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Narrative medicine practices as a potential therapeutic tool used by expatriate Ebola caregivers

Intervention 2017, Volume 15, Number 2, Page 106 - 119

Narrative medicine practices as apotential therapeutic tool used byexpatriate Ebola caregivers

Tim Cunningham, David Rosenthal &Marina Catallozzi

Key implications for practice� Frontline expatriate healthproviders

used narrative methods to managestress andmakemeaning of su¡eringwhileworking with Ebolapatients

� Narrative medicine o¡ers potentialtools for the psychosocial support ofexpatriate healthcare providers

� National and international health-care providers need e⁄cient ande¡ective psychosocial support tomanage secondary traumatic stress

Thisstudy examined how expatriate healthcare pro-

viders used narrative methods to process their experi-

ences of working with Ebola patients. Key

informant interviews and associatedmedia and blog

posts were analysed using an inductive thematic

approach. Open coding informed the creation of a

codebook which, in turn, was the basis for axial cod-

ing and thematic development. A team of researchers

collaborated in both coding and theme development

in order to address potential subjectivity bias. In

the results of 6.5 hours of interviews with 20 nurses,

physicians and nurse practitioners, four themes sur-

faced regarding use of narrative methods: memorial-

ising, advocacy, self-re£ection, and camaraderie.

Providers of narrative methods reported bene¢cial

and therapeutic e¡ects of writing and public speak-

ing, as well as the therapeutic value of sharing nar-

rative practices with other colleagues. Evidence in

this context suggests narrative medicine practices

may mitigate negative sequelae related to secondary

traumatic stress.

Keywords: compassion fatigue, Ebola,expatriate healthcare workers, narrativemedicine, secondary traumatic stress, WestAfrica

Stare out the window and weep,

Reality haunts those who sleep.

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Break fast in the black,

One week to normal, there’s no turning back.

One line at a time, step to the side.

Awar without pieces to divide,

With echoed laughter and fallen tears.

Oh begging that we change.

Here’s begging we change.

(Excerpt from a song co-written by astudy participant)

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IntroductionBackground: EbolaFrom December 2013 until March of 2016,Ebola virus disease (EVD) caused inter-nationalpandemoniumalongits swathofsick-ness and death [World Health Organization(WHO)2016].Theepidemickilledmore than11,000 people, infected more than 28,000 andcost the US Government alone, 2.39 billiondollars (USAID, 2016). Organisations such asUSAID,UKAID, theWHO,Centers forDis-ease Control, Me¤ decins Sans Frontie' res(MSF), Partners in Health, InternationalMedicalCorps, Save theChildrenUK,Inter-national Committee of theRedCross, aswellas the Cuban Government contributed sub-stantial funds and personnel to the response.At least 2,365 healthcare providers weretrained in EVD patient care and deployed toSierra Leone, Guinea and Liberia (MSF,2015; personal communication from Decem-ber 2015 to February 2016).

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Cunningham et al.

More than 800 healthcare workers wereinfected by the disease, and more than 500died (Statista, 2015). Humanitarian aidworkbrings with it the potential for extreme stress(Sokol, 2006) and the Ebola outbreakreinforced the challenges humanitarianhealthcare workers face when working withlimited supplies and rapidly spreading con-tagion (Kilmarx et al., 2014).With case fatal-ity rates of 75^80% for children under ¢veyears old in some Ebola treatment centres(ETCs) (Trehan, Kelly, Marsh, George, &Callahan, 2016) and unusually high rates ofdeath by secondary causes, medical provi-ders witnessed excess mortality on adaily basis.

Narrative medicine and compassionfatigueThe practice of narrative medicine (NM) isa relatively new concept based on centuriesold practices of artistic creation and abstractthinking (DasGupta, & Charon, 2004). If‘illness prompts secrets, con£icts and contradiction

along with brave sincerity and distilled identity’asCharon (2006) suggests, and if healthcareproviders can achieve a better understand-ing of their altruistic identity throughwitnessing illness andparticipating in narra-tive practices (McCormack, 2010), then the¢eld of NM merits close investigation interms of its utility in practical settings. Nar-rative theory relies on the power of plot, orthewholenessby which a story is told, so thatthe audience or writer is able to make mean-ing in an often more abstract and profoundmanner than if events were laid out inchronological order (Culler, 2006). Hauser,& Allen (2007) insists that a person’s abilityto develop plot in a narrative re£ects hiscapacity to manage adversity. Adversity, inregard to stressful challenges in one’s pro-fession or in witnessing traumatic events,can whittle away at psychological andemotional health (Epel, Daubenmier,Moskowitz, Folkman, & Blackburn, 2009;Hensel, Ruiz, Finney, & Dewa, 2015). If

ht © War Trauma Foundation. Unautho

narrative practices can enhance mentaland physical health by providing healthcareproviders with tools to examine and makemeaning of challenging lived experience, asPennebaker (2000) suggests, then they oughtto be employed more readily in a myriad ofcontexts. One context, in which there is adearth of literature regarding the bene¢tsor risks of narrative practices, is in the litera-ture regarding expatriate and national sta¡humanitarian aid workers.NM practices could o¡er potential mitiga-tion of stress. NM takes an art basedapproach to help medical providers honetheir communication skills, in order to bemore present with the people for whom theyprovide care (Shapiro, & Rucker, 2003). Asmall body of evidence suggests that thesepractices may encourage more compassion-ate care by providers, as well as girdingresilience (Krasner et al., 2009; Moore,Rivera Mercado, Grez Artigues, & Lawrie,2013). NM’s concept of a⁄liation or ‘theauthentic and muscular connections between doctor

and patient, between nurse and socialworker, among

children of a dying parent, among citizens trying to

choose a just and equitable health care policy’(Charon,2007, p.1267) is atheoretical explan-ation of how NM may function. Throughthese ‘authentic and muscular connections’ thewriter (or healthcare worker) may be able toconstruct meaning and develop a deeperunderstanding of su¡ering and pain. NMhas not been rigorously studied as a thera-peutic method for medical providers who usenarrative approaches, yet it holds promiseas an e¡ective psychosocial tool.Compassion fatigue (CF), also known as sec-ondary traumatic stress (STS) and burnout,are concepts ubiquitous to all health careproviders. The higher the exposure (dose) ahealthcare worker has in caring for thosewho experience extreme su¡ering or trauma,themore likely s/he is to develop symptoms ofSTS (Smart et al., 2014; Melvin, 2012). STSand burnout can also be positive predictorsfor shortening a professional career throughnegative physical or emotional health e¡ects.

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Table 1. Key informant interviewquestionnaire Frontline Ebolaresponders

^What are some coping mechanisms thatyou used to manage the memories ofexperiences while working in the Ebolaresponse? Please describe what you didwhile working inWest Africa, as well asafter you returned.

^ If youthinkabout yourqualityof lifebeforeyou left and since you returned, how is itthe same or di¡erent?

^ You indicated that youused creativemeanslike writing or the visual arts to describeyour experience.Will you discuss whatform you used andwhy you chose thismethod of communication?

^Were there anykeymessages or themes thatyouwanted to share?

^ You indicated that youused creativemeanslike writing or the visual arts to describeyour experience. Did you share this workpublicallyor privately withjust familyandfriends? Please explain why you shared itthe way you did.

^ Will you describe what your process waslike when youwere creating thesedescriptions of your time working withEbola patients?

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Humanitarian aid workers and frontlineexpatriate aid workers would be at high riskfor STS and other emotional detritus stem-ming fromwitnessing excessive death duringtheir work with EVD patients. It may bepossible that the practice of using narrativemethods to process, describe and/or evaluatetheir experience, may bu¡er against STSand burnout.

ObjectiveThis study examined how expatriate health-care providers used NM to process theirexperiences from working with EVDpatients, and whether these processeswere therapeutic.

MethodsAfter receiving Institutional Review Boardapproval from Columbia UniversityMedical Center, data for this study were col-lected from20 key informant interviewswithexpatriate healthcare workers (nurses, phys-icians and nurse practitioners). The partici-pants were self-selected from a largermixed methods study investigating STS,burnout and compassion satisfaction amongEVD frontline responders.The study designincluded developing open ended questions(Table 1) intended to assess the use of NMtechniques, aswell as the presence of dissatis-faction or satisfaction related to pasthumanitarian work.Interview questions were based on concep-tual frameworks illustrative of the narrativeprocess based on the Todorov NarrativeTheory (Todorov, &Weinstein,1969) as wellas anadaptationof Day&Anderson’s frame-work regarding the development of STSand the anticipated e¡ects of NM practiceson it (Day, & Anderson, 2011). Interviewswere conductedbyTC.TC reviewed all tran-scriptions and removed identifying data,then uploaded all de-identi¢ed transcriptsto an online, encrypted platform calledDedoose 4.12TM (2016).

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Acodebook was developed after coding fourtranscripts (numbers 20, 15, 10 and 5). Theanalysis teamthen applied open coding, util-ising this codebook, for all 20 transcripts.Axial coding and thematic development fol-lowed. The analysis team was comprised ofsix investigators:TC, MC and four graduatestudents. Subjectivity memos and exerciseswere undertaken by investigators to addresspotential biases during analysis.In addition to analysing key informant inter-views, the research team also analysed eightother narrative pieces that had already beenmade public throughblogs, websites or social

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Cunningham et al.

media. These additional examples wereselected for analysis because they were men-tioned by participants in the interviews asnarrative pieces that were reported to havebeen in£uential to the respondent.

RecruitmentTC contacted leadership at various nongo-vernmental organisations (NGOs) thatdeployed expatriate healthcare workers toprovide care in the EVD response. Herequested that their leadership send emailsto any potential volunteers or sta¡ membersrecruiting for the study. Additionally, TCsent direct emails to colleagues who hadserved in the response.Interested participants were sent a link to ananonymous online survey designed to quan-titatively assess STS, CS and burnout.Participants were given a prompt asking ifthey used narrative methods as a way todocument their experiences working withEVDpatients and if theywouldbe interestedin being interviewed. ‘Narrative methods’ inthis context, was based on de¢nitions ofNM practice, include writing, visual arts,public speakingand/ormusic. If the providersubmitted their email address, they werecontacted byTC.The ¢rst 20 who respondedto scheduling emails fromTC after submit-ting their consent were selected for inter-views. Interviews were conducted usingSkypeTM or FaceTimeTM.

ResultsEighty-four visits were logged to the onlinesurvey, and 63 participants completed it.Of those, 27 participants consented to beinterviewed.The average length of interviewwas just over 24 minutes, and total interviewtime was 6.5 hours.Twenty participants were interviewed andfrom those, one interview was removed fromthe analysis because the interviewee hadnot actually provided direct care to patientswith EVDas s/he had indicated in the onlinesurvey. Of the 19 participants, three

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mentioned that they had never worked in ahumanitarian response prior to their workin the EVD crisis. It is notable, however, thatall three of these had extensive travel experi-ence to and/or work experience in ‘develop-ment’ in resource poor settings. None ofthose interviewed were novices to workingin settings di¡erent to their own culture.Despite having experiences working inresource poor settings and having receivedtechnical training with regards to treatingpatients with EVD, respondents collectivelyintimated that they did not understandexactly how challenging this work wouldbe. One participant put it succinctly: ‘soI, no, I don’t think any of us was prepared for

what we saw on the ground’. Table 2 providesdemographic data of respondents. Mostparticipants stated they wrote, journaled,blogged or gave public presentations. Twoparticipants reported writing lyrics andcomposing music, and one participantreported using drawing and painting as anarrative methodology.Respondents o¡ered equally a⁄rmative andnegative responses as towhether they sharedtheir narrative works publically, withimmediate friends and family, or not at all.Also, in addition to producing some sort ofnarrative form, a preponderance of partici-pants noted that they readblogs andjournalswritten by other providers to manage thememories from the experience: ‘so. . . seeing itfrom somebody else’s point of view. . .made the

experience in a way, more real’.Axial coding facilitated the development ofpertinent themes that follow here. Thesethemes below best re£ect the lived experi-ence shared by EVD providers and theiruse of narrative methodologies within thiscontext.The themes: memorialising, advocacy,self-re£ection, and camaraderie illustrate thetherapeutic process that these providersused as they used narrative means toenhance or maintain empathic ability.Table 3 provides additional in depth themesandquotations to supplement the discussionthat follows.

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Table 2. Descriptive demographics from interviews by profession and yearsexperience

Mean/Median/Mode:Days spent inEbola response

Mean/Median:Years inprofession

Mean/Median:Past

humanitarianmissions

Full sample (n¼19) 129/42/42 15.7/10.5 7/4Nurses (n¼ 6) 84/63/42 15.7/12.5 11/4Physicians (n¼ 8) 51/42/42 19.3/19 12/4.5Nurse Practitioners/

Physicians Assistants (n¼ 5)120/63/� 10.3/10.5 3/4

0^5 years exp. (n¼ 2) 33/33/ � 2/2 06^10 years exp (n¼ 7). 67/42/42 8/8 4/411^15 years exp. (n¼ 3) 63/63/ � 12.8/13 3/3>16 years exp. (n¼ 7) 57/42/42 28.7/30 20/10Total recorded interview time: 6 hours, 30 minutes.Mean interview time: 24 minutes,12 seconds.

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ThemesMemorialisingA salient theme from the interviews centredon the desire not to forget.When promptedabout the writing process, one participantmentioned how challenging it was to sitand write in a journal, however, the partici-pant also remarked: ‘with me, it’s more like I’mgetting this down so that I have a nice, clear record

for the future’.During the interviews, respondents men-tioned EVD patients and their family mem-bers by name. There was a sense of clarityand precision in the tone of the interviewswhen providers spoke of children, in particu-lar, for whom they had provided care. Oneparticipant recounted the story of a childwho had survived:

‘And this goes to, I don’t know if you remember

[name removed] who survived and thenended up at the other hospital, that eight-year-

old girl.

Q:Yeah, she was severely malnourished for

quite a long time.

Response: Severely malnourished, some sort of

an odd B vitamin tremor and all kinds of

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weird things. Orange hair. I mean, she was

sick as [name removed]. By the way, she’sdoing tremendously.’

Stories of survival and defeat permeated theinterviews. Yet, more than emphasising thefrustrations of working in a resource poorsetting with EVD and addressing the health-care inequity they witnessed because of sys-temic challenges and NGO disorganisation,respondents overwhelmingly stated that theywanted others to understand that they weretreatingpeople,notstatistics.Bymemorialisingdetailed and individual stories about thepatients they treated, providers reported thattheywere able to solidify their ownmemoriesand advocate against the ‘othering’ that fre-quently occurs in humanitarian aid:

‘You know, I suppose to individualise these

people was the only thing that I could think of

to try to bring this home that this wasn’t just

anotherAfrican epidemic that the US doesn’t

have to think about.This was like these were

people with names and families, you know.

I don’t think that I did that consciously, but in

retrospect I think that’s part of what I tried to

get across, you know, so that theymattered.’

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Table 3. Data display re£ecting themes, codes supporting themes and additionalexcerpts illustrating themes

Theme ExcerptsMemorialising

Codes supporting:Memorialising

‘The themes are just. . .it’s very kind of straightforward. It’s notlike,‘‘Oh, God, things here are so miserable and terrible.’’And

like,‘‘Oh, the tragedy, oh, the su¡ering.’’It’s nothing like that.

Nothinglikethat. It’smore just, like, Ithinkrecordingbecause

I knewthat thingswere sohectic, itwould be reallydi⁄cult to

remember later.’ (1)Othering

Others not wanting to hearImpactWriting processNot wanting to forget

‘. . .itwasjustmoreofthesame, youknow...except eachbookthatI go into it’s like,‘‘Wow’’I was feeling this way then and...it

kind of amazes me when I can go back and read it and

go...‘‘Wow, what kind ofa place was I in?’’You know...’ (11)

‘Yeah de¢nitely, I think the. . .the act of. . .of. . .honouringa lifethat was lost by sharing the story. I think that

sometimes. . .prior to this I had felt. . .I felt sort of self-conscious or disingenuous sharing stories of patients that I

had lost.’ (17)‘And hopefully the memories will live on. And whatever, you

know, I don’t know if we’re going to do little written pieces

with it. I’m not quite sure of that part yet, but hopefully those

pieces will live on, and it will mean whatever it means if

anybody buys them. I don’t know.Maybe nobody buys them.’(4)

‘Like this. . .especially in other humanitarian situations, andthis made me realise, that how important it is to share those

stories and that it’s not sensational and it. . .sensationalism.It’s ^ it’s reallyhonouringandrespectingthestrugglethatthat

person had.’ (17)‘And that’s the most frustrating thing when you come back and

you’re trying to sort of deal with this insanity about people’s

fear with Ebola.You’re like,‘‘These are humans.These are

humans.’’You know? I think that, I felt like for me that was

themostimportantmessageIwantedtokeepgetting across.’(18)

Theme ExcerptsAdvocacy

Codes supporting: Advocacy‘You know, and Iwanted tobe able to tell themwhat Iwasdoing

and tosort ofget thatmessageacross.And then it stayedpublic

because it mattered to people to read it because people would

write back and say, you know,‘‘Thank you for writing that

and, you know, I’ve felt thatwayabout patients before, or I’ve

had that experience and I wasn’t able to articulate that.’’You

know, and it seemed to. . .it certainlywas helpful to me togetfeedback from people like I read it. I hear you.You know, I’m

glad you said that.’ (10)

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Writing processTherapeutic public speakingMedia in£uence responseSupportive feedback from peers

‘I had 3weeks ofquarantine so that wasgood just to have time toreally sit I think with it, and then when I came back to work

I just, I had it - I had to do a presentation and that actually

helped solidify some...for me, help solidify my experience

and...’ (14)‘So Imean Ispoke.My copingmechanismwas I ended upgoing

down, I felt ridiculously guilty as Imentioned, so I ended up

tryingto contributeasmuchas Icould after Igot back.Oneof

the ways that I did that was I helped with the [nameremoved] course to train other health care workers to godown, and I kind of felt like I wasmultiplyingmyself in that

way.’ (18)‘Themost therapeutic was putting togethera talk which meant,

you know, taking slides and telling stories.’ (2)Theme ExcerptsSelf-re£ection

Codes supporting:Self-re£ection

‘You know, so it was. . .it was a survivalmechanismforme.’ (7)

Therapeutic writingWriting processesTherapeutic meditationTherapeutic^writing^trying

‘Andthat they - theyhelpme...kindofsummariseandget througheachdayandtheneachweekasawholewhereIcouldlookback

and see...the negatives and the positives of the whole week.

And...and keep pushing forward with it in general.’ (16)‘Sotheart forme in like the sel¢sh reasonsofwanting to do this is

because Ifeel like it’s away that I can tell the stories and have

the stories live on, and they’re notgoing tobegraphic storiesof

people bleeding and kids dying and people being in. . .youknow, having to have their bones broken in order to get into

bodybagsand, youknow, that Ican tell those stories and these

threeartistswhoIreally,reallytrustwilltakethosestoriesand

will make their art with them. And so it will hopefully serve

my need of needing to kind of put some of this to rest, some

closure to some of it.’ (4)‘Which is a sort of...¢rst centring with simply following your

breath and then going through some simple things like...it

mightbemayIbesafe,mayIbestrong,mayIbewell,mayIbe

happy, you know...may Ibeat peaceandfree of fear.Maymy,

have Ibeen fullwith ease, but, and thenmoving that out to the

people around you so, or my family. It ^ it’s a Buddhist

meditation. So, I didMetta every single night. I did...I used

music.’ (8)Theme ExcerptsCamaraderie

Codes supporting: Camaraderie‘Imean, I think little things like the walk back and forth was

important, and you probably have, you know, saw it or heard

about this, the eating meals together was important because,

youknow, there’sthatpassage, I’msureyouknow, fromHenry

V,Act IVScene 3, you know,‘‘Hewhoshedshis bloodwithme

shall be my brother.’’’ (15)

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Dissatisfaction othersDissatisfaction organisational focusDissatisfaction health inequitiesDissatisfaction self

‘The majority of the people on the ground were phenomenal

humans. . .like some of the best human beings I’ve evermet.’ (10)

‘Yeah, and also theAfrican Union sta¡ at [location removed]wereoutstandingand, like, theKenyanscomingin tohelpand

then in addition to all theWestern expats and, like, the

colleagues who were directly in my cohort.’ (5)‘I think when I was there it really helped to just kind of talk to

other people about...you know, what we were doing every

day and so, and I think that just kind of happened naturally

like...in the, you know camp where we were...there was

kind of like a...like a...bar area and so after dinner or

sometimes we poured in there where we’d just like sitting

around and just talk about what had happened that day,

and...yeah, and I ^ I think that...just - just talking

through it with people was just...it was really, really

helpful.’ (12)‘I think the biggest coping mechanism was just talking about

and encouraging the folks that I lived with and worked

with to talk about what was going on, sharing our feelings,

and I think we were really a great support for one

another.’ (2)

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‘Othering,’ in this context, arises frommedicalproviders creating a sense of detachmentfrom the sickest of patients. Providers in thisstudy struggled with the way the mediaseemed to make ‘other’ or minimalise theway that this epidemic was portrayed asbeing so‘foreign’or ‘just anotherAfrican epidemic.’They detailed their journals and blogs, notonly for the sake of memory and to honourthose that they witnessed die, but also toadvocate for their patients and, in general,for the citizens of Sierra Leone, Liberiaand Guinea.

AdvocacyProviders found that it was bene¢cial in theinterviews to compare their work withEVD patients to extreme situations theyhad witnessed in other work settings. Theuse of metaphor was also a tool in some inter-views to express a theme. One respondentlikened the life changing experiences that

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occurred while working in Sierra Leone totaking the red pill —a cinematic allusion tothe ¢lmTheMatrix inwhich‘taking the red pill’enables the ¢lm’s protagonist to permanentlyvisualise the world in a completely newway. The provider used this metaphor as alaunch pad from the experiences of workingin West Africa to the provider’s homecountry:

‘You take the red pill and you can never see the

world the same way again. And so, I came

back. I was still a professor at the medical

school. I felt like I had taken the red pill. . .right around that period of time. . .the riotserupted in Baltimore around Freddie Gray,

and, you know, we had been thinking and

praying about a community where we could

live and serve, and the infant mortality infor-

mation in the area where the riots were was

just so stunning to me. It reminded me of

Africa. If you are an African^American baby

in Baltimore, you have a four to eight times

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Narrative medicine practices as a potential therapeutic tool used by expatriate Ebola caregivers

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higher chance of dying in your first year of life

than a wh i t e baby born in th e same

[city]. . .Washington is 10 times higher. If

you’re black and born inWashington, the black

baby has a 10 times higher chance of death in

the first year of life.’

Not only in the interviews did providersadvocate for people and populations wholive under structural, organisational andeconomic duress, but they also used the nar-rative form of public speaking to advocatefor the patients they served. A few respon-dents participated in aTEDTM programmecalled ‘The next outbreak?We’re not ready.’ It sup-ported the stance of its keynote speaker, BillGates, that this epidemic unveiled human-ity’s interconnectedness (Gates, 2015). Advo-cacy was a tool used by providers onintimate levels, as well as with broadinternational audiences.Public speaking among the interviewees wasmet with mixed reactions. Many of themwere asked to give lectures about theirexperience working with EVD patients.Some took this task on with vigour, othersweremorehesitant.Those that providedpre-sentations mentioned the therapeutic e¡ectthey felt from giving voice to their experi-ence:

‘My medical school advisor runs the Global

Heath Program at [name removed. . .andhe was going to do a seminar, a big lecture on

Ebola and he asked me if I would do it and I

said no. . .And he knows me reallywell. . .andhe said, ‘‘You really need to do this. It will be

really good for you’’.’

This participant went on to say that,although there was signi¢cant resistance topresenting initially, when s/he spoke a thera-peutic feeling of recovery occurred: ‘it tookme totally by surprise because, you know, ¢rst o¡ it

was eight months later, right? And how much do I

have to process, right?’ Not all providers gavepublic remarks about their work with EVDpatients. Those that did reported these

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practices as not only methods for which toadvocate for those a¡ected by EVD andthose living in challenging situations aroundthe globe, but also as tools that providedthem with a platform to address their ownfeelings of guilt, anger and sadness aboutworking in the epidemic.

Self-re£ectionThe following codes: therapeutic^writing,

therapeutic^writing^trying, therapeutic^medita-

tion and writing process formed the theme ofself-re£ection and showed the many ways inwhich participants spent time alone tore£ect, and then create and share.Participants reportedusingmusic in order tomake peace with the extreme su¡ering thatwaswitnessed. Escapingby oneself to aplaceto listen to a classical piece of music, or bycomposing a piece to share with others,re£ected how providers used both privateand public means to make sense of the day-to-day challenges they had facedwhile treat-ing EVD patients.After returning home, providers reportedthat it was therapeutic to readblogs or re£ec-tions on their experiences from other provi-ders:

‘I just felt like I had trouble puttingmy feelings

and experiences to paper. And so, finding other

people’s feelings and experiences and then just

sort of either reposting or sharing them with

like people who are more eloquent.’

One provider was suspect of people sharingtheir narratives publicly, suggesting thatthe writing was not entirely truthful.Sharing one’s self-re£ections was bothbene¢cial and potentially detrimental toother providers who chose to read thosenarratives.Self-re£ection manifested from a solitary actinto group activities and sharing. Peoplewrote, read and meditated in private, butthen sharedwith their immediate colleaguestheir creativity, thoughts and struggles.

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Cunningham et al.

A song titled,‘The Chlorine Blues’was writtenby one of the responders; it closes with thefollowing lines:

‘another man done gone,

I never knew his name,

another child done gone,

another baby done gone,

I never knew her name,

another woman done gone,

I never knew her name. . .’

The recording of this song was taken in alarge, open setting. Backing up the instru-ments that produced the melody are voicesof people laughing and talking as the songplays. It does not sound as if people in thebackground were laughing at the lyrics,rather, there was a sense of communitythat this recording captured, a communityin the setting of death and unspeakablesu¡ering.

CamaraderieUnsolicited by the interviewer, most of theEVD providers mentioned that sharing stor-ies, songs or the events of the day with theother providers was therapeutic. Thoughnot o⁄cially a ‘narrative practice’ it is import-ant to mention the role of camaraderie andits e¡ects on this research.

‘That doing this immediate work that

is...wonderful, beautiful, and...in ^ in the

sense that I’m, I’m engaging with people in

ways that...just amazing people, there’s a

beautyhere.There’s a love, there’s...Imean, just

this sense of ...the humanity is so incredibly

beautiful, and it’s overlaid with this horror.’

In light of the extreme stressors, providersspoke of paradoxical feelings of love andbeauty.These close relationships manifestedin email or Skype communication afterproviders returned to their homes.

‘Talking to people, which our country made it

ext remely d iff i cu lt because we were

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quarantined for three weeks. It was the most

important time that you need to decompress.’

While working with the EVD response,these providers had the opportunity to meetwith each other daily to debrief their experi-ences. On returning home, providers wereabruptly removed from the company of eachother, so just at the point when providerswere readjusting to a new normalcy, theydidnot have the same support theyhadwhileworking in the ¢eld. It is evident that manyproviders reverted to narrative methods inthe formof emails andblogs to communicatewith each other in order to maintain a senseof camaraderie. This camaraderie, accord-ing to the respondents, endures to this day.

DiscussionNarrative methodologies were readily uti-lised by some expatriate healthcare provi-ders during the EVD response. Thesemethodologies were not always used primar-ily as a therapeutic tool. Yet, providers whocreated works using narrative methods orread works by others, report therapeutice¡ects from doing so. In a few interviews,participants mentioned speci¢cally that itfelt therapeutic to incorporate narrativemethods, and these statements alignedwith claims from literature speci¢c to NM(Shapiro, 2008).The intention to not forget, to honour and tomemorialise patients with whom providersdeveloped unique relationships, pervadedthe interviews when respondents spoke ofwhy they used narrative methodologies.They wrote, they sang, they devised artisticprojects to preserve memories, both gro-tesque and gracious. This process supportsassertions byMacpherson (2008) andWesseland Garon (2005) describing how medicalproviders use narrative to honour the livesof the dead.Beyond intending tomemorialise, these pro-viders also worked to advocate for patientswho were e¡ectively voiceless in thecountries from which the expatriate

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providers hailed. Those patients that werenot voiceless were all too often portrayed as‘other’ in the media, a stereotypical poor per-son living in a stereotypically poor country.By advocating for the communities theyserved, providers reported a sense of comingto terms with the su¡ering they witnessed.In e¡ect, advocacy was therapeutic tosome respondents.Participants also used forms of storytelling,that is building a narrative with plot, so asto address a theme. In constructing plot totheir narratives, they developed a personalnarrative identity that likely connected themmore soundly to the stories, those to whomthey were telling the stories and the patientsthemselves (Culler, 2006; Hauser, & Allen,2007). Though camaraderie is not a form ofNM, providers embodied a sense of a⁄lia-tion through camaraderie thus makingevident the e¡ects of a NM theme.The pro-viders engaged with each other for therapyand to share their narratives. This act mir-rors the concept of a⁄liation that Charondiscusses, as it stands as a result of NM prac-tice (2007).From self-re£ection to devisingand sharinganarrative, this process appeared to providetherapeutic bene¢ts. Miller et al. (2014)describes the importance of self-re£ectionas a key ¢rst step in constructing a narrative,particularly in regard to medical care. Itwould be incorrect, however, to assume thatone particular step within the full processof an expatriate provider’s experience work-ing with EVD patients would be the only fac-tor providing therapeutic bene¢ts. It wouldalso be obtuse to ignore the positive attri-butes of narrative practices.When asked why a participant used narra-tive methods during this response, s/hemade it simple and clear: ‘Oh, survival I think.Emotional survival’.Though not a narrative practice itself, thetheme of camaraderie pervaded the inter-views. Providers used narrative methods inorder to bring groups of people together totell their stories, and they shared their

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creative works with other EVD respondersand continue to share their works backhome. The text that began this manuscriptare lyrics of a song that was released onlinein 2016 and will be available for downloadspring of 2017 (Foster, 2016).Providers used narrative practices toenchant their audiences, a theme that Felski(2011) highlights. Enchantment has thepower to remove someone from their currentsetting, or as in the case of providers whoneeded to read the words of their colleagues’experiences, it can provide a deep sense ofsolidarity with others in similar circum-stances. Providers were not just enchantedby the written words of their colleagues,but also by words spoken and sung.Throughnarrative practices providers enchanted oneanother and brought themselves together.By spending time together, re£ecting ontheir work with EVD patients, they devel-oped a close-knit community. This com-munity demonstrated emotional support,which arguably decreased the providers’ riskof STS and may have encouraged positivepost traumatic growth.

LimitationsThis study only focused on expatriatehealthcare workers from the USA andCanada. These ¢ndings are not representa-tive of thewholebodyof expatriate providerswho responded to the outbreak. It shouldalso be noted that TC worked as an EVDvolunteer and thus brings a unique perspect-ive, as well as bias to this analysis. Thoseinterviewed in this study reported, on theonline survey, that they used narrativemethods. It would be bene¢cial to thisresearch to interview similar providers whochose not to use narrativemethods, thus help-ing to mitigate a respondent bias in favourof the use of narrative methods. Finally, itshould be recognised that there is no wayto isolate the e¡ects of narrative practicesfrom other protective factors, such asexercise, meditation or other supporting

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activities that could also have contributed toemotional wellbeing.Although there are limited data that docu-ment the negative e¡ects of narrative medi-cine practice, it is important to recognisethat these practices may not be suitable foreveryone. The process of writing or crea-tively constructing a narrative around atraumatic experience can exacerbate intenseemotions. Theoretically, if one were toexperience such strong emotions and didnot ¢nd an outlet with which to expressthem, a practitioner of narrative medicinecould experience negative emotional seque-lae. There was no evidence of such compli-cations among the respondents in this study.It is also necessary to recognise that audi-ences witnessing or reading the narrativeworks by these providers could potentiatenegative e¡ects. Some providers, who pub-lished narratives about thework they experi-enced changed names of patients andremoved names of locations for ethical con-siderations. However, any time that sensitivenarratives are made public there is a riskof causing emotional stress to the readingaudience.

ConclusionsThe psychosocialwellbeing of humanitarianaid workers, expatriate sta¡ and nationalsta¡ merits innovative approaches toimprove the wellbeing of those dedicatedto helping.The authors recognise the importance ofunderstanding more accurately the psycho-social needs of national health sta¡ whooften do not have the luxuries of higher payscales, scheduled rest and relaxation days,and more comfortable accommodationsthan their expatriate counterparts. Manyhealth care workers inWest Africa, who sur-vived the Ebola epidemic, continue to servein hospitals and clinics, having had virtuallyno rest from the end of the epidemic untilnow. One might assume the stressors onnational humanitarian aid workers to be

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more than on expatriate workers, particu-larly those from resource wealthy nations.

AcknowledgmentsThe authors would like to acknowledge morethan 500 healthcare workers who died while¢ghting Ebola, protecting the rest of the worldfrom this disease.Special thanks for the advice and guidance ofAlastairAger andMichaelWessells.

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ht © War Trauma Foundation. Unautho

Tim Cunningham, DrPH, RN is an Assistant

ProfessorofNursingattheUniversityofVirginia,

Charlottesville,VA, USA. He worked as a nurse

in an Ebola treatment centre inWest Africa in

2014^2015. email: tdc2115@columbia.edu

DavidRosenthal,PhD, isanAssociateProfessor

at theMailmanSchoolofPublicHealth,Colum-

bia University. He works in Health and Policy

Management in the Center for Family and Com-

munity Medicine at the Columbia University

Medical Center.

Marina Catallozzi, MD,MSCE is Director of

the General Public Health program and Assist-

ant Professor at the Mailman School of Public

Health, Columbia University, New York, NY,

USA.

DOI:10.1097/WTF.0000000000000138

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