Psychological support post-release of humanitarian workers taken hostage: the experience of the International Committee of the Red Cross (ICRC)

ABSTRACT

Following release, former hostages face many challenges and may struggle to regain control over their lives. Research and evidence on how to effectively address the needs of hostages during their release and afterwards is lacking. The International Committee of the Red Cross has extensive experience in managing hostage situations and has strengthened the practice of care offered to its own affected staff by developing an inter-professional comprehensive seven phase care model adapted to incidents of extended duration with multiple stressors. This includes strong coordination between the different actors involved, combined with long-term peer, social and organisational support, as well as workplace reintegration with guidance by colleagues, and specialised counselling when necessary, to ensure positive outcomes, and minimise permanent sequelae.

KEYWORDS:

• Abduction
• post hostage care
• humanitarian
• critical incident stress management
• peer support

Background

Over the past decade, there has been a significant increase in attacks and abductions of humanitarian workers (Aid Worker Security Database, 2015) but there is scarcity of literature regarding the support, debriefing and follow-up given to victims of abduction (Alexander & Klein, 2010; Fletcher, 1996). Available literature on non-humanitarian related kidnapping events often report insufficient support and follow-up provided to ex-hostages (Correctional Service of Canada, 1997; Damiani & Lebigot, 2009).

The International Committee of the Red Cross (ICRC) has extensive experience in managing external hostage situations through its role as a neutral intermediary assisting released hostages at the request of the different actors involved (Salinas Burgos, 1989). However, through history the organisation has also been directly targeted and its own staff taken hostage. In these cases, the ICRC, within its Duty of Care and social responsibility frameworks (Chavanne, 2012), provides the means to resolve the crisis, supports the hostage’s family during the period of abduction while abduction lasts, and supports and provides care to the hostages and families during the release and post-release periods.

Since the ICRC works mainly in volatile and hostile environments (contexts affected by armed conflict) which have an increased risk of security incidents, its staff members are screened both upon employment and prior to deployment through medical examinations to ensure they are in good physical and mental health. When selected for a mission, they are briefed and sensitised about the appropriate behaviour when faced with risks whilst in the field and they are given the possibility of declining a proposed field assignment.

Over the past 10 years, with the aim of better supporting individuals exposed to critical incidents, key national and international staff members of the ICRC have been trained in an active and comprehensive five-day programme on Peer Support Debriefing (Dyregov, 2003; Mitchell, n.d.; Regel, 2012). The interventions of these trained staff members are closely coordinated with the ICRC’s Stress and Resilience Advisor as well with the medical personnel of the Staff Health Unit. In addition, the ICRC has built a worldwide referral network of psychologists and psychiatrists able to provide professional support that takes into consideration the multifacetic personal needs, many of them influenced by culture, of staff members affected by security incidents.

Since 2009, the ICRC managed more than a dozen hostage crises involving national and international ICRC staff members. These individuals have spent between one week and several months in captivity and, in some cases, several years. The conditions of captivity and release have been diverse based on the contexts involved: Africa, the Middle East, the Indian Subcontinent and Asia.

Critically, family liaison and support, provided under the guidance of the Crisis Management Team (CMT), is a key aspect of the comprehensive model of care developed by the ICRC and is provided during the crisis and post crisis periods. The CMT, based at the ICRC headquarters in Geneva, manages the crisis and acts as the decision-making centre. Members of the team include security advisors, human resources representatives, a communications team and clinicians from the Staff Health Unit. Strategic directions and substantive decisions are taken by a Strategic Committee, headed by the ICRC’s Director General.

Comprehensive care model based on peer support

This model ensures ongoing peer support to former hostages and is coordinated by the medical personnel responsible for the health of national and international staff. It is an interprofessional approach, which involves different ICRC actors such as medical staff, human resources and management, as well as external specialist counselling. The model also includes family support. If needed, other forms of support might be added based on individual needs and adapted according to the evolution of the recovery. Based on feedback of hostages from other humanitarian organisations (De Jong, 2012), ICRC’s Staff Health medical personnel has integrated some elements of Critical Incident Stress Management (CISM) (Berclaz, 2009; Regel, Joseph, & Dyregrov, 2007) and of “multiple stress debriefing” (Armstrong, Lund, McWright, & Tichenor, 1995) into peer debriefing. Towards the end of the peer debriefing, emphasis is put on effective coping mechanisms and on the transition from capture to release, through “homecoming”, whereby the length of the incident and the presence of multiple potentially traumatic events are taken into account.

In 2011, the Australian Centre for Post-traumatic Mental Health (ACPMH, 2011) conducted a study aimed at achieving an international consensus of expert opinion on a range of issues in peer support, within the contexts of high risk occupations, that is, emergency first responders, the military and humanitarian aid. These peer support guidelines were developed using the Delphi methodology, which recognises the value of experts’ “opinions, experience and intuition when full scientific knowledge is lacking” (Linstone & Turoff, 1975). The report produced succinct recommendations, which have already been met by the ICRC framework and which also encompass a variety of other interventions and settings.

CISM’s elements described in this paper are identical to those of other critical incident stress management models used by several high risk organisations such as, the British military and some first responders organisations in the UK (e.g. TRiM) (Greenberg, Langston, & Jones, 2008), and the American military and its “battlemind debriefing” (Adler, Bliese, McGurk, Hoge, & Castro, 2009). Similarly, many international first response agencies use peer support as their predominant model of workplace trauma support, with the National Institute for Care Excellence (NICE) Guidelines recently highlighting that early interventions for trauma need to be reviewed and reconsidered as a legitimate model of workplace trauma support in light of current evidence and practice (NICE, 2015).

As per ICRC’s model, comprehensive long term care of ex-hostages comprises seven phases: preparation for release, immediate care after release with support for media exposure, peer debriefing, welcoming ceremony by the institution, follow-up at one month, long-term follow-up, and professional reintegration (see Table 1).

Table 1. Phases and procedures of the comprehensive care model.

Phase	Procedure
Preparation	Information to family Contingency plan for the release: identification of peers, medical facilities, logistic considerations, media management, distribution of roles and responsibilities.
Immediate care	Assessment of general health and immediate needs; restoration of independent functioning through facilitation of communication with relatives and provision of financial resources; peer support encouraging of effective coping; referral, if needed; preparation for potential media exposure.
Peer debriefing	Peer debriefing addressed to colleagues of the same institution; time divided into capture – critical moments during detention – release – return home; focus on psychoeducation, home reintegration, coping mechanisms.
Welcoming ceremony	Ritualistic aspect: “back as member of the institution”, acknowledgement of the ordeal, exchange of experiences, peer and social support.
Follow-up at one month	Physical and mental health care provided as needed by specialists with ongoing peer support addressing the challenges of home reintegrating.
Long-term follow-up	Post release adaptation, distancing from the event and sharing of the experience with continuous peer support.
Professional reintegration	Assignment to a new mission with low security risk, progressive phasing out of peer support, the frequency of which is adapted to the needs.

Phase 1: preparation

Considering the positive influence of appropriate immediate support and adequate follow-up of persons held hostage (Berclaz, 2009; Boisseaux & Vallet, 2009; Centre for Trauma, Resilience and Growth, 2008; Damiani & Lebigot, 2009; Fletcher, 1996), sound preparation for contingency plans takes place both at the headquarters and the field level. Particular care is given to how to deal with unpredictable “unknowns” such as the venue and the timing of release. Similar to the CMT at headquarters, a team is created in the country where the abduction has taken place. Roles and responsibilities of all CMT-members are defined and assigned at this stage and recorded in the contingency planning of the preparation phase (see Table 2).

Table 2. Contingency planning: roles and responsibilities of departments involved.

Department / unit	Role and reponsibilities
Staff Health Unit – headquarters and field	Identification and briefing of trained peers who will give support to the hostage and be in charge of follow-up on release Identification of medical reference facilities (on site and in home country), with defined medical evacuation routes Planning for the briefing of families at the release
Logistics and Administration Department – headquarters and field	Identification of transportation modalities, travel documents, visas, and other specific context-related considerations that might delay the evacuation of the hostage after release
Administration Department – field	Identification of places for immediate support, debriefing, accommodation
Communications Department – headquarters and field	Media management during and after the abduction and at the release: this involves former hostages and team members who have contributed to the release and potential co-hostages

Peers

In addition to applying the usual selection criteria for peer support (ACPMH, 2011; Réseau national d’aide psychologique d’urgence, 2013), excellent active listening skills are required from the peers, who are essentially medical or paramedical staff members. The identified and briefed peer should ideally be of the same gender and come from a culturally-appropriate background, without kinship or close personal connections in the country of abduction. This last point is essential to allow peers to leave the context should threats arise as a result of information obtained during the debriefing.

However, based on ICRC’s experience, if sexual abuse of any nature is suspected in male hostages, a female peer from a different cultural background might be more appropriate. Sexually abused males can find it difficult to speak about sexual assault with a person of a similar cultural background and gender due to shame. If sexual assault is suspected, there is a need to medically expedite the response.

Given the variable duration of abductions, and succession of potentially traumatic events, the briefing of peers includes managing long-lasting incidents and expected reactions after an abduction; information on family networks and, if available, on the general health condition post release; and, information on the circumstances of the capture, detention conditions, and known critical events during the period of captivity and release. These elements contribute to a tailored management of the person being released and influence timing, duration and place of the debriefing as well as type and number of resources required.

Infrastructure

Potential modes of transportation, venues and facilities in different locations are identified for immediate physical and psychological support, together with places for treatment and medical evacuation if necessary. The venue chosen for peer support must be safe, comfortable and neutral, guaranteeing confidentiality. It should ideally be located outside the institution’s offices, to ensure containment, safety and security.

Family support

As families undergo constant, ongoing traumatic stress during the abduction, they are supported by family liaison personnel from the ICRC, under the guidance of the CMT. The family liaison person is in continuous contact with the relatives by phone or through face-to-face meetings. During the discussions, the needs of the family members are identified and reported to the CMT. The type of social support can be informational (regular update on the hostage’s situation, legal framework of hostage crisis management within the country), practical (how to organise themselves in the absence of their beloved, contact with hostage support organisations, forensic, media management support), and emotional (direct support through active listening by the family liaison person), and would vary over time, according to individual needs. It is critical to match the provision of support services to the needs of individuals and families, which is a key part of the ICRC’s model. Families in these situations are recognised as “mental hostages” with no control over the wellbeing of their abducted relative and also exposed to significant trauma (Navia & Ossa, 2003). Social support, as well as external professional support (e.g. psychologist), is associated with better adjustment, since it has often been shown by studies that levels of social support given, relatively soon after a traumatic event, can predict the way reactions and symptoms will develop over the forthcoming months (Joseph, 2003). Therefore, quality and accessibility of social support can be major protective factors after exposure to traumatic events (Brewin, Andrews, & Valentine, 2000). Upon release, the levels of stress at family level decrease because of the notion that suffering is over. To ease the return, families are briefed about the challenges of reintegrating their relative, bridging the gaps and the need of privacy and respect, as well as of the former hostage’s regaining of control. Social support to families during the abduction crisis and after the release contributes to the comprehensive care and psychological support provided to the ex-hostage, facilitating his or her return and reintegration.

Media

Considering the role media might play in reporting during the abduction and after it, communication with media outlets calls for sensitive management. If not managed properly, the impact on the lives of both the hostages and their families could be significant, turning a hostage/captors’ relationship, into a hostage/captor/external world triad (Boisseaux & Vallet, 2009; Garden-Breche, 2003), in which the media might interfere with the negotiations, and prolong the captivity period (by, for example, raising the hostage “value”). Following release, the situation could become an ex-hostage/family/external world triad. In addition, both during the abduction and after their release, personal aspects of the abductees such as their family life and their social and professional background could be made public. With this they become “public persons” and their privacy is breached. During abduction, when abductees are “displayed” before the public, hostages often appear in a state of total dependence, forced to play the role of an object for bargaining (Boisseaux & Vallet, 2009). Therefore, relatives are briefed on how to manage the media (Hostage UK, n.d.-b) and on their possible intrusion into their private lives. Families are advised to avoid or reduce media contact as much as possible in order to protect the privacy of the hostage. The ICRC provides a spokesperson to act as a reference point for the families. At their release, former hostages are briefed on media management and assisted with it (see following section).

Phase 2: immediate care of the hostage after release

A rapid succession of events takes place after the release and the immediate care phase of the contingency plan must be implemented without delay (see also Table 2) (Berclaz, 2009). This involves: providing an immediate update to, and maintaining constant communication with family members; performing an assessment of the ex-hostage’s general health status to identify needs that require immediate referral to specialised resources (this first general assessment will be completed later through a comprehensive medical examination) (Boisseaux & Vallet, 2009); providing a calm environment to restore a sense of security and protect the former hostages from the intrusion of curious others (especially the media); and supporting the sense of self-control in the ex-hostage by providing both means of communication and financial resources. Identified, trained and briefed peers provide immediate psychological support (Canbrera, n.d.; WHO, 2011; Mitchell, n.d.) with a follow-up (Fletcher, 1996), respecting the principles of proximity (beginning management of the case close to the site), expectations (which are the reactions that are to be expected after an abduction and their evolution over time), simplicity (discreetly addressing immediate needs), providing consistency over the long-term, and proportionality (Réseau national d’aide psychologique d’urgence, 2013). The peer supporter(s) remain(s) at the colleague’s disposal and act(s) as “guardian of resilience” (Cyrulnik, 2008) or confidence person, providing stability, acknowledging the ordeal, facilitating understanding and encouraging effective coping. It is essential that the former hostage remains an active participant in all decisions that he or she is offered and sufficient time is provided for decision-making (lessons learnt from ex-hostages’ feedback). Throughout the follow-up, the key aim of this support is to “listen” to the ex-hostage who will – herself or himself – express and identify personal “psychological markers” (elements such as reactions and behaviour) that are to be monitored, with indications of when and where to look for help.

Briefing of the hostage at release – media management

Media exposure can occur when the ex-hostage is presented again to the public as being back home “safe and sound” and can be interpreted as a “relief” or as a “burden” by the ex-hostage. In order to give control back to the ex-hostage, and prepare him or her for media exposure, interviews are prepared, pre-recorded and edited with the agreement of the interviewee, and used for media circulation. It is essential to give the former hostages the possibility of expressing themselves using their own words (Boisseaux & Vallet, 2009). In case of a live interview, and based on the wishes and state of the ex-hostage, a person representing the institution is present (especially if other colleagues are still kept captive). In addition, a message or interview posted in internal communication platforms provides the former hostages with an opportunity to publicly thank all those involved in their release. Often, the ex-hostages only realise the significance of this gesture a few months later – when it might be difficult to re-address as the early opportunity has been missed. Therefore, it is important for the ex-hostage to receive a rationale as to why he or she might wish to publicly thank people in general terms.

There are special circumstances that could make the first media encounter particularly sensitive. For example, in some cases authorities or groups collaborating in the release process hold a press conference directly at the moment of release expecting the hostage to speak. As the person is likely tired and/or emotionally overwhelmed, and may not wish to be seen in public in a vulnerable state or, wearing clothes that are either foreign or linked with a particular group, the ICRC will seek a short period to brief the hostage on what he or she is to say (so as to not antagonise any group), and to cater to immediate personal hygiene and personal needs.

Phase 3: peer debriefing

While peer debriefing is described in this model as a phase in itself, it is also an ongoing process carried out by the briefed peer that continues throughout the different phases. Debriefing aims at restoring autonomy and control to former hostages. It is an opportunity to share their experiences and receive information on what to expect and where to access help and support (Fletcher, 1996). In the case of the simultaneous release of persons held together as hostages, the peer debriefer should assess whether or not it is appropriate to have peer support group debriefing in addition to individual debriefing. In this case, the following points have to be considered: tensions within the group, group size, cultural background, gender distribution and impact of the abduction, both on individuals and on the group. In the absence of a contra-indication to group debriefing (absence of tension in the group, similar cultural background, all persons appear to be affected similarly), this option can be chosen, but will be followed by the offer of an individual debriefing. Peer debriefing usually takes place in sessions with a fixed duration, taking into consideration that ex-hostages are fatigued and have difficulty concentrating. This process usually begins, within 3–14 days after the release (Correctional Service of Canada, 1997).

The duration of the critical incident and the presence of multiple potentially traumatic events requires the adaptation of conventional 7 stage CISM models (De Jong, 2012; Canbrera, n.d.; Mitchell, n.d.) to the specificities of a hostage situation (see Table 3).

Table 3. Peer debriefing components, goals and specificities/remarks.

Components	Goal	Specificities/Remarks
Introduction and ground rules: welcome, aim of the meeting, confidentiality	Create trust, clarify expectations (establish the difference with an operational debriefing)	When determining the duration of the debriefing consider fatigue and the concentration difficulties those who were released might be experiencing
Facts	Go through events in a structured way, with focus on the most critical moments, acknowledge, validate	Time divided into the most critical moments: capture, incidents during the abduction, release, homegoing – if debriefing happens after reunification with family
Thoughts	Acknowledge, validate	Fear of being stigmatised due to displayed behaviours resonant with Stockholm syndrome
Emotional reactions	Acknowledge, validate	Frequently observed reactions: helplessness, guilt, sadness, anxiety, doubts about previously accepted values, numbing of emotions, irritability, hyper-vigilance, difficulty in making decisions and memory disturbance
Normalisation, psychoeducation	Acknowledge potential impact, reactions Normalise reactions Discuss feelings of guilt and avoidance Propose self-monitored timetable (expect reduction in frequency, intensity and duration of reactions over 6–8 weeks if back in a safe environment)	Refer to reactions experienced by other former hostages and their coping mechanisms Provide information on common reactions regarding abductors Regarding guilt feelings towards relatives, inform about ongoing support provided to families Focus on the transition home
Future planning and coping	Discuss about effective coping mechanisms, advise on regaining routines and selfcare, caution on use of alcohol and medicines, deal with “what if” questions, advise on ongoing support and management	Key resilience factors mentioned by former hostages are family and social support, religious beliefs, physical activity, and routines decided by oneself
Disengagement, closure	Summarise the aim of the meeting	Verify peer contact details, hand out information on responsible staff health, provide relevant reading material

Facts

The session is structured so as to cover the critical moments of the incident and divides time into different periods: (a) the capture; (b) the detention, with a focus on the most critical moments; (c) the release; and (d) the return home, incorporating elements of “multiple stress debriefing” (Armstrong et al.,1995) and with an emphasis on the transition to home.

During abductions, often the most dangerous moments are those of capture, attempts at releasing and/or military operations. The moment of release also poses high risk because abductors are often in a state of high alert and could behave in an unpredictable manner (Damiani & Lebigot, 2009) (Boisseaux & Vallet, 2009; Garden-Breche, 2003).

Thoughts and common emotional reactions

The most common reactions mentioned by former hostages after their release are feelings of helplessness, guilt, sadness, anxiety, and doubts about previously accepted values, numbing of emotions, and irritability, as well as hyper-vigilance, difficulty in making decisions and memory disturbances, reactions which have been documented as well in persons exposed to critical incidents (Alexander & Klein, 2010; Correctional Service of Canada, 1997; Fletcher, 1996; Garden-Breche, 2003; Hostage UK, n.d.-a; Rudge & Regel, 2014). A feeling of guilt for having caused anxiety to their families, or for the way they responded to events during captivity, has often been observed. Ex-hostages have also described various ways of behaving towards their abductors during captivity: submission, opposition, superficial cooperation, indifference and cooperation (Baroche, 2009). These types of behaviour vary greatly from one person to another, based on the deprivation and hardships endured during their detention and fluctuate over time. Sometimes hostages become emotionally closer to their abductors in order to create a less hostile environment (Damiani & Lebigot, 2009; Garden-Breche, 2003). In such cases, they fear stigmatisation and rejection by friends, colleagues and society upon their release, because of displayed behaviours resonant with Stockholm syndrome (Alexander & Klein, 2010).

Normalisation, psychoeducation

During the “normalisation” or psychoeducational process (De Haan, 1998) it is important to refer to the experience of other former hostages who had undergone similar abduction-related emotional reactions, in order to demonstrate their “normalcy”. Information is provided on what to expect, emphasising how those other ex-hostages were able to overcome the situation and re-adapt. To address feelings of guilt regarding their families former hostages are briefed about the support they have received during their period of abduction.

Future planning and coping

A realistic time frame for recovery also takes into consideration the context and the duration of captivity as well as all additional potentially traumatic events. Documented key factors for resilience and recovery are family and social support, religious beliefs, physical activity, routines decided by oneself (Alexander & Klein, 2010; Armstrong et al.,1995) and professional reintegration. It is also important to monitor cognitive and behavioural avoidances (Navia & Ossa, 2003), cautioning against the excessive use of alcohol and other substances. The use, or overuse, of medications should also be addressed.

A great emphasis is placed on the transition home, given their prolonged absence whilst held hostages (Armstrong et al., 1995). The various challenges on returning home are discussed, such as the exchange and sharing of experiences lived during their absence (their own and those of their loved ones), the clarification of mutual expectations and relationships, and the development of new roles. Importantly, former hostages should gradually distance themselves from those who became close to them during captivity (Armstrong et al., 1995).

Disengagement, closure

At the end of the debriefing, information describing common reactions to stressors and coping strategies is provided (Centre for Trauma, Resilience and Growth, 2008; Dyregrov, 2005). Former hostages are informed about the ongoing support and management coordinated by the peer, further follow-up meetings – by phone or face to face – are agreed upon, and contact details for psychological referral are provided. Spiritual support is provided on an individual basis as/if required.

Critically, peers who give support to former hostages would benefit from internal and or external supervision, in order to prevent any occurrence of vicarious traumatisation (Armstrong et al.,1995; Réseau national d’aide psychologique d’urgence, 2013).

Phase 4: welcoming ceremony

The institution organises a welcoming ceremony for released hostages. It has an important ritualistic aspect, allowing released persons to change their status from being hostages for whom many were worried, to colleagues coming back. The ceremony is well prepared and involves the former hostages. The peer who was in charge of debriefing, and who knows the ex-hostage’s wishes, assesses if the person is ready to participate or if it may be counter-productive. He or she coordinates with the CMT and provides peer support during the ceremony to prevent the newly released ex-hostage to become “hostage” of the ceremony (Boisseaux & Vallet, 2009). The ceremony enables colleagues to feel reassured, strengthens bonds and allows the ex-hostage to publicly thank all without having to repeat his or her story from individual to individual. The ceremony includes an institutional recognition of the ordeal of ex-hostages and the acknowledgment of the experience of persons directly involved in the hostage crisis and its management. It is followed by ongoing social and peer support that facilitates coping after a professional exposure to a critical incident (De Soir, 2004).

Phase 5: follow-up at one month – short-term post-release adaptation and challenges of home reintegration

Based on the physical and mental health status of ex-hostages, they receive specialised care (Boisseaux & Vallet, 2009), which is coordinated by the Staff Health medical personnel and aligned with the former hostage’s wishes. Psychological consultation for all family members is offered to those ex-hostages who have a partner and/or children. If needed, further individual, couple or family consultation takes place. Some persons also seek spiritual support. Parallel to specialised care, the peer support continues, either through face-to-face meetings or through phone calls. As mentioned in the section on peers, due to specific language and cultural considerations, peer support for national staff members is frequently provided locally by a national or international colleague, whereas follow-up of international staff members is undertaken by international peers. While peers are initially in daily contact with the former hostage, the frequency of the sessions is later spaced in accordance with needs. During these discussions several topics are addressed to help former hostages recover control over their lives and information on what to expect and how other former hostages have dealt with similar challenges is provided. Offers of additional/specialised support are made if deemed appropriate.

During captivity, some hostages elaborate lists of important things to do upon their release, setting new priorities in their lives, “catching up with all that they missed.” However, on their return, they often find themselves still as “hostages”, and dependent on the will of others with an agenda dictated not only by relatives and friends, but also by the media (Boisseaux & Vallet, 2009). In addition, strangers, and others who have become close to their family during their absence, might confront them with morbid curiosity, intruding into their private lives.

Finding a balance between their own needs and the expectations of family and friends is quite challenging, and could cause a high level of frustration. Experiencing even pleasant activities as a burden is a phenomenon often observed around one month post-release. Therefore, once they have spent some time with their loved ones, some individuals need to find a “neutral space”, that allows them to spend time alone, in a protected environment without external disruptors, so they can reconnect, reformulate priorities and regain control. Some ex-hostages who have recovered volunteer to encounter recently released colleagues and exchange their experience with them at this stage.

The return to what ex-hostages consider “normality” may take some time. It is not possible to “compress” this period, which will vary from individual to individual. Ex-hostages, as well as their families, must also inevitably fill the “gaps” stemming from the forced separation in their lives, rebuild a life together (Alexander & Klein, 2010) (Centre for Trauma, Resilience and Growth, 2008; De Soir, 2004) and find ways to re-connect and communicate. If the ex-hostage is the head of the family, other family members may have assumed this role during his or her absence and it will take time for the different members of the family to recalibrate their place and identity in the family system. In many ways, the pattern ressembles that of a family unit following a loss, in which family dynamics shift and where changes must gradually be accepted. However, unlike a loss, following the release, the family member returns and a “new order” is reintroduced, which brings challenges that need to be addressed.

Phase 6: long term follow-up – post-release adaptation, distancing from the event, sharing of experience

Institutional commitment

The rehabilitation of persons held hostage is facilitated by continuous institutional support through ongoing peer support, coverage of medical expenses, payment of wages during the phase of post release adaptation and the gradual reintegration to the workplace (Fletcher, 1996). Peer support to former hostages is maintained at least until the beginning of their next mission – and often beyond that. Phone calls and meetings are scheduled as required.

The ICRC’s insurance scheme covers the salary during the hostage’s absence, as well as the cost of treatments and follow-up. This coverage, in addition to secure employment, is part of the institution’s Duty of Care and social responsibility frameworks (Chavanne, 2012). To provide the former hostage with sufficient time to rebuild links, and to reintegrate to their life and home, salary may be paid during a “compensation” period which has the same duration as that of captivity. This “compensation” period corresponds to social security coverage (Navia & Ossa, 2003) and starts at the end of specialised medical care. Former hostages can decide whether they wish to take advantage of this offer or return to work.

Post-release adaptation and coping

Sharing of the experience and closure

During the months following the release the peer keeps in regular contact with former hostages, listening to them and, depending on the issues raised, discussing ways to help them to find their own solutions. If appropriate, the peer conveys what others have done and discusses different coping mechanisms, such as writing about their period of captivity, to facilitate the reacquisition of autonomy and the emotional distancing from the traumatic events (Assal, 2009; Gagnayre, 2006; Niederhoffer, n.d.). At a later stage, if so desired, the former hostage may choose to share the journal with selected individuals or family members. Former hostages may also volunteer to share their experience with colleagues during trainings and seminars, as well as with persons who have recently been released. Offering the possibility to an ex-hostage to “discuss, listen and ask for advice” from somebody who has undergone a similar hostage situation has shown to be highly beneficial in ICRC’s experience. Participating in the development and/or updating of specific institutional guidelines for hostage and family management or for strengthening of coping mechanisms during captivity, is another way of transforming, transmitting and processing the experience of abduction.

In cases where there is a sequential release of the hostages, the already released individuals are not “completely free” until the release of the last one from captivity and might experience guilt and responsibility for the welfare of their captive colleagues (Fletcher, 1996). An encounter, accompanied or not by a peer, with the relatives of colleagues still in captivity may be considered, depending on the experience, stage of recovery and wishes of the released hostage. This meeting may allow ex-hostages to share their experience, to transform it, and to play a positive role for families of colleagues still held hostage.

A meeting, in a safe place, of all persons abducted together after the release of the last hostage, gives an opportunity to “catch up” and to exchange and process their experience of the period of abduction. Frequently they stay in touch and support each other over the years (Garden-Breche, 2003) while they reintegrate with their families, demonstrating the powerful protective factor of social group support (Alexander & Klein, 2010; Berclaz, 2009; Damiani & Lebigot, 2009).

In case of release in a country other than that of the abduction, a visit to the country of abduction could facilitate closure in those cases in which it is deemed appropriate. Meeting with former colleagues on-site and re-revisiting places may also facilitate their processing of that experience.

Factors leading to posttraumatic growth

Many former hostages develop a new sense of resilience and demonstrate positive changes following their traumatic experiences (Fletcher, 1996), a process similar to that observed in former prisoners of war (Vythilingam, 2008). Posttraumatic growth is a wide-ranging concept, still under development, but for which three broad domains of positive change have been noted. Fristly, relationships are enhanced in some way. For example, ex-hostages describe that they come to value their friends and family more and that they feel an increased sense of compassion for others and a longing for more intimate relationships. Secondly, to a certain extent people change their views of themselves. For example, they acquire a greater sense of personal resiliency, wisdom and strength, perhaps coupled with a greater acceptance of their own vulnerabilities and limitations. Thirdly, people describe changes in their philosophy of life. For example, finding a fresh appreciation for each new day and revaluating their understanding of what really matters in life, thus developing new priorities. (Joseph & Linley, 2006; Tedeschi & Calhoun, 1996) (Joseph, Murphy, & Regel, 2012). These developments in our conceptualisation of how humans deal with traumatic experiences further builds our understanding of resilience with recent literature highlighting that, for many people, a traumatic event catalyses internal resources of competence, coping and resilience (Bonanno, 2004).

Phase 7: professional reintegration

After recovery, the ICRC offers former hostages the possibility of returning to work within the institution while reducing risks as much as possible. The offer a new assignment to a former hostage is aligned with the institution’s “obligation to protect” its staff and the need to “restore autonomy” for the former hostages through work resumption. Since the abduction took place while being on a mission, going back to a mission is frequently described by former hostages as essential as it allows them to regain their identity as humanitarian workers. However, work resumption should be well planned. In cases where the former hostage decides not to return to his or her aid work, the health insurance coverage continues for two years after the end of contractual obligations.

A new mission is proposed for expatriates in a country with low risk of security incidents. Depending on vacancies and on the competencies of former hostages, an assignmenrt is organised respecting their wishes as much as possible. After the successful completion of this new field mission and with the former hostages’ consent, they are placed into the regular assignment system – while ensuring they will not be assigned to countries with significant risk of abductions. The comprehensive management of work resumption includes informing the supervisor and former hostage of possible stress reactions, and of when and whom to call for support. The peer remains available for support, particularly during the first months of the new mission and during its most critical moments: for example, those recalling the event, such as working in a similar environment, or when the date of the event “anniversary” takes place (Garden-Breche, 2003).

On release, national employees are assisted in returning to normalcy by accompanying them during their gradual re-exposure to the environment. As they remain in the country where the abduction took place, they may be more vulnerable than expatriates, and in case of impunity, face the risk of meeting the abductors. Exposure to “media reminders” related to abductions may also be higher than among expatriates. These factors may contribute to longer recovery times of ex-hostage national staff members, added to the persistent insecurity related to conflict or other situations of violence in their country of residence. Social support by the institution, and the possibility to resume work, helps them in their adaptation. This is even more important in fragile environments, where otherwise families are the only reliable source of support and safety (Navia & Ossa, 2003). If national employees are not able to resume work, long-term support has to be adapted to each situation.

Conclusions

This paper describes the processes employed by a leading humanitarian organisation, with extensive experience in managing post-hostage situations. Following release, individuals previously deprived of liberty, do not immediately feel “free” (Boisseaux & Vallet, 2009) and it takes time to reintegrate the person upon return (Armstrong et al., 1995; Hostage UK, n.d.-a). The purpose of peer support is to restore control, and mobilise personal resources and those of the person’s relatives. In addition, social and professional support allows those released to process their experience (Boisseaux & Vallet, 2009). It is important for the former hostages to realise that their reactions are common among people subjected to captivity. Being aware of what to expect and where to find support, if needed, is critical for adaptation and recovery. The longer the duration of the potentially traumatic incident and the succession of critical moments during an abduction, the longer the follow-up required compared to cases of single critical incidents (Fletcher, 1996). Accompaniment by a humanitarian peer, coordination of follow-up (Boisseaux & Vallet, 2009) and the ongoing institutional support including workplace reintegration, are key factors in ensuring post-release recovery of ex-hostage staff members.

Acknowledgements

The authors wish to acknowledge Michel Berclaz and Christian Progin, in charge of peer support training in Geneva, Switzerland, who supported early outlines of the article. Special recognition is given to Andreas Notter, ICRC staff and former hostage, for his invaluable contributions and friendship in ensuring successful comprehensive management of hostages at the ICRC.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Sigiriya Aebischer Perone, MD, works at ICRC’s Health Unit and the division of tropical and humanitarian medicine at the Geneva University Hospitals, Switzerland, with clinical, project management and training activities focusing challenges in fragile environments. As a former head of ICRC’s Staff Health, she developed a comprehensive care model for critical incident management.

Fabrice Althaus, MD, is specialist in General Internal Medicine, has a postgraduate degree in Tropical Medicine and International Health. He is Head of Staff Health Unit of ICRC, has experience as research physician in Tanzania (Swiss Tropical Institute) and for the Vulnerable Population Unit of the Lausanne University, Switzerland.

François Chappuis is heading the division of tropical and humanitarian medicine of the Geneva University hospitals, Switzerland, and is Associate Professor of humanitarian medicine at the University of Geneva. He has worked as medical adviser for neglected tropical diseases at Médecins sans Frontières since 1999.

Natalia Aguirre Zimerman, MD, Obgyn Specialist from Colombia worked as a Health Delegate for the ICRC. She participated on the ground for the release process of seven international hostages in Sudan and in the Incident Management team in Damascus and as family liaison to two families of a prolonged hostage situation.

Dr. Esperanza Martinez is the Head of Health for the International Committee of the Red Cross (ICRC). She is a medical doctor/general surgeon, specialised in International Public Health and Health Management. She has worked for the private sector, UN agencies, government bodies and NGOs and her experience includes over ten years of field work in conflict-affected contexts.

Stephen Regel is Professor/Director and Founder of the Centre for Trauma, Resilience and Growth, School of Education/Nottinghamshire Healthcare NHS Foundation Trust, Nottingham UK. He is also a principal advisor for Hostage UK and consultant for the ICRC’s Peer Support Programme.