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I wake suddenly in the middle of the night, drenched in sweat, continuing to speak the same words of horror I was uttering in my nightmare of rape, bombing, and war.
I disengage or drop out of meetings, relationships, and social engagements – overwhelmed by fear and shame.
I avoid feelings so I don’t collapse. And then I feel nothing at all.
As an aid worker, I spent nearly two decades working in and around war zones, including in humanitarian responses for Afghanistan, Palestine, Sierra Leone, Sudan, and Syria. Last year, I was diagnosed with complex post-traumatic stress disorder following the deterioration of prolonged symptoms.
My psychiatrist recently told me that my symptoms resemble those he sees in military veterans. I was lucky to work with some great people and organisations. Yet the aid sector as a whole has not kept pace with military and other high-risk professions in recognising, preventing, and responding to the mental health risks its staff face.
We need to catch up.
Aid workers regularly face every one of the operational and combat stressors listed by the US military’s health system, apart from taking someone’s life – the deaths of colleagues, witnessing killings, personal injury, and difficult work environments, among them. Exposure to war is exposure to trauma; it is not limited to combatants or to victims of violence.
Aid workers make decisions that can and do lead to death, injury, suffering, and near-miss incidents – of colleagues, and of civilians they’re unable to help. We ask our colleagues to risk their lives, knowing full well the dangers of airstrikes, kidnappings, drones, and all the facts about record aid worker attacks.
Exposure to war is exposure to trauma; it is not limited to combatants or to victims of violence.
Many aid workers go to bed wondering if they will wake up in the morning, or if they will make it through the day. Many survive multiple traumas.
But too few aid organisations implement basic measures, such as systematic stress management or psychological risk assessments. Few have career-based risk planning and support for staff repeatedly taking on high-exposure roles. Few recognise and adapt for the unique challenges faced by local aid workers in particular. And few have serious conversations about the impact and validity of moral injury.
Instead, quiet endurance is praised as resilience, while showing signs of distress may be seen as a performance issue – even a disciplinary one.
It’s time not just to acknowledge the risks and harms our colleagues experience, on the job or after – but to fulfil our duties and responsibilities. Aid organisations, donors, and aid workers all have a role to play.
Symptoms of a wider problem
In a 2022 report made as part of efforts to improve its own policy and practice, the International Committee of the Red Cross estimated that as many as 40% of its staff are at risk of developing mental health conditions. Last year, a peer-reviewed paper assessed that 21.5% of the cohort of aid workers it studied met the criteria for either PTSD or complex PTSD, compared to 1.1% among the general population. Some 12.5% reported having thoughts about suicide, and 3% said they made plans.
Stress and trauma don’t manifest only as PTSD. They also contribute to anxiety, depression, withdrawal and isolation, alcohol and substance misuse, insomnia, forgetfulness, anger, and irritability – among other signs, symptoms, and conditions. And complex trauma often appears “dispirited” rather than “spectacular” – emotional numbing and dissociation as much as reactivity and agitation.
In the past 18 months, I’ve learned of aid workers who have died by suicide. I’ve heard from aid workers who say they feel nothing, feel anxiety and sleeplessness they’ve never experienced before, are concerned about colleagues’ drinking, or have been upset and disturbed by seeing dead bodies or repeatedly hearing detailed accounts of sexual violence.
Yet aid workers often struggle to accept their own symptoms, even when they are visible to others. They blame themselves, and feel shame and guilt for struggling with their own needs in contexts of overwhelming suffering – feelings often reinforced by cultural attitudes the sector promotes.
The view that an aid worker who displays trauma reactions isn’t fit for aid work is too frequent in the sector – and completely misplaced. It is not a case of screening out aid workers at risk of or experiencing stress and trauma-related challenges. It is about identifying and mitigating risks, signs, and symptoms, and treating them not as matters of individual weakness or failure, but as the structural and occupational issues that they are.
Instead, some aid organisations risk exploiting the very traits they rely on in the toughest places – hyper-focus, emotional detachment, relentlessness, a personal sense of mission, and a willingness to take personal risks. These are often the traits associated with trauma in the long term. Some people are repeatedly or continuously assigned to the most hazardous environments or roles without sufficient career planning.
Moreover, those with the least power and support are often the most exposed. The majority of people who work in the aid sector come from the places they serve. Many NGO people-related systems are built for stable, corporate environments, for donor compliance, and upon principles and practices from the commercial sector – not for the needs and realities of staff who live and work in conflict zones. As a result, stress reactions and trauma-related behaviour or impairment are easily racialised, gendered, penalised, or moralised. Harm is compounded, not mitigated.
Mental health and trauma have long been misunderstood and dismissed across societies, and many workplaces are playing catch-up. But it’s striking how far behind the aid sector is compared to health, safety, and disability law, and to other high-risk sectors – especially given the available knowledge and evidence.
For example, the British armed forces and police services explicitly recognise mental health as a leadership and command responsibility – not just operational commanders, who are themselves at high risk and need informed support, but strategic leaders. In the US and UK defence departments, it is standard practice to monitor operational stress and conduct psychological risk assessments – the very minimum occupational safety and health standards.
Steps forward
So how do we do better? The knowledge exists – the Antares Foundation guidelines for managing stress in humanitarian work (first published in 2004), guidance on traumatic stress management for organisations in high-risk environments, the UK-developed “TRiM” trauma risk-management framework, or the US military operational and combat stress control policies, among other examples – but practice too often falls short.
Employers must ensure mandatory psychological hazard and stress assessments and mitigation as part of operational planning, implementation, and follow-up. They must ensure normalised, evidence-based rest, rotation, and pacing in high-risk roles and careers. They must ensure trauma-informed management, leadership, and administration – not just access to therapy for operational staff. And services must be locally accessible and culturally appropriate.
Donors should increase conditionality and scrutiny tied to duty-of-care standards and actual practice, not just policy. It is feasible and affordable – even in today’s financial crisis. It is a question of occupational safety and ensuring assistance reaches those most in need.
It’s not good enough for organisations to say they didn’t know.
Finally, the sector must do more to destigmatise stress, distress, and trauma in aid work. Stress and trauma are biopsychosocial realities, not moral qualities. The actions and attitudes of peers, supervisors, and colleagues can make the difference in potentially traumatic events turning into pathology or resolving in good time; between mild symptoms and disabling ones.
Of course, risk cannot be eliminated entirely even with the best effort. And I’ve both supported and failed people in my career.
But we should be clear. The risks and harms are real and foreseeable: It’s not good enough for organisations to say they didn’t know. If senior leaders and boards aren’t hearing or talking about them, then they have a problem, not a resilient workforce. Avoidance is a symptom of trauma; avoidance of responsibility is neglect.
