Transcript for Episode 30: Providing Psychosocial Care at Doctors Without Borders

NASW Social Work Talks Podcast

Cat McDonald:
This is NASW Social Work Talks. I'm Cat McDonald, and today we're speaking with Athena Viscusi. She's a psychosocial care specialist at Doctors Without Borders, which is also known as Médecins Sans Frontières, or MSF. Athena Viscusi has directed mental health programs at MSF in Haiti, South Sudan, Liberia, Sierra Leone, Myanmar, and Palestine. She has 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 Viscusi, thank you so much for agreeing to speak with us today.

Athena Viscusi:
You're welcome. Thanks for your interest.

Cat McDonald:
Can you tell us about your work, and what your role is at Doctors Without Borders?

Athena Viscusi:
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.

Cat McDonald:
And what does that look like exactly when you're taking care of the staff?

Athena Viscusi:
So, I meet either in person, or on the phone with all of our US-based fieldworkers before they go to the field, and then when they come back. We have a chat about what it was like, what they experienced, and then if they need any followup 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 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, they have somebody to talk to about those things. So, the majority of our staff is local to the countries where we work. 90 to 95% 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 the compounds 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 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?

Athena Viscusi:
So, I think we actually have a leg up when we go into this field, compared to some other professions where that's not people who are in administration, or people who are in 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.

Cat McDonald:
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?

Athena Viscusi:
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 are subject to ambushes on the road, to abductions, kidnappings. In one instance, we had our base attacked, so I was there leaving sessions, both group sessions, and individual sessions with staff both national, and international to help them overcome the effects of these incidents, and then make any recommendations to how to better support them. Near to where I was, but I didn't visit that region, some of the Ebola treatment centers where we were working in northern Kibo 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, the work has some risks, but much harder for our local staff who are living in the communities whose families are affected by the violence that's going on, who 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, just because they're there all the time, but also, they're members of the community. So, whatever the community is facing, they're facing too.

Cat McDonald:
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 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?

Athena Viscusi:
Yeah. Well, in terms of social workers, it's the same thing that compels the 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, 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 we get to see the best, and the worst of humanity. 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 let's say, especially African countries in the US press that has a particular view, or particular analysis, that I get to go, and talk directly to people that are impacted by these events, and hopefully bring some solace, and leave them with some skills to cope with them. There's also some of us that are what we call "adrenaline junkies," right? That just love the excitement. You know, I think when I originally joined MSF, I had been a social worker 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 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, that there is a cost to this, but I would say there's also a benefit to caring. It's incredibly rewarding, and it's a real privilege to go into somebody else's community, and be received, and trusted, 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 you're 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. You have incredible team bonding working with people in a challenging context, but who are all on the same page, all trying reach the same goal, we don't always get to experienced 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, economic context, the cultural context, and sometimes, those are the things that are causing the health disparities, and the need to provide health service, that can be difficult too, but that's like I said, that applies to social work in this country too, right?

Cat McDonald:
I wanted to ask what some of the biggest challenges are that you encounter doing this work?

Athena Viscusi:
I mean, 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 it. 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 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 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 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 stand alone mental health.

Cat McDonald:
So, you touched on cultural differences. What should social workers be mindful of when they're working with people from different cultures?

Athena Viscusi:
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. 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, 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. So, you're doing the best you can, right? Yeah, I think really meeting people where they're at, and I think that's a skill that we have as social workers, as opposed to I think maybe medical professionals who are told, "This is the way you diagnose this, and this is the way you treat it." You know, that we have more understanding of a holistic assessment, building on strengths that we don't know everything, and that we want to mobilize support to leave something sustainable behind us, and not just 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 to provide support to their peers, right? So, that 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 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.

Cat McDonald:
That's incredible. I can't even imagine how intense an experience that must have been.

Athena Viscusi:
It was intense, and 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 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, you know, I guess you've seen pictures 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, for the preciousness of every human life, and when people were cured, and would come out of the center, we'd have a party for every single person.  I mean, sometimes it was 10 in a day, or sometimes it was one, but I mean, it was just so precious to save a life, and we had a wall in the Ebola treatment center in Monrovia in Liberia where every survivor would make a hand print. 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 a vaccine, now there's some experimental treatments that are being used, so the outcomes are much better than at that point. There were a whole bunch of things associated with that, for instance, burial. So people, 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, 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 when people have practices, and beliefs that are interrupted, it's not just the illness, it's the disruption of the whole belief system. It's a disruption of the whole cultural system that supports people normally in times of grieving, right? Those systems, those systems that sustain people are taken away from them. So, not only the relative is dead, but the whole ways 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 group kind of grieving activities. I think that 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. I mean, those were my patients 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 US workers coming back. It's just so hard to express what you've been through. People just don't have the frame of reference for working in a 200-bed facility that's built out of tents with mattresses on the floor where you're trying to keep people alive. It's hard to describe. Sometimes, it 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 considered contagious when we weren't. You know, we had 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 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.

Cat McDonald:
Yeah.

Athena Viscusi:
I think that's an example. You know, we talk about going to countries where people are ignorant, and educating them about healthcare, and disease transmission, and everything, and then we come back to our own country, and the ignorance is just as high, and inexcusable, because the information is available.

Cat McDonald:
So, what do you do to take care of yourself in all this?

Athena Viscusi:
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'd just go to work, and come back to our house, and don't go anywhere else. So, yoga is lovely, because there's always enough space to do yoga, you know, you don't need a lot. I think maintaining a practice of gratitude 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. Making sure that I have a lot of support, I do have people in my life, I'm blessed, 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 it's 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?

Cat McDonald:
So, what advice would you give to a social worker, or a social work student who's thinking about a career in international aid?

Athena Viscusi:
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, we're mostly training local people to do the work, right? We're rarely actually giving services ourselves 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 in a minimum in training, I would say, and supervision, even better, project design, and implementation, because 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 them your skills in assessing, designing, training, supervising. So, giving some kind of experience like that, but 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 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 with any oppressed population here, 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, maybe an earthquake, or right now, the hurricanes, and floods in Mozambique for instance, or 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 a epidemic where we're helping people who are grieving who've faced losses. Unfortunately, there's a need for those skills right here with responding to mass shootings, 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 in languages that I never knew existed before, what a gift that is, but then I also learned my skills here. I worked mostly with immigrants, and refugees before I work for MSF abroad, I worked in this country. So yeah, and I found my skills were transferable, which is rewarding, but sad at the same time, right?

Cat McDonald:
So, what's next for you?

Athena Viscusi:
Well, I work right now in the headquarters office in New York at MSF USA. So, I'll continue doing that for a while. I do then go visit projects maybe three, four times a year to support local staff, and then I also do that remotely by Skype, or by phone. So 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. 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 more depleted you can become. You don't become more resilient just by enduring. You become more resilient by working on your coping skills, right? And by getting the support that you need by taking care of yourself. You do not develop resilience by suffering, but people say that all the time, "I've been doing this for a long time, I'm fine," and they're not fine. So, finding ways to support people better through their whole humanitarian career. We've been working a lot in this organization, like in the rest of the world in addressing abuse, sexual harassment, but other abuses of power. Then those things definitely are 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 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, I just learn so much in this work, and I feel really lucky. There is one drawback to being a social worker in that clinical, social work is not recognized as a profession outside of basically the United States, Canada, and Australia. You know, social work in other countries is really different from psychology, that it's psychologists do clinical work, and social workers do 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, you know? 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, 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 at our best. We're respectful of the communities that we serve. We look at our own interventions, that they are 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 in other countries to understand that, that we have unique skills, and unique ability, and a unique contribution to make. They need more of us.

Cat McDonald:
Thank you for this, Athena Viscusi. I really appreciate you talking with us about your work.

Athena Viscusi:
Well, thank you for being interested.

Cat McDonald:
Bye.

Athena Viscusi:
Bye.

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