Aid Workers, Too, Suffering Post-Traumatic Stress

Stefan Lovgren
for National Geographic News
December 3, 2003
One night in 1994, John Fawcett was watching television with his family
at home in the Cambodian capital, Phnom Penh, where he was working for
the humanitarian aid agency World Vision.

Suddenly, a gun battle broke out on the street outside. The crackle of gunfire was common. Cambodia was a lawless and desperate place at the time. Fawcett simply turned up the volume on the television to drown out the noise.

Stepping out of his house the next morning, he encountered the gruesome aftermath of the previous night's shoot-out. A gang of car thieves had been ambushed and killed by a military police patrol. Their bodies were laid out on the side of the road, left there as a warning to other criminals.

A few years later, Fawcett was back in his native New Zealand, reviewing a fundraising movie the agency was putting together. The clip showed a group of children with sticks, pretending to be soldiers.

"Suddenly I found myself standing up, sweat breaking out all over, desperately casting around the room for the danger I was certain was there," Fawcett recalled. "I had to get out of the room, take some deep breaths, and think things through."

His reaction is hardly unusual. Many aid workers who experience traumatic events have difficulty coping with them later on. Some find themselves reliving stressful episodes weeks, months, or—as in Fawcett's case—years later.

Most often associated with soldiers, post-traumatic stress disorder is a psychological reaction, occurring after a highly stressing event, that is usually characterized by flashbacks, nightmares, depression, and jittery nerves. These symptoms are now known to be common among aid workers.

Exactly how common no one knows. While numerous studies have been conducted on the psychological effects of war on military personnel, far less research is available about aid workers. Experts warn that many aid organizations are not providing adequate psychological support to their staff.

"Until recently, people had not even recognized that this is a problem," said Barbara Lopes-Cardozo, a psychiatrist with the international emergency and refugee health department at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia.

Lopes-Cardozo is now planning a CDC study that will track 300 aid workers over several years to see how they cope psychologically with their work. It's the first-ever longitudinal study of the little-understood problem.

Death Threats

Aid work is dangerous business. Toiling in trouble spots from Angola to Afghanistan, aid workers from agencies like the International Red Cross, CARE, and Doctors Without Borders sometimes risk their own lives to help victims of everything from natural disasters to war.

Aid workers may experience traumatic events such as watching colleagues get killed, being shot at, receiving death threats, handling dead bodies, or witnessing children die from starvation.

Everyday problems, like having to live without running water or worrying if a short-term contract will be renewed, can also take an emotional toll.

"Aid workers are repeatedly confronted with the suffering of victims and the apparent meaninglessness of catastrophic events," said James Guy, executive director of the Headington Institute in Pasadena, California, which counsels aid workers who suffer from mental distress. "To go on with their work, they must find answers to the same questions of meaning and purpose that confront the victims they serve."

In a 1998 World Health Organization survey of active aid workers, half of the respondents felt they were unable to function well on the day they were interviewed. Six out of ten reported general fatigue, while one-half of those interviewed had frequent headaches. Sleeping difficulties, irritability, and anger were also common.

Stress Symptoms

The issue of post-traumatic stress disorder (PTSD) among aid workers is gaining attention. PTSD is a psychiatric diagnosis that applies only to people who have experienced a specific, extraordinarily traumatic event.

Symptoms come in three forms: nightmares and flashbacks; psychological problems, like jittery nerves and sleeping difficulties; and avoidance issues, where a person withdraws from relationships or becomes emotionally numb.

One study that was published in 2001 in the Journal of Traumatic Stress showed that 30 percent of returning relief workers reported stress symptoms, and about 10 percent could have been diagnosed with PTSD.

"Up to one-third of the staff reported having personally experienced traumas such as being threatened with physical harm, experiencing a life-threatening illness, being within the range of gunfire, or being shot at," said Cynthia Eriksson, an assistant professor of psychology at Fuller Theological Seminary in Pasadena, California, who co-authored the report.

So what kind of person is most susceptible to the stress of aid work?

"One thing we've seen is that people who have experienced previous psychiatric problems, like depression, seem more likely to develop mental illness after working under stressful conditions," said Lopes-Cardozo.

Unrealistic expectations among aid workers can also prove dangerous.

"Some aid workers may be convinced that their work can stem the tide of suffering and redeem the horrors of civil war or genocide, while others are satisfied to know that they have brought help to just a handful of individuals," said Guy. "Those with the highest expectations may find themselves most vulnerable, as they discover that there is seemingly no end to the atrocities of which we are capable."

Pushed to the Limit

In the past, many aid organizations have focused their recruiting efforts on finding staff perceived to be inured to hardship. In a recent survey, one aid agency reportedly admitted to employing workaholics or alcoholics on purpose because "some situations require people who can destroy themselves and thrive on chaos."

"There's a misconception out there that says, if you just pick the right people, they'll be OK," said Eriksson. "But there are some things inherent about the work that can create an environment that really pushes a person to their absolute limits. While many aid workers flourish and create incredible benefits to the communities they serve, others end up in situations where they're simply lost, and the organization may or may not know if that person is a casualty."

Researchers contend that aid organizations must do a better job of preparing their staff before sending them into crisis situations and offer better psychological support for aid workers while they're in the field. Local staff may be particularly vulnerable.

"Organizations sometimes recognize that there's a problem, but they don't know what to do about it," said Lopes-Cardozo. "We need more scientific data to tell organizations what is happening and what they can do about it."

The CDC project, which involves several other agencies, is in its initial phase. The study will track 300 humanitarian aid workers before, during, and after their deployment to gauge their mental health.

Meanwhile, several support groups, like the Antares Foundation, based in Amsterdam, and People in Aid, based in London, and the Headington Institute, are helping aid organizations to set up or better manage psychological support programs.

"Avoiding traumatizing situations is not possible," said Fawcett, who is now back in Cambodia and working as a stress management consultant to aid agencies. "In first-world environments, people with these experiences would be in psychological treatment. Humanitarian workers just keep on going, often to their own detriment."

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