Lost in memory

Forced to work in secret using pseudonyms, shunned by families and communities, all the while risking their own lives for the thousands who had been struck down by Ebola. The national healthcare workers in Sierra Leone faced scores of barriers and intense psychological trauma during the height of the epidemic. 

In a country with no state-employed psychologist and only 20 mental health nurses the future could look bleak for the Sierra Leonean healthcare workers. However, a small team of psychologists from the South London and Maudsley NHS Foundation Trust (SLaM) has recently launched a pilot service to help them. The three-phase service has already reached more than 70% of those who worked tirelessly for months in the six Ebola treatment centres in the country that were funded by the UK government's Department for International Development (DFID).

This pilot project is part of a wider Ebola Psychological Support Service set up by SLaM and funded by the DFID, which also offered one-to-one Skype support to NHS workers who also gave their time to help those affected by Ebola in the country. Idit Albert, Consultant Clinical Psychologist and expert in complex trauma and PTSD, leads the service for UK aid workers. She said that when faced with the numerous psychological challenges of Ebola SLam, DFID and other trusts within the NHS were quick to act to implement a service to support UK workers in the country.

She explained that at the time Ebola broke out, a team from the King's Centre for Global Health had already been in the country for around 18 months. 'A mental health nurse from the Kings team had been receiving Skype support from a psychiatrist and she wanted to ensure this type of support was available for the rest of her team in Sierra Leone.' The mental health nurse asked her boss to contact Alison Beck, the head of Psychology and psychotherapy at SLaM, to see if any of its team of psychologists and therapists were willing to help the Kings staff. Around 10 per cent of the workforce said they would be happy to volunteer their time in supporting the people fighting Ebola in Sierra Leone. 

The Kings Global Health Team were paired up, one-on-one, with psychologists and therapists from SLaM to speak to whenever they needed. The Chief Medical Officer Dame Sally Davies heard about the service and suggested linking it up with the Department for International Development to offer the service to NHS workers who would soon be sent out to the country.

Although there are only a few NHS staff in Sierra Leone at the time of writing, and 20 staff on standby to be deployed to Sierra Leone in case of increase in Ebola cases, the service is still supporting NHS volunteers who have returned home. The Skype support sessions from psychologists and psychotherapists who volunteered their time varied from counseling and psycho-education through to higher-level clinical interventions.  For the majority of aid workers, it involved discussing their work during deployment, processing what they saw, debriefing and also offering advice on improving personal resilience and protecting their wellbeing.

Dr Albert explained that in other cases aid workers presented with anxiety, depression and PTSD-type symptoms. She added: 'The service aimed to encourage people to think about self-care as well as giving them a place to process their experience during their deployment as well as supporting them in the adjustment to life in the UK. The psychologists and psychotherapists can be flexible in how they offer help.'

Despite the traumatic scenes many of the aid workers witnessed Albert said some came out of the experience feeling stronger. She added: 'We haven't analysed all of our data yet but it's encouraging to see that after this experience people's priorities in life have shifted and many discovered they were stronger than they initially thought. 

The DFID were also keen to offer support to Sierra Leone nationals who had been working at the Ebola Treatment Centres. Elaine Hunter, a Consultant Clinical Psychologist and expert in complex trauma, psychosis and cross-cultural psychology, was chosen to lead this pilot project. She visited Sierra Leone in April to assess the 2,000 workers' needs and developed a three-phase pilot project to give culturally-appropriate support to treatment centre staff across the country and recruited an in-country team of 15 Sierra Leonean nationals to deliver the service.

The first phase of the project proved incredibly popular and attracted more than 1,600 people. This included group workshops with questionnaires which assessed general wellbeing and those who had moderate to high scores were then invited to take part in the second phase.

The second phase, also open to anyone who is interested in taking part, will include group self-help sessions focusing on six areas which were found to be most problematic during Dr Hunter's initial visits to the country; stress, sleep, anxiety, low mood and grief, anger and alcohol, and relationships. National staff have been able to sign up to attend any of these problem areas and already over 3,500 participants have been booked. The third phase will offer brief individual CBT-style guided self help over six weeks for anyone who is still experiencing psychological problems.

Hunter painted an alarming picture of the challenges that so many of the Sierra Leonean healthcare workers face, many of whom have no clinical background. She explained after Sierra Leone shut down schools and places of business to attempt to prevent the spread of the disease, many were drawn to work at treatment centres – one of the few places of paid employment in the country.

'People who work around Ebola are really stigmatised, they often work in secret and used pseudonyms,' Hunter told me. 'I talked to the burial team, who were some of the most stigmatised because they're preventing people from carrying out traditional burial practices. They were such a dignified team despite their very grim job – they had to bury up to 12 people a day. People's relationships broke up, if found out people were pushed out of their families. They all witnessed a huge number of people dying and some of them very suddenly.'

Even experienced clinical staff, including nurses, were left in shock after witnessing the many children who were killed by the disease. She added: 'They don't normally see children dying; with Ebola it has a 100% mortality rate for anyone under five years old. Most people knew others who were dying, family, friends and colleagues.'

While speaking to national staff, Hunter was struck by the ways in which people described their psychological problems. 'People speak of having "problems with their imagination" following their experiences. People who experienced flashbacks, feeling like they were back on the wards again, said they were "lost in memory". They described having anxiety symptoms as a "restless heart" and they spoke of themselves as being "sick at heart" when describing grief or depression.'

This pilot project will run until the end of December, and the Maudsley team will evaluate data from questionnaires and outcomes to assess whether the project could be expanded. The Maudsley is currently in discussion with the DFID and the organisations recruiting NHS staff for humanitarian aid missions for providing formal psychological screening and support in future.

NHS workers on their experiences and the help they received:

Scenes of devastation
'We had piles and piles of rotting bodies and nowhere to put them… there were times it felt like the whole world's going to die.'

Fear of contamination
'Because of the nature of the disease you have virus all over you and you've got fabric less than a millimetre thick…from getting infected.'

On returning to the UK:
'The period of coming home was the most traumatic for me, it was really hard.'
'It took me a full month to really feel happy to be back at home again. And that was a little bit of a surprise.'

On the Ebola Psychological Support Service:
'It's an important service and one that really should be mandatory for anyone kind of deploying for an emergency like an Ebola outbreak… where there's just a lot of human suffering that you're dealing with and... I think some people process it better by just talking to someone just a little bit more disconnected, who might have a little bit more of a kind of objective perspective.'

'She was the only person that I'd speak to – it's funny I spoke to her about work and what was happening and what I was struggling with and whatever, and I didn't do that with my family and with my husband, I just spoke to her about it.  And she was great.'

- See also our news report from December 2014.