NASW Social Work Talks - EP30: Providing Psychosocial Care at Doctors Without Borders

Episode Date: April 30, 2019

Athena Viscusi, LCSW, is a Psychosocial Care Specialist at Doctors Without Borders. She's directed mental health programs in Haiti, South Sudan, Liberia, Sierra Leone, Myanmar, and Palestine. She's hired, trained and supervised local workers in refugee camps and worked with clients in cholera and Ebola treatment centers. Prior to this, she was a community mental health provider in Washington, DC. She worked with immigrants and refugees, at a domestic violence shelter, and a homeless outreach and substance abuse treatment program. She also directed a gang intervention program that provided services to youth and their families.

This is NASW Social Work Talks. I'm Kat McDonald, and today we're speaking with Athena Viscousi. She's a psychosocial care specialist at Doctors Without Borders, which is also known as Médecins Sans Frontières, or MSF. Athena Viscousi has directed mental health programs at MSF in Haiti, South Sudan, Liberia, Sierra Leone, Myanmar, and Palestine. She's hired, trained, and supervised local workers in refugee camps and worked with clients in cholera and Ebola treatment centers. Before this, Athena Viscusi was a community mental health provider in Washington, D.C. She worked with immigrants and refugees at a domestic violence shelter and at a homeless Outreach and Substance Abuse Treatment Program. She also directed a gang intervention program

that provided services to youth and their families. So, Athena Viscousi, thank you so much for agreeing to speak with us today. You're welcome. Thanks for your interest. Can you tell us about your work and what your role is at Doctors Without Borders? Currently, my role is staff support. I run the psychosocial care unit at MSF USA. So MSF, Doctors Without Borders, is an international organization. We work in 70 to 80 different countries at any given time. And we have offices in many of the countries where we don't have projects, but where we do recruitment and training of staff, as well as fundraising communications. So the USA office does that. We recruit people to send to the field and we take care of them before, during, and after

they're in the field. And so my role is to provide psychosocial care, so emotional support and whatever else people need, because the work that we do is very demanding, stressful. Occasionally, we experience critical incidents, traumatizing episodes, but also just working in resource-poor conditions, working with people who are experiencing a lot of suffering, obviously causes emotional reactions. So in my current role, I take care of that. Previously with Doctors Without Borders, I used to go to our projects and run mental health interventions or psychosocial interventions for the population but right now i take care of the staff and what does that look like exactly when you're taking care of the staff so i meet either in person or or on the phone with um all

of our u.s based field workers before they go to the field and then when they come back we have a chat about what it was like what um what they experienced and then if they need any follow-up services. I connect them to that. Also, I'm available while they're in the field if they want to talk if the work is stressful. All conversations with me are completely confidential, so it doesn't affect their career or the perception of them or anything to avail themselves of this service, and they can discuss things that they don't maybe want to discuss with other people, such as if they've previously had mental health care maybe they don't want to you know disclose that but we're going to talk about how they can manage that in the field or if they have personal

issues going on if they have other things about themselves that they're not comfortable disclosing with their colleagues in the field then we just they have somebody to talk to about those things so the majority of our staff is is local to the countries where we work 90 to 95 percent of our staff we recruit locally where we work. And so we send just very few international workers because of their special skills. The minority of our workers are international workers. The majority are recruited locally. But the international workers then will be living typically in a compound together. So you're living with 10 people who you didn't choose, who are from maybe 10 different countries who have 10 different communication styles. And so that can be hard

to manage. And then the work is difficult. It's typically long hours. It's typically making do without a lot of the supports that you would have working at home. It's typically working with people who have a lot of needs in countries that have a lot of needs. So burnout is one of the major risks of our, well, of the social work profession in general, right, but of humanitarian workers too. Actually, I think that social workers are better equipped when they go to the field because we're so aware of the toll that our work takes. It is part of our training to be aware of the toll that our work takes on us, vicarious trauma, compassion fatigue, burnout. We're aware of those things, and we're used to getting supervision to check ourselves and to increase our skills and our coping skills, right? So I think we actually have a leg up when we go into the field.

compared to some other professions where that's not people who are in administration or people who are engineering or many of the medical professions. I think more and more it's become part of medical residents training to talk about the toll of the work. But I think maybe it's less ingrained in the profession to keep taking care of yourself while you're working. So I try to help people with that. Yeah, it sounds like the support that you're providing is really vital. I know that you just returned from the Democratic Republic of Congo. What were you working on there? So there I was providing staff support, again, but to the entire team, so also the local staff. It's a context where there's been a civil war, now there's just a lot of banditry, and since our

staff typically go do outreach to more remote areas to bring medical care to the areas where it's needed. They're subject to ambushes on the road, to abductions, kidnappings. In one instance, we had our base attacked. So I was there leading sessions, both group sessions and individual sessions with staff, both national and international, to help them overcome the effects of these of these incidents and then make any recommendations to how to better support them near to where I was but not I didn't visit that region some of the Ebola treatment centers where we were working in northern Kivu in Democratic Republic of Congo were attacked by local people and burned so our staff was

evacuated from there and I have talked to several of them but I was not in that area directly I've only talked to them since they've been evacuated so we do face you know the work has some has some risks but you know it much harder for our local staff who are living in the communities who are you know whose families are affected by the violence that's going on who you know have to navigate this constantly whereas the international workers are coming in We're living in a compound. We do not protect ourselves with weapons ever.

So weapons are not allowed anywhere in our facilities. Even if we have a guarded compound, it's not guarded by people with weapons. So it's always vulnerable. But the pressures on our local staff are tremendous, both just because they're there all the time, but also, you know, they're members of the community. So whatever the community is facing, they're facing too. There are people who are local on the ground, and then there are folks who are international staff who actually volunteer to go into these situations where there's danger or there's, you know, contagion or there's something that's putting themselves possibly in harm's way. And as you're talking, I'm just wondering, what compels someone to go into a situation like that?

Well, in terms of social workers, it's the same thing that compels social workers to go into communities in this country that are dangerous, that have been neglected and oppressed. both the desire to make things better, but also the gift of getting to know people who overcome hardships, to get to experience their resiliency, to be part of their recovery from terrible things. It's also very satisfying. I mean, we talk about post-traumatic stress, but we also talk about post-traumatic growth right that um we get to see the best and the worst of humanity um we get to you know one thing that i enjoy about the work i feel like i get to go behind the headlines you know i'm not just subject to reading about uh let's say especially african countries and the u.s press right that has a a particular view or particular analysis that i get to go and talk

directly to people that are impacted by these events and and hopefully bring some some solace and leave them with some skills to cope with them there's also some of us that are you know what we call adrenaline junkies right that just love uh the excitement and the the it's very challenging you know i think when i originally joined msf i had been a social worker in in Washington, D.C. for like 25 years, and I really wanted the professional challenge to see if my skills really were applicable in any setting, you know. Had I just been skating by, you know, in my own environment, or did I really know something that could be applied abroad? And then to learn something new. We learn so much when we go on these projects, both about the local

communities and solutions that they've already found, but also figuring out ways to solve problems that we've never confronted before. So it's incredibly rewarding, but it does take a toll if you don't watch out. I have a colleague in Norway who talks about the cost of caring, you know, that there is a cost to this. But I would say there's also a benefit to caring, You know, it's incredibly rewarding, and it's a real privilege to go into somebody else's community, you know, and be received and trusted, you know. It's a real gift. So there's a lot of benefits even while there's a lot of risks. You're definitely not worried about your problems at home when it's full on, if that relationship's working out or if you should have invested your money better.

You get a break from all those worries because you have to deal with what's right in front of you. So you have incredible team bonding, you know, working with people in a challenging context but who are all on the same page, all trying to reach the same goal. We don't always get to experience that in our work. That's also very rewarding. But it does definitely take a toll. I would say it's not just the violent security incidents, but also just witnessing that level of suffering and not being able to alleviate all of it because we're a medical organization. So we go in to provide medical care, but we don't solve everything, right? We don't change the political context, the economic context, the cultural context.

And sometimes those are the things that are causing the health disparities and the need to provide health. So that can be difficult, too. But that's, you know, like I said, that applies to social work in this country, too, right? I wanted to ask what some of the biggest challenges are that you encounter doing this work. When I go to the field to provide staff support. I mean, really, it's wishing that that was available all year round to the staff because they really need. So in some cases, we have been able to put up staff support permanently in countries where there are qualified mental health professionals to provide that kind of support. But that's in many countries there aren't.

So they're pretty much dependent on us providing remote support or occasionally coming to visit. In my previous work, then designing mental health programs and running mental health programs in communities, the challenges obviously are making sure to be respectful of the local culture to first build on the strengths that are already there before imposing something else. The reception sometimes of just of the idea of psychological care is something that we have to overcome. Obviously, working where you don't speak the language, working through a translator is very frustrating, but also, you know, very rewarding. You get to talk to people that you wouldn't get to talk to otherwise. And then stamina-wise, some of our work involves traveling two hours a day to get to a location, doing your work, and traveling another two hours to come back on dodgy roads or on creaky boats. It's physically tiring. I think we've made a lot of progress as an organization in including mental health as a component of health care.

That wasn't always the case, so we had to kind of fight for acceptance among our medical colleagues who were like, we're doing the real work. But I think we've made a lot of progress in that, and we try to incorporate mental health care in many of our activities at this point. And we even have some projects that are just standalone mental health. So you touched on cultural differences. What should social workers be mindful of when they're working with people from different cultures? Well, you know, we talk about cultural competence, but we've started talking about cultural humility. And I think that's much more relevant, you know, definitely doing some research beforehand. I always like to read a literature from the country to expose myself to the art and literature that's been generated there.

But really doing local research when I start a project or even when I go to take over an existing project, meeting with the local leaders, with the local influencers, you know, that could be the mayor or the chief, but that could also be just the people, the religious leaders, the people that have been providing support to the community before we got there, right? So that could be the traditional birth attendants, that could be the elders in the community, that could be the artists in the community, the traditional healers. So really working alongside them, not in conflict with them, but alongside them and asking them what they think their people need, you know, and how they would receive it best. I would say like when I worked in Myanmar, I worked with a translator from English to Burmese who then worked with a translator from Burmese to the local Rohingya language. So I don't really know what anybody said that whole year because, you know, so you're doing the best you can, right? Yeah, I think, you know, really meeting people where they're at, you know, and I think that's a skill that we have as social workers, you know, as opposed to, I think, maybe medical professionals who are told, you know, this is the way you diagnose this and this is the way you treat it.

That we have more understanding of a holistic assessment, building on strengths, that we don't know everything, and that we want to mobilize supports to leave something sustainable behind us and not just depend on our wonderful, that people will benefit while our wonderful skills are there and then they'll have nothing when we leave. So typically that can look like training local people to be counselors, even in areas where the educational level is not very high. So training people to the highest level of their competence. So I've worked in countries where there's university-trained mental health professionals, psychologists. So then, of course, we'd be working with them. But I've worked in situations where I just hired every woman who was literate. there were six of them in the community and trained them, you know, to provide support to their peers, right? So, there can be a whole range of things. One of the things I'm most proud

of is having worked with survivors of Ebola during the Ebola epidemic in West Africa. And so, we trained people who had survived the illness to be patient support caregivers, both because they were immune, but also because they, you know, they gave so much hope having survived themselves. They were such role models, but then also giving them actual skills and not just relying on the fact that because you're a survivor, you can work with people, giving them skills to really listen, to meet people where they're at, to be supportive. That was really a unique experience.

That's incredible. I can't even imagine how intense an experience that must have been. It was intense. And so, you know, the death rate was very high. The risk to our colleagues was high. You know, some of us got infected. But the fear, the stigma also in the population was very intense. But we had an amazing psychosocial intervention in Ebola.

We had support for the patients. We had support for the staff because, you know, they were working hard and seeing all these bad outcomes. and we had support to the families of patients and we had support to the families of staff because even the families were worried about their loved ones bringing the disease home or getting sick at work, and then the work was very hard. I mean, it was dressing in these astronaut suits. I guess you've seen pictures, right, of the suits that we had to wear, And so it's 80 degrees outside, it's about 110 degrees in the suit.

So just physically, sometimes the work is difficult. There's nothing like an epidemic to give you an appreciation for the beauty of life, you know, for the preciousness of every human life. And when people were cured and would come out of the center, we'd have a party every single, you know, for every single person. I mean, sometimes it was 10 in the day or sometimes it was one. But, I mean, it was just so precious to save a life. We had a wall in the Ebola Treatment Center in Monrovia, in Liberia, where every survivor would make a handprint. You know, just the inspiration of all that, all those people who fought so hard for their lives. Because the treatment at that point was very basic.

Now there's vaccine, now there's some experimental treatments that are being used, so the outcomes are much better. But at that point, there were a whole bunch of things associated with that. For instance, burial, so people were not, if their relative died, they could not handle the body because it was contagious. And so in Liberia, all the bodies were being cremated, which is something that people in that culture do not do usually. And then in other cultures, they were being given burial, but by people wearing biohazard suits, you know, and zipped in a body bag. Also, when I worked in Haiti during the cholera epidemic, and initially they were not letting people bury their dead loved ones, understanding how traumatic that is, you know, when people have practices and beliefs that are interrupted. You know, it's not just the illness, it's the disruption of the whole belief system, it's the disruption of the whole cultural system that supports people normally in times of grieving, right? Those systems, those systems that sustain people, right, are taken away from them.

So not only the relative is dead, but the whole way that they usually cope with this is removed. So we would try to do things like taking a picture of the dead person so that they could have a ritual with the photograph, at least, or different things, having a group kind of grieving activities. I think that's something that gets so neglected is helping people through the grieving process, you know. And for our workers, too. I mean, we experience a lot of grief, you know. I mean, those were my patients, you know, that died. And there's just a lot of grieving for us.

and then coming home and people don't really understand what you've been through. And so that's something that I deal with a lot for returning, you know, U.S. workers coming back. It's just so hard to express what you've been through. People just don't have the frame of reference, you know, for working in a 200-bed facility that's, you know, built out of tents with mattresses on the floor. where you're trying to keep people alive um it's hard to describe sometimes you know can be frustrating if people don't understand it's even more frustrating when they really don't want to hear about it because they just can't deal with it and then in ebola we were also rejected and

you know and considered uh contagious when we weren't um you know we had uh colleagues who were quarantined unnecessarily or rejected by their families, you know, don't come near me, don't come near my kids, even though, you know, we knew that we were not contagious if we were not symptomatic. And we certainly knew what the symptoms were because we'd been working with the disease. But there was so much stigma and discrimination during that epidemic. I mean, not just to returning humanitarian workers to anybody from those countries that was in this country yeah so we talk about i think that's an example you know we talk about going to countries where people are ignorant and educating them about you know health care and disease

transmission and everything and and then we come back to our own country and the ignorance is even you know just as high and inexcusable because the information is available yeah So what do you do to take care of yourself in all this? Well, I'm a social worker, so I have clinical supervision, you know. I took up yoga when I was working in the field because often if the security situation is really bad, sometimes we just go to work and come back to our house and don't go anywhere else. So yoga is lovely because you can, there's always enough space to do yoga. You know, you don't need a lot.

I think maintaining a practice of gratitude, you know, to keep perspective is really important. You know, our brains are wired to the negative because they're trying to keep us safe, right? So they're always on alert for bad things. And we really need to rewire ourselves towards the positive, you know, making sure that I have a lot of support. I do have people in my life, I'm blessed, you know, who do want to hear about the work that I do, who support me when i'm in the field and when i come home i'm very lucky but yeah definitely always some physical activity and you know spiritual activity and then clinical support to me is very valuable so that's kind of what i'm trying to pass on to my non-clinical colleagues

right so what advice would you give to a social worker or a social work student who's thinking about a career in international aid? You know, one thing that's great about the United States is there's opportunities here to work with people who are different from you, no matter what you are, right? There's many groups that are different from you in this country. So for people considering humanitarian aid abroad, often working with immigrants and refugees in this country is a good way to prepare yourself for working across cultures. Also being clear about what level of discomfort you're able to tolerate, both cultural discomfort and physical discomfort. Also getting experience in supervision and training, because most of the times when we go to the field as

social workers, it's as mental health professionals or maybe community education professionals so um we're mostly training local people to do the work right we're rarely actually giving services ourself directly through an interpreter we're usually training and supervising and project designing so i would say getting experience not just in direct services but also at a minimum in training i would say and supervision even better project design and implementation. Because, you know, you want to go to the field bringing something that's not there already. So if you're going to a country where they have university-trained mental health professionals, you want to be bringing something better, right? But even going to places where

there's not mental health professionals, you want to be bringing then your skills in assessing, designing training supervising so getting some kind of experience like that but um in terms of humanitarian crises we have them right here in this country you don't need to go very far obviously on the southern border of the mexican border there's a there's a humanitarian crisis but then also we have humanitarian crisis with our incarcerated population both in the criminal justice system and the immigration detention system we have many humanitarian crises here where you can cut your teeth as a social worker for sure in working you know working with any any oppressed population here you

know violence prevention and both street violence and domestic violence and the kind of mass violence that we have here. I mean, unfortunately, the same skills that we apply helping people after a disaster, you know, maybe an earthquake or right now the hurricanes and floods in Mozambique, for instance, those same scores, the skills that we're applying when we work in a refugee camp with populations who've been displaced, who've lost everything, or in an epidemic where we're, you know, helping people who are grieving, who've faced losses. Unfortunately, there's a need for those skills, you know, right here with responding to mass shootings, you know, responding to having relatives incarcerated, responding to having relatives

deported or the fear of deportation. So a lot of ways to acquire the skills in this country. you know humanitarian work in other countries is incredibly rewarding you know i've learned how to say some words and languages that i never knew existed before you know what a gift that is but then i also learned my skills here i worked mostly with immigrants and refugees before i worked for msf abroad i worked in this country so um yeah and i found my skills were transferable which is rewarding but sad at the same time right so what's next for you um well i i work right now in the uh headquarters office in new york at msf usa so i i'll continue doing that for a while i do then go uh visit projects

maybe three, four times a year to support local staff. And then I also do that remotely, you know, by Skype or by phone. Trying to design some more. So we do, when people are newly recruited, we do do some training on stress management and coping skills, but trying to design some new programs so that's throughout people's careers. that they have that support um there's a myth people tell me well i've been doing this for a long time i'm used to it it's quite the contrary the longer you do it the the the more depleted

you can become you don't become more resilient just by enduring you know you become more resilient by working on your coping skills right by getting the support that you need um by uh by taking care of yourself you do not develop resilience by suffering right um but but people say that all the time you know i've been doing this for a long time i'm fine and they're they're not fine so um finding ways to support people better through the um through their whole humanitarian career um we've been working a lot uh in this organization like in the rest of the world in addressing, you know, abuse, sexual harassment, but other abuses of power, then those things definitely are, you know,

from my role in psychosocial support, those are stressors that need to be addressed. So being involved in efforts to reduce those and to address them more quickly and justly when they do happen. making it a more inclusive workplace for everybody is also, I think, the purview of psychosocial care, right? So a bunch of initiatives that I'm working on, but I think I'll stay here for a while. It's interesting work, but I do believe that I still have a few field projects left in me And that eventually I will be back in a country, hopefully either in an epidemic or a refugee crisis, because I've learned so much from intervening in those situations. You know, like I said, meeting people I had never heard of, working with diseases I had never heard of, you know, I just learned so much in this work.

I feel really lucky. There is one drawback to being a social worker in that it's not clinical social work is not recognized as a profession outside of basically like the United States, Canada and Australia. You know, social work in other countries is really different from psychology that psychologists do clinical work and social workers do, you know, public benefits, that kind of thing. So that can create problems working in international organizations that your credentials aren't valued or recognized. Nurse practitioners have the same issue, that that credential is not recognized in other countries. You're either a nurse or you're a doctor. They don't recognize their ability to diagnose and treat and medicate. So that is a drawback for social workers.

People really considering international work, I would look at that, you know, having a degree that's more recognized in other countries. However, I do believe that our training as social workers here is the best training ever for doing humanitarian work because of our holistic approach and our ability to look at the individual, at the family, at the community, at the culture, at the political systems, that we know how to look at all of those and how to design interventions that best meet people where they're at. You know, that we're a respectful profession, you know, at our best. We're respectful of the communities that we serve. You know, we're not, you know, we look at our own interventions that they're not duplicating oppression, right, or colluding with oppression. And I think that social work value is really useful in working in other countries. So I do think it's a great training for helping people in need all over the world. it's the best training and so also getting people to understand that getting people in

other countries to understand that that we have a unique unique skills and unique ability and a unique contribution to make they need more of us thank you for this Athena Viscousi I really appreciate you talking with us about your work well thank you for being interested bye You have been listening to NASW Social Work Talks, a production of the National Association of Social Workers. We encourage you to visit NASW's website for more information about our efforts to enhance the professional growth and development of our members, to create and maintain professional standards, and to advance sound social policies. You can learn more at

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