After a Guardian survey suggested a high number of humanitarians experience mental health issues, we asked experts what needs to change

“Many of the people we treated had feelings of guilt, that they could have done more to help, especially for the young children who died,” says Idit Albert, one of several psychologists from the South London and Maudsley NHS Trust to provide psychologist support to healthcare workers responding to Ebola in Sierra Leone. “It’s not normal for children to die, but we tried to normalise the fact that they’re not the only people to find the deaths of children difficult.”

Through Skype, phone calls and face-to-face sessions, Albert and her colleagues help workers from the King’s Centre for Global Health and the NHS to process and reflect on their experiences – before, during and after their deployments. The Ebola Psychological Support Service provides different levels of support, from being a listening ear to treating the symptoms some health workers had developed.

“Some people had – and still do have – intrusive memories of their experience, particularly around the time they go to sleep,” says Albert. “What was more prominent, though, were the feelings of guilt and self doubt over the care they provided: did they do the right things?”

In a survey into aid worker wellbeing and mental health by the Global Development Professionals Network, 79% of respondents stated that they had experienced mental health issues. The vast majority, 93%, of those aid workers believe the problems are related to their work. Of concern to 66% of survey respondents was the lack of psychological support made available to aid workers by their employers.

Are organisations supporting their staff?

“Most aid workers are prone to burnout and many that I have worked with have PTSD. But little or no psychological support is provided pre or post-deployment to support aid workers deal with these issues,” said one respondent. “Many organisations have a hotline that staff can call to talk to a psychologist in another part of the world that they have never met – this is simply a tick box process.”

The provision of psychological support for aid workers and humanitarians is patchy. Some NGOs do offer support, but the quality varies between organisations. Fewer still provide support once aid workers return home from a mission.

“Even the bigger NGOs don’t seem to have the capacity to provide the full package of care; screening, and support during and after deployment,” says Albert. “They might do some of it but it’s not consistent in provision and quality.”

Why might NGOs not provide adequate psychological support to their staff? It may be, says Emmanuelle Lacroix, people capacity and development manager at CHS Alliance, that many international NGOs want to improve the level of support they provide but are constrained by a lack of resources, as well as a focus on output and the delivery of programmes.

Problems may also occur due to a lack of awareness at headquarters. “At head office, there are staff who have not been abroad, whose careers have progressed well and were probably not affected themselves, or who have gone up through a developmental route and so are unfamiliar with the acute cases,” says Graham MacKay, director of business strategy and finance at Bond.

There are, however, guidelines in place to address the psychological needs of aid workers. Developed by the Antares Foundation in 2012, the guidelines state (pdf) that it is up to the organisation to develop policies to prevent and mitigate the effects of routine and unexpected sources of stress on aid workers.

So are the guidelines enough? Probably not, says MacKay, who despite working in the humanitarian sector for around 20 years, was not aware that the Antares guidelines existed.

“The guidelines are only as good as how you adapt them to the context,” says Lacroix. “It is not enough to say: ‘Oh yeah, we have the guidelines.’ because they need to be contextualised and reviewed and updated based on feedback and the changing contexts. It has to be a living thing.”

While there may be gaps in the system, it could also be true that aid workers are not seeking the support they say they want. Despite working in the field of psychological trauma since the late 90s, Albert had never treated a humanitarian or aid worker before leading the Ebola Psychological Support Service. In fact, most of her colleagues in the trust – the biggest mental health trust in the UK – hadn’t either. Seeing themselves as help-providers rather than help-seekers and worrying about being a burden to their employer are some of the reasons Albert hears aid workers give for not seeking help through the NHS.

But perhaps one of the main reasons aid workers are reluctant to seek psychological support is because of the stigma associated with it. “People are starting to realise that if they have an issue they need to be able to face it, but it’s true that some organisational cultures maybe don’t facilitate that, or that it might be seen as a weakness,” says Lacroix. Because of this, Albert and her team think support for aid workers should be an opt-out, not opt-in, service.

What could NGOs be doing differently?

Pre-screening aid workers for mental health issues before they are deployed is often suggested as a possible solution. “I think screening is a really clever idea and I wish more aid agencies would do it,” says MacKay. “But there’s no overarching body that says: ‘No, you can’t operate here because you don’t screen your staff.’ It’s difficult to imagine a situation where that’s going to happen.”

Lacroix says that NGOs have to be realistic about what they can do within their own networks and partnerships they have developed. “It doesn’t have to be an all-singing, all-dancing provision,” she says. “For example, in one region where a number of agencies are working, is there a way to access a pool of on-call psychologists if someone has been through a really difficult incident, to be able to diffuse the initial trauma?”

While the psychological support available to humanitarians already varies across different organisations, there are calls for an industry-wide standard that all NGOs would be encouraged to adhere to. Albert and her colleagues at the Maudsley Psychology Centre have been meeting with the DfID to raise awareness about the need to support aid workers, and push for a standard that would meet the needs of the aid industry.

And over the next few years, one of the areas of focus for the CHS Alliance will be to set up a standard of excellence around staff care. While it is intended for the standard to still be adapted and contextualised, the alliance will be working with organisations such as the Antares Foundation and InterHealth, as well as using data and lessons from the sector, to develop it.

Lacroix says: “The idea is to set up a standard that says regardless of who you are – whether you’re an expat or national aid worker – and regardless of where you are based or currently operating, this is what your organisation should have in place to support you.”

This article first appeared on the Guardian on 25 November 2015. 

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