central theme11:

1. Direct assistance: the face-to-face distribution 

of goods and services (these services often 

embrace a meaningful security component).

2. Indirect assistance: activities such as transporting relief goods or relief personnel (at 

least one step removed from the population). 

3. Infrastructure support: general services 

such as road repair, airspace management, 

or power generation that facilitate relief but 

are not necessarily visible to or solely for the 

benefit of the affected population. 

4. Peacetime missions: responses to large-scale 

natural disasters (eg, the Indian Ocean tsunami).

5. Training and exercises conducted in a region 

with no hostile intent. 

The UN’s Guidelines on the Use of Military and Civil 

Defence Assets in Disaster Relief,

1

 originally released in 

1994 and revised in December 2005, is the principal 

document specifying the obligations and limits of 

military support in humanitarian relief. Because the 

original document was developed at an international 

conference in Oslo, Norway, it is generally referred to 

as the “Oslo Guidelines.” Under these guidelines, UN 

military and civil defense assets in humanitarian space 

are under UN control. 

Other peace operations or support missions include 

a range of tasks undertaken by military forces that may 

not be under UN command, including peacekeeping, peace enforcement, peace building, and other 

operations with forces deployed under parameters 

that dictate a minimum necessary use of force. In 

some circumstances, the humanitarian mission may 

exist alongside traditional combat missions, including 

behavioral health services for detainees, as in Iraq and 

Afghanistan. 

Principles and Practice of Civil-Military Collaboration in Behavioral health

The practice of civilian aid workers sharing the 

humanitarian space with the military is not new. Much 

of the recent interest in civil-military collaboration, 

however, may be traced to the success of Operation 

Provide Comfort in 1991, when NGOs and the military, 

working toward a common goal, achieved unprecedented success in providing humanitarian relief for the 

Kurds of northern Iraq.12 Since that time, many senior 

military training institutions have developed curricula 

dedicated to civil-military issues. Civilian and military 
623

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

organizations differ greatly in their respective cultures, 

but each group possesses knowledge, skills, and assets that in collaboration create a synergy neither can 

achieve independently.

The coordination of these skills and assets, however, 

can be a critical challenge. Bessler and Seki13 have 

provided a useful overview of common problems in 

the development of civil-military collaboration in the 

humanitarian space They point out, for example, that 

civilian humanitarians may express concern over the 

militarization of aid, especially in the area of military 

civil affairs projects designed to “win the hearts and 

minds” of the populace. These efforts are often a key 

part of the reconstruction process and have great 

pragmatic value; however, they can also create the perception that humanitarians might be used as de facto 

force multipliers or field operators of the local government. Humanitarians note that the perception of a 

military affiliation may compromise their principles 

of impartiality and neutrality, with a negative effect 

on the security of their staff or their ability to access 

affected populations. Given such problems, military 

and civilian workers must have a clear understanding of each other’s needs to create a pragmatic and 

principled response. 

Security Needs and Information Sharing

McHale11 offers useful general guidance on security and informational requirements of civilian and 

military actors in the humanitarian space. Although 

specific needs of humanitarian actors vary widely, civilian humanitarians commonly seek military support 

for the following:

	 •	 security in the area to allow humanitarians to

conduct operations, although usually not to 

the extent of one-on-one protection of their 

staff;

	 •	 reaction forces to assist personnel in danger,

possibly requiring one-on-one security and 

evacuation of humanitarian staff;

	 •	 access to airfields, ports, and facilities if these

are not readily open for humanitarian use;

	 •	 communication technology;

	 •	 logistical transport of materials and possibly

personnel;

	 •	 emergency medical support and possible

medical evacuation of personnel; and 

	 •	 emergency infrastructure repairs.

McHale advises military operators in the humanitarian space to avoid classifying information unless 

necessary for security of operations or personnel. The 

military can often share with NGOs the following 

information:

	 •	 details on the security situation to inform humanitarian risk assessment, including areas of 

ongoing military action, banditry, or general 

instability;

	 •	 status of air and sea points of debarkation and

lines of communication; 

	 •	 checkpoint locations and pass-through procedures, which greatly reduces the chances 

of accidental injuries to humanitarian staff;

	 •	 location of unexploded ordnance, mines, and

mine action activities;

	 •	 information on population movements, conditions, and activities;

	 •	 types of humanitarian (relief or support) projects planned by military; and

	 •	 poststrike information, including location of

persons in need and unexploded ordnance.

Civilian humanitarian organizations are often hesitant to share information with the military, concerned 

over the perception of alignment with military intelligence. However, military personnel have suggested 

that security and efficacy is improved for both partners 

when NGOs offer the following information: 

	 •	 location of humanitarian staff and operations,

which lessens the chance of accidentally 

targeting areas with ongoing humanitarian 

operations or humanitarian staff;

	 •	 locations for possible evacuation of humanitarian staff if necessary; and

	 •	 a complete list of humanitarian projects, to

avoid competition and duplication.

Practical Considerations 

Because effective behavioral health services are an 

integral part of the overall disaster response, providers must be familiar with the coordination mechanisms and position themselves to be an ongoing and 

integrated part of the response. The most common 

administrative mechanism for coordination is the 

civil-military operations center (CMOC). The US Department of Defense defines a CMOC as 

an ad hoc organization, normally established by the 

geographic combatant commander or subordinate 

joint force commander, to assist in the coordination 

of activities of engaged military forces, and other 

United States Government agencies, nongovernmental organizations, private voluntary organizations, and regional and international organizations. 
624

Combat and Operational Behavioral Health

There is no established structure, and its size and 

composition are situation dependent.14

The Center for Excellence in Disaster Management 

and Humanitarian Assistance agrees that the physical 

structure of the CMOC and the liaison arrangement 

best suited for the mission are determined on a caseby-case basis, outlining four principal approaches to 

liaison placement (Figure 38-1).11 Civil and military 

leaders benefit from a careful consideration of perceptions, accountability, the need for transparency, and 

how these issues may affect the security of civilian 

humanitarian staff and beneficiaries. The center also 

offers a number of operating principles obtained from 

successful CMOC endeavors (Exhibit 38-1).11

Figure 38-1. Civil-military coordination: four approaches to 

liaison arrangements. Collocation: humanitarian agencies 

and military units operate from within the same compound. 

The perception that civilian actors may be affiliated with 

the military can have negative security implications for the 

civilian humanitarian agency staff. For this reason, collocation is rarely used and should never be used in a complex 

emergency. Liaison exchange: liaison officers are assigned 

to and work in the offices of the other unit or agency. Limited exchange: liaison officers maintain an office in their 

own unit or agency but travel to the other actor’s office to 

conduct business. Interlocutor: liaison officers maintain an 

office in their own unit or agency and travel to a neutral 

site to conduct business, such as a United Nations or local 

governmental office. This is often the most secure option for 

civilian humanitarian agency staff operating in an insecure 

environment.

Civ: civilian LO: liaison office Mil: military

Mil

Should never 

be used in a 

complex 

emergency

Collocation Liaison 

Exchange

Mil

LO

Limited 

Exchange

Civ

LO

Mil

LO

Interlocutor

Civ

Mil

Neutral 

site

Civ

LO

Civ

LO

EXHIBIT 38-1

OPERATING PRINCIPLES LEARNED 

FROM SUCCESSFUL CIVIL-MILITARY 

OPERATIONS CENTERS

	 •	 Remember that coordination is personality and

perception driven.

	 •	 Have respect for other actors and their operations;

your personality and how you are perceived will 

dramatically affect whether coordination occurs.

	 •	 Have meetings chaired or co-chaired by civilian

actors.

	 •	 Understand the roles, responsibilities, and constraints of the other humanitarian actors.

	 •	 Understand that nongovernmental organizations

(NGOs) vary in their degree of comfort in working with the military; some NGOs will never be 

comfortable working with the military.

	 •	 When possible, work to establish areas of common

responsibility.

	 •	 Establish open communications and sharing of

information.

	 •	 Avoid classifying information unless necessary.

	 •	 Respond in a timely manner to requests for information or assistance.

	 •	 Understand that civilian actors may be hesitant to

share information with you, especially in an open 

forum.

	 •	 Ensure that communications equipment (radio,

mobile phones, e-mail) is compatible. 

	 •	 Offer assistance when possible; understand that

offers may be rejected.

	 •	 Know the market prices for local goods and services.

	 •	 Do not drive up prices by overbidding.

	 •	 Work with civilian actors to build consensus in

operations.

	 •	 The collaborative process may benefit from a third

party (eg, the US Office for the Coordination of 

Humanitarian Affairs) through which to share 

information.

Adapted from: McHale S. The International humanitarian 

community: overview and issues in civil-military coordination. Paper presented at: Combined Humanitarian Assistance Response Training; June 29, 2006; Marine Corps 

Bases Japan.

Special Behavioral health Considerations in Complex Humanitarian Environments

Equipped with an understanding of the players and 

a strategy for coordinating services, behavioral health 

providers can next consider important contextual issues 

that affect service delivery. Among the more important 

of these issues is how the psychic environment of CHEs 

differs from that of natural or technological emergencies. Although a CHE has several definitions, the UN 

Inter-Agency Standing Committee characterizes such a 
625

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

situation as 

a humanitarian crisis in a country, region or society 

where there is total or considerable breakdown of 

authority resulting from internal or external conflict and which requires an international response 

that goes beyond the mandate or capacity of any 

single agency and/or the ongoing United Nations 

country program.15

Many recent CHEs originated in the 1940s and 

1950s, when the historical colonial powers began divesting themselves of overseas outposts. This trend 

accelerated at end of the Cold War, as the world experienced a dramatic rise in struggles for autonomy 

among newly liberated groups. These struggles often 

emerged along ethnic or religious lines, accompanied 

by a volatile mix of social, political, economic, and 

cultural variables that fueled internal conflicts. Humanitarian disasters that have emerged from these 

conflicts approximate civil wars and are labeled 

CHEs. CHEs are typically characterized by politically 

mediated excess mortality and morbidity; loss of civil 

police and judicial processes; massive displacement 

of people within the country (internally displaced 

persons) or across borders (refugees); destruction of 

critical infrastructure; and widespread damage to civil 

society and economies. The UN Office for Coordination of Humanitarian Affairs adds that 

[r]esponders typically face the need for a large-scale, 

multi-faceted humanitarian response in which delivery of assistance is hindered or prevented by 

political/military constraints, including significant 

security risks for humanitarian aid workers.16

Frequently, CHEs emerge from a weak or failed 

political infrastructure confronted by catastrophic 

economic distress or a natural disaster. The disaggregation of the former Yugoslavia and the Rwandan 

genocide of 1994 are illustrative of CHEs at the state 

level. The specific targeting of civilians to terrorize, 

displace, and create psychological distress is often a 

military goal. Garfield and Neugut note that World 

War I produced civilian casualty rates of approximately 14%; in World War II the rate had risen to 67%. By 

the 1990s the rate of casualties among noncombatants 

reached 90%.17

Factors Influencing Survivor Psychic Distress 

Behavioral health providers should understand the 

ways in which the anarchic aspects of CHEs create 

psychic environments that differ greatly from those 

typically associated with natural or technological 

disasters. Any individual’s subjective experience 

of psychic distress is a product of the complex interactions between the personal characteristics of 

the survivor and characteristics of the traumatizing 

event. Survivor characteristics may include a history 

of previous trauma, personality organization, physical health, availability of psychosocial support, and 

material resources. 

The two principal characteristics of the traumatizing event itself are the gradient of exposure and the 

magnitude of personal loss and impact. The gradient 

of exposure defines how much trauma survivors were 

exposed to: how “close” it was and how many times 

they were exposed. The magnitude of personal loss 

and impact concerns the comprehensiveness of the 

event: Did the survivor hear about it, read about it, 

see it on electronic media, or witness it personally? 

Did it happen to someone they know? A loved one? 

Did they experience it personally? How many times? 

In general, the more directly and persistently an individual is affected, the higher the risk of meaningful 

behavioral health problems. In complex emergencies 

where losses result from intentional, human-mediated 

violence, the emotional proximity, comprehensiveness, 

and persistence of the trauma can be devastating to 

survivors and their greater communities. 

Psychic Ground Effects

Measured by the gradient of effect and magnitude of 

personal loss, CHEs expose survivors to physical, emotional, and environmental sources of psychic trauma 

that are persistent and highly interrelated. Specific 

sources of distress may include persecution, oppression, marginalization, detention, incarceration, torture, 

witnessing atrocities, and separation from loved ones. 

In natural or technological disasters, emergency relief 

personnel and assets are limited largely by logistical 

constraints. In addition, the immediate cause of the 

threat is usually time-limited (eg, cyclonic storm, 

earthquake), so survivors can begin the response and 

recovery process in a fairly short time. CHEs, however, 

often involve an ongoing threat of armed aggression, 

including hostile resistance to both military humanitarian support and civilian aid workers. 

Even following the official cessation of hostilities, 

threats in a CHE may extend into the “postconflict” 

environment for both survivors and responders. In 

the aftermath of a complex emergency, survivors may 

know not only victims, but also perpetrators. After the 

Rwandan genocide of 1994, aid workers frequently 

encountered Tutsi survivors who returned to their 

home areas only to encounter the very people who 

had killed members of their families.18 Retributive 
626

Combat and Operational Behavioral Health

violence can also persist long after the official “peace” 

has been declared. 

In addition to ongoing physical and psychic threats 

to their safety and autonomy, survivors in CHEs often 

experience meaningful material deprivation, including 

loss of home, personal possessions, important records, 

economic and material resources, employment, social 

position, or authority. These problems are exacerbated 

by the loss of customary social, psychological, spiritual, 

and cultural institutions that could otherwise provide 

support.

Among the most distressing of behavioral health 

issues in CHEs is gender-based violence. Especially in 

CHEs involving ethnic conflict, sexual violence against 

women and girls is often a planned and systematic 

military weapon designed to humiliate, induce terror, 

and destabilize communities. Although reliable statistics are difficult to obtain, a large body of information 

obtained from NGO and international organization 

investigations documents the problem. Concerning the 

protracted conflict in Sudan, for example, the Watchlist 

Project notes that gender-related violence

connected to conflict, including sexual slavery 

of women and children, rape by military forces, 

forced prostitution and forced marriage, is known 

to be a widespread problem in Sudan. No statistics 

are available. Children, especially girls from these 

areas, are victims of sexual exploitation, sexual 

slavery, forced marriage, rape and other forms of 

violence after abduction by . . . militias and opposition groups.19

Similarly, Roque reported,

In Bosnia, for example, public rape of women and 

girls preceded the flight or expulsion of entire Muslim populations from their villages, and strategies 

of ethnic cleansing included forced impregnation

In Rwanda, Hutu extremists encouraged mass 

rape and sexual mutilation of Tutsi women as an 

expression of contempt, which sometimes included 

intentional HIV transmission.20

In addition to the trauma of the violence itself, 

survivors of gender-based violence may also experience social rejection from their own group. In many 

traditional collectivist societies, family, tribe, or other 

group affiliation largely determines the sense of self 

and social role. Forcing women to bear the children of 

their enemies disrupts the social fabric of community 

organization. Gourevitch has described a Tutsi woman 

who had survived the Hutu massacre in Rwanda 

commenting on her relationship with the restored 

government: 

And they would say, “If they killed everyone 

and you survived, maybe you collaborated.” To a 

woman who was raped 20 times a day, day after 

day, and now has a baby from that, they would 

say this.18

This circumstance might be thought of as an interethnic, multigenerational psychic insult A successful 

clinical response to such a problem would require an 

exceptionally well-resourced, culturally embedded, 

long-term commitment. UN-sponsored programs for 

the reintegration of former child combatants may provide a heuristic model for program development. 

Environmental Threats

Environmental threats, both direct and indirect, 

negatively affect survivors’ subjective sense of safety 

and security and are a major source of psychic distress. 

In addition to active armed conflict, direct threats 

may be represented by the loss of secure shelter or 

the presence of landmines and unexploded ordnance. 

Indirect threats often involve destroyed or degraded 

infrastructure, including utility and public health assets associated with transportation, power generation, 

water, sanitation, and basic health services. For many, 

living circumstances are austere and overcrowded. 

These problems often have the effect of forcing traumatized people to live in close proximity to others 

who are equally distressed, and with whom they may 

have to compete for scarce resources. The effects of 

this situation are especially deleterious for the most 

vulnerable people. Groups at high risk include children 

(especially unaccompanied minors), pregnant and 

lactating women, the elderly and infirm, the chronically and persistently mentally ill, displaced persons, 

and refugees. 

During complex emergencies, the definition of 

“high-risk group” may evolve through the life span 

of the emergency. In general, anyone who is physically or psychologically vulnerable may be thought of 

as a high-risk individual, but because of the political 

nature of CHEs, high-risk groups may be determined 

by social, religious, educational, or political affiliation. 

For example, during many long-term CHEs such as the 

civil war in Mozambique (1975–1994), male adolescents became vulnerable to kidnapping and induction 

into irregular militias or paramilitary groups because 

of the depletion of older male soldiers lost in the fighting. Social and medical risks are often reflected in a 

high incidence of drug and alcohol abuse, domestic 

violence, and related pathology. These aspects of the 

psychic environment of CHEs have meaningful implications for behavioral health providers attending to the 
627

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

needs of both civilian survivors and military personnel operating in theater. Little doubt exists that the 

severity and persistence of human-mediated trauma 

in complex emergencies carries a much higher risk of 

long-term psychic distress than the trauma of natural 

or technological disasters.21

The most common behavioral health diagnoses 

among survivors of CHEs include anxiety disorders, 

especially acute or posttraumatic stress disorder, and 

mood disorders, especially depression. These conditions are often accompanied by a range of somatic complaints including body pains, sleep disturbances, and 

restlessness. Neglect of one’s own health is common, 

as are substance use disorders. Apart from diagnosable 

disorders, however, the single greatest source of psychic distress is typically the problem of loss and grief. 

Loss and grief are axiomatic to human experience, but 

in CHEs the sheer magnitude of loss coupled with the 

absence of usual support structures can present a special clinical challenge for practitioners. The successful 

resolution of grief is an essential part of the recovery 

process; unresolved grief can be a rate-limiting factor 

in the successful return to predisaster functioning for 

both individuals and communities at large. 

Although the response to acute grief is unique 

to each person, a number of descriptive models of 

bereavement and mourning have been advanced to 

describe common themes.22–26 For a vast majority of 

survivors, the early grieving process includes preoccupation with persons or things lost and feelings of 

profound sadness, loneliness, fear, powerlessness, anger, anxiety, and despair. A central component of grief 

is the need to engage the mourning process to achieve 

appropriate levels of relief, resolution, reintegration, 

and return to functioning. In mourning, the reality of 

the pain is consciously identified and openly expressed 

with some degree of support seeking, psychological 

unburdening, and reestablishment of equilibrium. In 

unmourned loss, however, the reality of the pain is denied or suppressed, and the pain tends to remain fresh. 

The bereaved have a critical need for timely support to 

properly mourn their losses. Not grief itself, but grief 

that is unmourned, is associated with the development 

of more serious psychological problems; these may 

include pathological grief responses, depression, and 

posttraumatic stress disorder. These serious psychological problems are especially significant in complex 

emergencies, where the scale of destruction and social 

disorder creates cumulative risks at the same time 

that it precludes the ability of survivors to engage the 

normal mourning process in a timely way. 

Despite the intensity of their experiences, some of 

the bereaved may initially fail to seek help because 

they are overwhelmed or immobilized by the shock 

and magnitude of their losses. Other survivors may 

actually decline help in an effort to preserve their 

sense of autonomy, competence, or dignity. Because 

social customs, religious practices, and traditional 

rituals exert great influence on the mourning process, 

behavioral health support should be integrated into 

other support and recovery activities provided by 

local providers and organizations. If possible, service 

providers should seek collaborative relationships with 

local traditional healers. 

Principles of Behavioral healthCare in Humanitarian Environments

Because of cultural and logistical problems, many 

traditional Western behavioral health interventions 

may be of limited use in disasters requiring a multinational response, especially complex emergencies. 

The most effective behavioral healthcare strategies 

pursue integration of sociocultural, medical, and 

psychological assets, ideally involving collaboration 

among relevant organizations. Practitioners are often 

less invested in direct clinical care for individuals and 

small groups and more focused on supportive and 

facilitative activities.

 The WHO Department of Mental Health and 

Substance Dependence offers some general behavioral health service principles that have demonstrated 

utility across a range of disasters and cultures.27 If 

circumstances permit, predisaster preparation should 

include a plan that identifies specific tasks, responsible 

personnel, and detailed communication and coordination strategies for key actors and agencies. If the key 

actors include international organizations, the leadership should be reminded that, to the degree possible, 

staff (including managers) should be hired from the 

local community. This practice increases the cultural 

competence of care and sets the stage for the development of long-term, self-sustaining programs.

Acute Phase

In the acute phase of a complex emergency, the 

crude mortality rate generally rises after loss of basic 

needs, including security, food, water and sanitation, 

and access to primary and public health services. 

Disaster behavioral health workers note that the reestablishment of these basic services is also essential in 

helping survivors recapture a sense of autonomy and 

efficacy in their environment. The process is enhanced 

by dissemination of information about relief efforts, 

including location of aid organizations and, when 
628

Combat and Operational Behavioral Health

possible, information concerning the location of relatives. For survivors with behavioral disorders, whether 

disaster-induced or not, basic behavioral healthcare 

is best provided through general health services or 

through community-based primary healthcare resources within the health sector. In addition, providers 

should ensure the availability of essential medications 

for persons with acute psychiatric emergencies. 

During complex emergencies, when the acute 

phase may be protracted, many survivors respond 

well to the principles of “psychological first aid.”28

Credentialed providers can also use psychological 

first aid materials to provide on-the-job training 

and supervision in core psychological care skills for 

existing healthcare providers, social service workers, 

and community leaders. This training expands the 

cadre of service providers available to the community 

while facilitating the integration of behavioral health 

into primary healthcare for the longer term. Also 

useful is the creation of community-based support 

and self-help groups to provide emotional support 

and enhance coping strategies, especially in grief 

management. Other helpful efforts, when possible, 

include encouraging the reestablishment of normal 

religious and cultural activities, specifically including orphans, those who have lost partners, and those 

without families. 

One of the most practical behavioral health priorities is reopening schools. Schools normalize life 

for children and provide opportunities for them to 

interact with others in a familiar environment. Children in school are also much less likely to become 

involved in criminal or other high-risk behavior, and 

less likely to become victims of child exploitation, a 

tragically common occurrence following large-scale 

disasters. With children in a secure environment, 

other family members are freed to attend to pressing 

needs. Schools are also an accessible, low-visibility 

platform for disseminating behavioral health and 

social services information in an environment that is 

culturally confluent and preserves self-esteem. Uncomplicated, empathic information should focus on 

normal reactions, give practical advice, and provide 

specific information about availability and location 

of behavioral health and social service resources. 

These self-empowerment techniques provide immediate practical relief as they establish templates for 

self-sustaining, locally managed programs that can 

eventually serve the medium- and long-term needs 

of the community. 

Reconsolidation Phase

 In the reconsolidation phase, survivors often face a 

lengthy period of adjustment to the losses created by 

the disaster. Especially in response to very large-scale 

events, the enormity of the losses often predicts a rise in 

the most serious behavioral health problems, including 

posttraumatic stress disorder, depression, and suicidal 

thoughts. To meet the long-term needs of survivors, behavioral health services must be organized, sustained, 

and integrated into the local community. 

The US Department of Veterans Affairs National 

Center for Posttraumatic Stress Disorder29 recommends that following disasters, long-term tasks for 

behavioral health providers should include public 

education, screening, and where indicated, referral and 

treatment. Educational activities include programs on 

enhancing self-care and coping techniques, and providing information about social, financial, legal, and 

medical services. These activities help survivors normalize their reactions to trauma and develop healthy 

forms of coping. Screening seeks to identify those at 

increased risk for negative psychological outcomes. 

Survivors with a prior history of psychiatric illness, 

psychological trauma, or substance use disorders are 

particularly vulnerable, as are members of historically 

marginalized or disenfranchised groups. Survivors 

typically have a brief interview with a behavioral 

health provider and complete a risk-assessment questionnaire. Where appropriate, the screening process 

may rely on informal sources, including aid workers, 

friends, or family members. Based on screening assessments, survivors can be referred to counseling for 

specific problems, such as alcohol abuse or complicated 

bereavement, or to more medically or psychiatrically 

based interventions. 

A principal behavioral health challenge of the reconsolidation phase is the establishment or reinvigoration 

of sustainable economic support programs to respond 

to the long-term consequences of the disaster’s impact. 

Especially for survivors whose predisaster livelihoods 

depended on subsistence work, the ability to generate income is a critical link to emotional recovery. 

In disasters involving a multinational response, the 

success of these programs requires a high degree of 

collaboration among public and private programs 

from both the host nation and donor countries. Because of the sensitivities that invariably accompany 

humanitarian aid, the host government must be able 

to exercise maximum administrative influence over 

the community’s return to predisaster functioning. 

Andrew Natsios, former director of the US Agency for 

International Development, describes the concepts of 

local ownership, capacity building, and sustainability 

as the “iron triad” of all successful reconstruction and 

development projects, an observation that generalizes 

well to behavioral healthcare.30
629

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

SUMMARY

health services typically occurs during the emergency 

phase of the response. However, evidence shows that 

the need for behavioral health services actually goes 

up over time, so that the most pressing needs often 

surface after the assets available in the acute period 

have diminished. The best strategy for responding 

to this problem is to ensure that local planners and 

other leadership are aware of the circumstance and 

that providers invest maximum effort in the establishment of culturally competent, indigenously managed 

programs. Behavioral health providers should initiate 

training and supervision of local personnel early in 

the response to ensure long-term behavioral health 

support. 

Successful behavioral health service in the humanitarian space demands a high level of clinical expertise 

in an environment fraught with meaningful challenges. 

To meet these challenges, providers must develop 

skills in fields ranging from cultural anthropology to 

diplomacy, logistics, economics, and organizational 

behavior. The successful integration of these skills is 

rewarded with the development of timely, efficacious, 

and self-sustaining behavioral health services to help 

those in need. 

Established principles and evolving research in 

the reconstruction and development fields inform the 

civilian and military humanitarian response communities, including behavioral health providers. In the 

humanitarian space, it is critical for behavioral health 

providers to know the key players, their respective 

roles, typical tasks, and relationships to each other. 

In part, this knowledge requires an understanding of 

the host culture, the challenges and opportunities of 

civil-military collaboration, and the best mechanisms 

to share resources and expertise among contributing 

groups. These knowledge sets permit practitioners to 

function as behavioral health force multipliers through 

their identification and support of community-based 

psychosocial and educational programs, the development of information networks, and collaboration 

with traditional healers and other local assets. The 

most effective practitioners also understand how the 

psychological ground effects in complex emergencies 

differ from those in natural and technological disasters, and how those differences affect the potential 

for psychological trauma and disability, especially in 

response to grief.

The greatest impetus and funding for behavioral 

REFERENCES

1. United Nations Office for the Coordination of Humanitarian Affairs. Guidelines on Military and Civil Defence Assets in 

Disaster Relief—“Oslo Guidelines.” Rev 1. Geneva, Switzerland: UN; 2006. 

2. March A. The Australian government’s response to the Indian Ocean Tsunami. Liaison. 2006;3:50–54.

3. Perez JT, Coady J, De Jesus EL, McGuinness KM, Bondan S. Operation Unified Assistance: population-based programs 

of the US Public Health Service and international team. Mil Med. 2006;171:53–58.

4. International Committee of the Red Cross. Proclamation of the Fundamental Principles of the Red Cross and Red Crescent. 

ICRC Web site. Available at: http://www.icrc.org/web/eng/siteeng0.nsf/html/p0513. Accessed December 15, 

2009. 

5. United Nations Inter-Agency Standing Committee Working Group. Civil-Military Relationship in Complex Emergencies. 

Geneva, Switzerland: UN; 2004. Available at: http://ochaonline.un.org/mcdu/guidelines. Accessed December 15, 

2009.

6. United Nations. Convention relating to the Status of Refugees; July 28, 1951. UN Office of the High Commissioner for 

Human Rights Web site. Available at: http://www2.ohchr.org/english/law/refugees.htm. December 15, 2009.

7. Ditzler T, Hubner M, Batzer W. Caring for former child combatants: evidence-based practices for reintegration. Aust 

J Hum Security. 2005;1:15–12

8. The World Bank. Involving NGOs in Bank-Supported Activities. Washington, DC: World Bank, USA; 1989. Operational 

Directive 14.70.

9. Hall-Jones P. The rise and rise of NGOs. Global Policy Forum Web site. May 2006. Available at: http://www.globalpolicy.org/component/content/article/176-general/31937.html. Accessed December 15, 2009. 
630

Combat and Operational Behavioral Health

10. InterAction: American Council on Voluntary International Action Web site. Available at: http://us.oneworld.net/

member/interaction-american-council-voluntary-international-action. December 15, 2009.

11. McHale S. The International humanitarian community: overview and issues in civil-military coordination. Paper 

presented at: Combined Humanitarian Assistance Response Training; June 29, 2006. Marine Corps Bases Japan. 

12. Successful aspects of the NGO-military interface. In: Davidson L, Daly-Hayes M, Landon J. Humanitarian and Peace 

Operations: NGOs and the Military in the Interagency Process. Washington, DC: National Defense University; 1996. Chapter 

3. Available at: http://www.dodccrp.org/files/Davidson_Humanitarian.pdf. Accessed December 15, 2009. 

13. Bessler M, Seki K. Civil-military relations in armed conflicts: a humanitarian perspective. Liaison. 2006;3:4–10.

14. US military glossary. About.com: US military Web site. Available at: http://usmilitary.about.com/od/theorderlyroom/l/

blglossasry.htm. Accessed December 15, 2009.

15. United Nations Inter-Agency Standing Committee Web site. Available at: http://www.humanitarianinfo.org/iasc/

content/default.asp. Accessed December 15, 2009.

16. US Office for the Coordination of Humanitarian Affairs. OCHA Orientation Handbook of Complex Emergencies. New York, 

NY: UN; 1999. Available at: http://www.reliefweb.int/library/documents/ocha__orientation__handbook_on__.htm. 

Accessed December 15, 2009.

17. Garfield RM, Neugut AI. The human consequences of war. In: Levy BS, Sidel VW. War and Public Health. New York, 

NY: Oxford University Press; 2000: 27–38.

18. Gourevitch P. We Wish to Inform You That Tomorrow We Will Be Killed With Our Families. New York, NY: Picador USA; 

1998: 304–308.

19. Watchlist Project. Watch List on Children and Armed Conflict. New York, NY: Women’s Commission for Refugee Women 

and Children; 2003. Available at: http://www.womenscommission.org/pdf/wl_sd.pdf. Accessed December 15, 

2009.

20. Roque H. Addressing gender-based violence: if not now, when? The United Nations Chronicle [serial online]. 2002;39(3). 

Available at: http://www.un.org/Pubs/chronicle/2002/issue3/0302p77_gender_based_violence.html. Accessed 

December 15, 2009. 

21. Ditzler TF. Psychic Trauma in Complex Emergencies: Sources and Interventions. Health Emergencies in Large Populations 

2005: A Training Course for the Management of Health Intervention in Armed Conflict [CD-ROM]. Honolulu, Hawaii: DoD 

Center for Excellence in Disaster Management and Humanitarian Assistance and International Committee of the Red 

Cross; 2005.

22. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry. 1994;151(6 suppl):155–160.

23. Engel GL. Grief and grieving. Am J Nurs. 1964;64:93–98.

24. Kübler-Ross E. On Death and Dying. New York, NY: Macmillan; 1969.

25. Bowlby J. Attachment and Loss. Vols 1–3. New York, NY: Basic Books; 1979.

26. Westphal R. Dynamic grief model. Paper presented at: Shea-Arentzen Nursing Symposium; “Navigating New Frontiers 

of Nursing Practice: The Challenges of Health Care Reform,” La Jolla, Calif. March 20–24, 1995; La Jolla, Calif. 

27. World Health Organization, Department of Behavioral Health and Substance Dependence. Behavioral Health in Emergencies: Mental and Social Aspects of Health of Populations Exposed to Extreme Stressors. Geneva, Switzerland: WHO; 2003. 

Available at: www.who.int/whr/en. Accessed December 15,2009.

28. National Child Traumatic Stress Network, Department of Veterans Affairs National Center for Posttraumatic Stress 

Disorder. Psychological First Aid: Field Operations Guide. 2nd ed. Washington, DC: DVA; 2006. Available at: http://www.

ncptsd.va.gov/. Accessed December 15, 2009.
631

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

29. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder. Secondary behavioral health treatment following disasters. National Center for PTSD fact sheet. Available at: http://www.ncptsd.va.gov/. Accessed 

December 15, 2009.

30. Natsios AS. The nine principles of reconstruction and development. Parameters. 2005;Autumn:4–20.
632

Combat and Operational Behavioral Health