What’s Unsaid | Aid worker trauma is preventable 

Ali Latifi:

Today on What’s Unsaid: The preventable trauma of humanitarians 

 

Imogen Wall:

The primary stressor for most aid workers is not what they witnessed and experienced. It's the way that organizations are run and managed.

 

Latifi:

This is What’s Unsaid, a new bi-weekly podcast by The New Humanitarian where we explore open secrets and uncomfortable truths at the heart of the world’s conflicts and disasters. My name is Ali Latifi.

 

Humanitarians working in emergencies see some of the worst things in the world. From supporting the thousands of people who lost their homes and loved ones after the earthquakes in Morocco or Turkey, to struggling to provide food and shelter to those in need, like we’re seeing now after the devastating floods in Libya

 

This work can leave a mental toll on the humanitarians. But the way aid organizations are managed can do just as much damage to the aid workers' mental health as being confronted with war, hunger, and human rights abuses. 

 

This is What’s Unsaid. I’m Ali Latifi, staff editor at The New Humanitarian. 

In today’s episode: The preventable trauma of humanitarians 

 

Joining us today is Imogen Wall, a longtime aid worker who's retrained as a psychologist after her own burnout. Imogen, thank you so much for being with us

 

Wall:

You're welcome. Thanks for having me.

 

Latifi:

So you've been a humanitarian on the ground for 15 years. And when you were first going into this, when you were starting all of this, did you understand that there would be these psychological risks?

 

Wall:

No, I had no clue at all. And I think that's true of most people in our sector. No one warns you, no one briefs you, no one tells you. They certainly didn't when I started out. My first emergency posting was the tsunami in 2004, in Indonesia. But no, these things were not discussed at all. 

 

Latifi:

If we look at the tsunami, it had such a devastating effect. We remember the coverage, just how far wide it was, and how many people suffered. Since you weren't sort of prepared ahead of time, how did being there actually affect and impact you, having to do that work?

 

Wall:

That's a really hard question to answer because, on the one hand, it was very challenging, but on the other hand, I loved it. I loved my work, as I think most of us do. We don't go into this sector for an easy life. And the involvement of being on the ground, of being able to actually talk to people affected, be able to understand the problems, be able to work on solutions was really, really rewarding. And like many aid workers, I found that throughout my career with my frontline work. It's not actually where the challenge tends to come from. The other thing is that the data is really, really clear that actually witnessing and being involved in frontline experiences is not the primary stressor for most people in the aid sector. There's a very clear paper from 2018, which actually reinforces learning from many, many industries that suggests that actually, the primary stressor for most aid workers is not what they witnessed and experienced. It's the way that organizations are run and managed. That's where the pressure comes from.

 

Latifi:

Well, what does that mean?

 

Wall:

It means, for example, that I burned out in Haiti. I did a year in Haiti after the earthquake. I burned out in Haiti. I really loved being in Haiti, actually, it was a fascinating assignment. What it did for me, wasn't the Haitians. It was the fact my office was fifty percent understaffed for the entire year I was there. So we had to work absolutely crazy hours. We were asked to do far more than was within our capacity, far more than was in my skill set. I did everything from negotiating camp relocations to picking people up at the airport because we didn't have enough drivers. So I fell over. But that was the organizational management. It wasn't actually the Haitian context itself.

 

Latifi:

Just based on what you just said, do you think that that aspect of the burnout could have been prevented?

 

Wall:

Yes, I do. And I work with a lot of organizations who are now increasingly concerned about their staff, which is really nice to see. The conversation about mental health really opening up. But they are quite surprised sometimes to discover that the things that we end up talking about are not to bring a staff psychologist into the organization. It's much more about making sure that senior management don't work weekends because if senior management work weekends, then everybody works weekends,  particularly national staff. It's about modeling behavior and leadership, making sure that people do take proper breaks, making sure that they aren't asked to work above and beyond, particularly, what they're technically trained to d. It’s making sure that they get paid on time, it's making sure that they do have access to support if they need it. It's making sure that their managers are appropriately trained to cope with staff members who are struggling and in distress. And this is something I hear a lot, that managers often take their pastoral responsibilities toward their staff really, really seriously, but they're not trained in the skills, in identifying somebody who's starting to struggle, opening up the conversation, making it safe for people to disclose that they are starting to wobble, and certainly making it safe for people who maybe have a history of something like depression and anxiety to actually talk to their organizations openly about that before they get involved in situations that might challenge them. This is what I hear over and over and over again, is that staff will not tell their organizations, because they think they’re going to be judged on that.

 

Latifi:

And has that changed at all, in the last 10 or 15 years? Was it very different when you started around the tsunami time than it is today, for someone who will be going to Turkey or Syria?

 

Wall:

I'd like to think so. And I think generally, yes, but it's very organization-specific. Some organizations have more resources than others. It's very hard to get donors to fund support for staff, for example. And for a small organization, it's really hard for them to find the budget. So the good news for them is actually you can do a lot in terms of your organizational practice, rather than needing to bring in expensive specialist support. I'd like to think that onboarding has got better for some organizations. And certainly, there's a lot more conversation online and in spaces, like CHS. CHS is really the Common Humanitarian Standards, who've done a lot of work to open up space. And there's organizations like Thrive, which have also been banging this drum for a long time. But, I still see a lot, I supported somebody last year who got in touch with me. She was actively suicidal in an extremely high-risk country, she had just arrived in post. She didn't want to tell her organization, even though she was feeling that unwell, because she thought that they would decide that she wasn't up for the job. She was a consultant, that not only would she lose her post, but that she'd never get hired again. So even somebody that unwell, life or death situation, did not want to go and talk to their organization. And a lot of the support I gave this person was about supporting them in going to their organization. 

 

Latifi:

So that must impact people feeling comfortable to speak out. Do you feel that there are a lot of people like this woman you were speaking about?

 

Wall:

Anecdotally, yes. I've certainly had people come to me because they didn't want to use their organization's employee assistance program. And these employee assistance programs are always set up to be super confidential. They’re run by outside parties, working to a therapeutic code of conduct with respect to confidentiality, but people just don't trust them. In a lot of cases, people would rather go to an external therapist, even for an initial conversation because they still don't quite have faith that that information isn't going to get back to their organization if they use the employee system, which is really sad, because organizations I think, are really investing a lot more in this than they were. But the destigmatization work is one of the pieces that’s still missing, I think.

 

Anonymous quote:

In my recent experience in Ukraine, some colleagues and I all noticed the same thing: internal functioning within the organization makes people feel worse than the shelling and the security risk outside. It is fine to deal with the risk in a country of intervention, but people need a bit of safety to perform properly. Although some organizations now propose staff care, it mainly consists of well-being activities. That doesn’t compensate at all for the lack of institutional support and lack of care in our daily work.

 

Anonymous quote:

I think more attention is given to issues related to mental health that stem from the complex places where we work, than the mental health issues that derive from the lack of accountability in the institutions that we work in. I’ve experienced this firsthand in a large INGO where a bully seriously affected the professional trajectory of several non-white women. I submitted a whistle-blower report. But the COO himself told me he couldn’t pursue, unless I was willing to disclose my name and the name of the other women. Myself and the other women were mobbed out of our role, and the bully continues to work in the same place. I still struggle with the effects of the trauma. I just can’t understand how a system supposedly built to protect the most vulnerable people is able to inflict so much harm to certain people within the institutions. 

 

Latifi:

You founded a Facebook group for aid workers to discuss different kinds of work-related issues. And obviously mental health, I'm sure, came up a lot. What did you see in those groups that maybe people felt more comfortable discussing there than they would have openly discussed with their colleagues or friends? 

 

Wall:

I mean the really interesting thing about 50 Shades of Aid – the group that you're referring to – is that I founded it entirely by accident. But it turned out to be a space that was really, really needed, because there wasn't anywhere where aid workers could share experiences. So yes, we saw a lot come through about mental health quite early. One of the themes definitely was that people who were experiencing struggle felt incredibly isolated in that and they genuinely thought it was just them. They didn't realize actually, it's a very large percentage of people in the aid sector who struggle at some point. And frankly, that mirrors in the general population, that's not because even necessarily because of what we're exposed to. But people felt that there was something wrong with them. They felt that they were bad humanitarians. They felt that they certainly couldn't tell anybody. So having a space where they could share, and they could hear, most powerfully, overwhelmingly, they were not alone. And one of the services we provided 50 Shades of Aid - which they still do is - that people could post anonymously. So they could share experiences and ask questions: How do I find a therapist? How do I tell my organization I'm really not coping in my job? Do I leave my job? Do I try and do things differently? I don't think my boss is receptive. All these kinds of really, practical conversations came out. And I think most powerfully what a lot of people heard was, they really, really weren't alone in what they were going through.

 

Latifi:

What are some of the common themes or experiences or issues that aid workers sort of exhibit to you that you work on as a psychologist?

 

Wall:

A lot of them, first of all, is understanding that the risk is not been created by you. It's not because you're bad at your job or because you can't cope. It’s the risk has either been created by the environment you're in, or by the way the organization is managing it. So if you're working for an organization that has taken on or promised donors so much that you have to work every weekend, that is going to start to impact you. And it's not your fault, you've been put in that position. So we do a lot of helping people understand that they are actually very competent aid workers, they're just being put in impossible situations and asked to do things that are risky. I do a lot of helping people overcome the idea that looking after themselves is somehow a selfish thing, or a dereliction of responsibility, or something that's self-indulgence. We do quite a lot of reframing self-care as something that is actually not just really important but should be part of the job description.

 

Latifi:

Do you think that part of the problem is, like, you can sort of study to be a journalist, you can study to be an accountant, you can even study to be obviously a doctor or scientist or whatever. But I feel like humanitarian work is something you can't really prepare for it, right? You just kind of jump into it. It's not like there's a university course or something else that will help you prepare. You just end up in the Central African Republic or Libya or Morocco - do you get what I'm saying?

 

Wall:

I do. And it's true, you talk to ten different aid workers, and you'll get ten different stories of how they came into the sector. But I don't think that at all negates an organization's duty of care, which is a legal requirement to take care of their staff. And that duty of care does extend to psychological well-being. It's there in the CHS code of conduct. If you're in the UK, your organization's a UK-based organization, then the legal requirement to provide a safe workplace does apply to psychological well-being legally. The one person who has succeeded in taking his organization to court for failing to provide adequate support when he was kidnapped, and won, was Norwegian. And that was a big part of the case that he made was the organization had failed in their duty of care. That was Steve Dennis, back in 2015.

 

Latifi:

So the example you just gave was about Britain and Norway. And obviously, in these situations, there are a lot of inequalities and disparities between national and foreign aid worker staff, right? How do you see that play out? How does that impact mental health?

 

Wall:

On the one hand, ninety percent plus of aid workers are people working in the countries that they're born in. Shorthand for that is usually national staff. And on the other hand, you take the most recent research by WHO which shows, for example, that twenty-two percent of people who live in a conflict zone will be significantly psychologically affected by that experience. That's twice the numbers in a country that's peaceful. So not only have you got national staff who make up the vast majority of our workforce, but also they are very often coming from countries which are very profoundly affected. So their risk levels are already higher. There is another kind of weird mythological subset to mental health that says if you're starting to struggle, the best thing to do is to take you out of the workplace. And actually, it's really, really not true. A lot of people find being able to work, contribute, find community among colleagues, find identity in organizations in the work they do. They find that incredibly helpful when working in these contexts. So the employment can be a very big part of the solution. If it's done, done well. It's not that people who are struggling automatically need to be removed from the workplace. That's also part of the stigma and the myth around mental health. 

 

Latifi:

So I'm really happy that you pointed out that ninety percent of aid work is done by people from the country itself. Because I think we have this tendency to think that all of the aid work is done by foreigners flying in. So how do the sorts of inequities in these inequalities play out on the ground, in terms of the difference between a national and a foreign staff?

 

Wall:

It starts there, with understanding that you're an organization that the staff who are working with are going to have a different risk profile, put it that way. I went to do some short-term work for an NGO. This was in the Rohingya crisis. She was a translator. She's a really good example and she stayed with me because her story was so common. It turned out she had been working for about six months, translating the stories of genocide survivors, of Rohingya populations in the camps. Literally all day every day, she was sitting there and these stories of horror were literally passing through her because she was having to move them from one language to the next. She was coming home from work, and showering for two hours at night to try and cope with the feelings that she was left with, after that. Really complicated feelings around guilt, around overwhelm. She didn't dare tell her employer because she thought if she told her employer that she was struggling with the amount of content that she'd get fired, because she wasn't doing her job properly, or she wasn't up to the work. And no one had ever talked to her about the fact that there is substantial clinical evidence to show that if you are exposed to this content over time, you're going to start to struggle.

 

Latifi:

Do you think that it wasn't brought up to her because she's Bangladeshi herself, or just because the organization probably didn't even realize that reading stories or hearing stories can be almost as traumatic as seeing them? Or maybe both?

 

Wall:

The fact that people don't speak out, and the fact that there's not a lot of awareness, and this is where the aid world, I think, he's very behind. In social media, I mean, Facebook, actually got sued a few years ago by the content moderators, who was sitting there, looking at all the horrible things that people did on Facebook. You know, far right content, abusive content, really graphic content. They sued Facebook, because they said, you're not creating a safe workplace for us. This is an inherent part of our job. And one in two of them were starting to show early signs of post-traumatic stress disorder. And they won. That's the really key thing here, Ali, organizations in our sector need to take care of is that this has been positioned as a workplace safety issue, because if it's an inherent risk in the nature of the work you do, then it is part of the organization's job to anticipate that risk and help you mitigate it.

 

Anonymous quote:

The times in my twenty-year career in the humanitarian sector when my mental health has suffered has not been as a result of witnessing the suffering of the communities we serve. After an intensive leadership role for two years, I turned down a new role because I said I needed a break. Six months later, I applied for a different role. The HR team informed the hiring manager that I might not be 'stable' as I had turned down going straight from one intensive humanitarian response to another with no break. Rather than being encouraged and supported to take breaks between leadership roles, this was weaponized, and noted in my personnel file. 

 

Anonymous quote:

I just wanted to share a huge mental health problem that I experienced while working with one of the UN agencies: the precarity of contracts for junior staff. It was pretty common that you wouldn't know if your contract would be renewed or not until the week an ongoing contract ended. I lost my housing during a contract extension process because I couldn't prove to my landlord that I would be able to keep my income or visa. I spent the next few months sleeping on various colleagues sofas, and had several panic attacks. It's frustrating, because my supervisor knew the situation, and could tell that the additional stress was impacting my work, yet there was relatively little she could do. For people higher up in the system, the poor conditions for junior staff just don't seem like much of a priority. I really felt I was working in a two-tiered system, and it's a big reason that I don't want to return to that organization, even though the projects are important and I have plenty of relevant experience. 

 

Latifi:

Earlier you mentioned that you were on a short-term contract, that is obviously very common in the humanitarian sector. But the question is, how do these short-term or consultancy contracts affect the type of support aid workers can receive when it comes to their mental health. 

 

Wall:

There is data to suggest that, in common with other human experiences, it's really not unusual for people to experience their reactions to what they've been exposed to about three to six months after they've come back from their deployment. So this post-mission support thing is really, really important. Again, organizational choice. Do you continue extending access to your consultants to what services you provide for up to six months or a year after their deployment? That's what I would tell organizations to do. Make sure that those are available. Those kinds of things. Again, practical, cheap, easy. They are a question of organizational choice and policy. They're not about elaborate, medical systems to get people involved in long-term care.

 

Latifi:

Is there data or research on mental health impacts amongst humanitarians?

 

Wall:

Mental health data is really hard to come by. And we assume it's always an underestimation. But if you want some figures. In 2015, for example, The Guardian newspaper ran a survey through their global development professional network, asking people to complete a survey about their experiences. 79% of those respondents said they experienced mental health issues. 93% of those believe those issues were related to their work in the sector. Now, that’s self-assessment, that's not diagnostic conditions, that's going to skew very English language, because it was the Guardian and probably quite British as well. But those numbers are really high. So you kind of balance those two things. Yes, you can critique it. So it's not representative. Yeah, but those numbers are really high. In 2015, the UN Medical Services Division carried out a survey of their staff, asking people about, among other things, symptoms consistent with mental health conditions. 49% of UN staff were experiencing symptoms, not diagnosed conditions. That's reporting to an employer, so that's going to be a significant factor. So again, you can put it apart, but again, that's half of UN stuff. That’s a lot. And the anecdotal data, it's really, really hard to ignore the big picture, even if you can't pin it down. I know of at least three organizations in the last 18 months who've lost a staff member to suicide. There is not a single study that I'm aware of looking at suicidal feelings in the aid sector, not one. Ever.

 

Latifi:

Wow. Are mental health screenings, are they mandatory for aid workers?

 

Wall:

Again, that's an organizational choice. 

 

Latifi:

Should they be?   

Wall:

I come down on the side of no. And I'll tell you why. It's because there's very little evidence to show that they are reliable, that you're actually going to pick up data that’s useful. There was an attempt, couple of decades ago, with the Afghanistan conflict, there was an attempt to screen soldiers going into conflict to see if you could identify in advance who was going to develop post-traumatic stress disorder from going into active deployment. And I think they picked up one in six. That means they got five out of six wrong. Even the people who wrote that said that shows that our screening process certainly was unreliable. The other thing about screening processes that I don't like is they're really stigmatizing. So they start from the point of view that somebody who is struggling or has a history, is inherently problematic. I am somebody who has a history of depression. Had my first episode in my mid-20s. That means when I fill in forms for jobs, and it says, ‘do you have a history of psychiatric disorders’, I have to tick yes. I really hesitate. I'm a campaigner on this stuff. I care very much about it. But when I got my UN job in New York, in 2012, and I had my medical and I had ticked that box, I really hesitated because I thought, if I say yes, are they’re going to not send me somewhere, are they going to decide I'm a problem. So if you are going to screen, you have to be really, really clear about how you're going to handle those staff. I have had several people, through my mental health first aid training, for example, who lived with bipolar disorder, who are holding down extremely successful and high-profile jobs within the aid sector. And who are now brave enough and able and supported enough by their organizations to talk about that and make sure that they get what they need. Like any other health condition, they get what they need in order to do their job. But it consistently surprises people when I say that, because we don't realize that actually, we're surrounded by people, it's such a common thing to have had a diagnosis at some time. We're surrounded by those people. And actually, those people, when I trained them were so full of self-awareness, and the ability to self-manage. And they knew what they needed, and they knew when they needed it, and they knew how to spot when they started to struggle. And they knew very much how to take care of other people. So actually, that experience in their lives have left them with significant assets. And really things that should have been seen as very helpful by the organization. You want staff with those skills. So there's a danger, I think, with screening that it's sort of premised in this inherent idea that people who've had negative experiences with mental health that this is inherently a problem. And this makes them compromised. And I don't think in my view it does, partly because I include myself in that.

 

Latifi:

So we had a contributor, Country Director from the NGO GOAL who wrote an op-ed for The New Humanitarian about the grief faced by their aid workers after the Turkey-Syria earthquake. So they wrote ‘Where's the boundary between our accountability to affected people? And the duty of care agencies have to staff when humanitarian workers are themselves collectively affected?’ What do you think about that?

 

Wall:

Well, first of all, my heart absolutely went out to GOAL in that situation. They lost so many staff. I've been there myself. I worked on the Haiti earthquake for the UN, and my colleagues were spending half their time trying to organize a response, and half the time trying to find out if their colleagues were still alive. It's awful. I read that op-ed, with a great deal of kind of sympathy and recognition. I think for me, the answer is to stop seeing those two things as contradictory. This is a real problem across the sector, that, somehow, taking care of ourselves and our staff is seen as a zero-sum game with providing assistance to affected populations. It’s seen as an either-or. I think they're part of the same thing. I think affected populations deserve aid workers who are whole and healthy and able to do the job that they're there to do. I think that's a basic part of our responsibility towards them as organizations is to ensure that we don't send them support staff who are overwhelmed, exhausted, burnt out, and unable to do the work for absolutely no fault of their own. You can't go to something like that, and not have a reaction. But I think again, taking a more nuanced view. And this is no criticism at all of GOAL, because they were right in the thick of it. And it was horrific. Certainly, when I was working on the Haiti earthquake, organizations realized they didn't have protocols for sending cash grants to local staff who'd lost everything. They didn't have standard operating procedures for supporting the staff members of people who died. So those kinds of things you can put in place in advance. But I think we need to stop seeing these things as either-or. And start seeing them actually as an integral part of our responsibility, both to our staff and to the people affected by crisis. And understand that employment and working on response can actually, as I said, be a really important part of someone's recovery and someone finding meaning in their own way through what is a very personal experience to them, as well as being a professional one.

 

Latifi:

So our final question comes back to all of this: what more can aid organizations do to better support their staff and maybe focus on specific concrete things, like specific steps that they can implement? And would that be somehow different for a big-name organization - like an MSF or an ICRC - as compared to a smaller national organization?

 

Wall:

Yeah, in terms of resources, it really can. But I think the big shift, and it's ironic because we're so good at talking about the shift in terms of disasters and the work that we do but applies to us - is to move away from a response-based model and into a mitigation and prevention model. And look at how you mitigate risks. And, as I said, so much of that comes down to practical choices about how the organization is run. It's everything from not over-promising donors not taking on more work than your staff can actually deliver. Helping the staff prioritize and making sure your staff have the right skill set. Making sure you don't leave a post empty for months on end so that someone else is doing two or three jobs and make that normal. So those organizational practices, I think there's a lot that leaders can do. And I've actually seen the Foreign Office do this really well during the pandemic where their senior leadership were really open about how difficult they were finding working from home and how lonely and how isolating, and that opened up the space for conversations among staff and for really practical things around what can you do to help people feel less alone if they are working in remote duty stations. Everything from scheduled check-ins, to care parcels, to online platforms that include chatlines about pets or jokes or silly stuff. the single greatest protective factor in an organization is the people around you. So actually how teams are run is really important. Looking through a mental health lens at your HR policies, at your payment policies, at your recruitment policies, at your team management approach is really the most practical thing. And when it comes to specific risks, like precaurious trauma, or moral injury or traumatic incidents generally work in high-risk environments, regard those risks as on a par with any other risks. You can anticipate them. You can mitigate them. You can think about having correct procedures in place. You can think about what is available for staff. You can provide staff with training ahead of time. There is a lot you can do and it's not actually very expensive, most of it. A lot of it is about creating a healthy, working culture. 

 

Latifi:

Imogen, thank so much for being here.

 

Wall:

Thank you. I'm really looking forward to hearing it. Thank you so much for having me. Thanks.

 

Latifi:

That’s it for today’s episode of What’s Unsaid, with psychologist Imogen Wall. For any humanitarians looking for psychological support, please visit headington-institute.org or thrive-worldwide.org.

 

What are people afraid to talk about in today’s crises? What needs to be discussed openly? Let us know: send us an email: [email protected]. 

 

Subscribe to The New Humanitarian on your podcast app for more episodes of What’s Unsaid – our new podcast about open secrets and uncomfortable truths at the heart of the world’s conflicts and disasters. With new episodes every other week. Hosted by Irwin Loy, and me. 

 

This episode is produced and edited by Marthe van der Wolf, sound engineering by Mark Nieto, with original music by Whitney Patterson. And hosted by me, Ali Latifi.