Awareness and evidence of the potential impact of occupational roles and cultures on mental health in certain professions has been steadily growing for a number of years. In the first of a series of posts, the issues impacting those reporting on conflict and disaster are considered.
As I write, the headlines are dominated by the worst escalation of violence between Israel and Palestinian factions in Gaza since 2014 (my own recollections of which I have written elsewhere). Meanwhile the vicious and relentless undertow of the COVID pandemic continues to rip across the world. At times, and recently none more so than in the past year, the flickering ray of the often brighter stories introduced by the words ‘And finally…’ can seem as insignificant in the gloom of the daily news cycle, as the hope is fleeting of there ever being a repeat of the infamous 1930 BBC news bulletin’s proclamation that ‘there is no news’.
As an audience we are hardwired to attend to negative news,1 and the potential negative psychological impact of consuming distressing fare regurgitated by oft-maligned journalistic vultures has been widely studied.2–6 So too are audiences attracted to stories of the consequences of traumatic experience. Google Trends shows an increase with time of interest in searches for that most headline-grabbing diagnosis, post-traumatic stress disorder (PTSD), with some intriguing region-specific spikes coinciding with high-profile news stories or cultural highlights.
Journalism can undoubtedly be a potentially corporally threatening profession in itself. Figures from the Committee to Protect Journalists show an upward trend in the global numbers of media workers killed, imprisoned or missing. This week, Gaza offices used by AP and Al Jazeera were destroyed in airstrikes, and violence against journalists was a feature of sections of pro-Trump groups in America. Naturally the risks are higher in unstable or conflict-ridden countries, yet declining press freedoms, civil liberties and consumer trust in sections of the media, combined with increasing misinformation and political polarisation make for an increasingly volatile atmosphere where journalists find themselves a ‘legitimate’ target for violence (the RISJ Digital News Report is a great starting point for an excellent overview). So what of the health impact of this (consciously clichéd) vulturine diet of what Kristof calls ‘war scandal and disaster’ on journalists themselves?
Newshounds of WAR
According to the BBC’s John Simpson, the ‘only good thing about television news – is that it forces you to go and see things for yourself’.7 Accordingly, conflict and foreign journalists who willingly expose themselves to violence, unrest and strife in far-flung lands have thus far understandably received the majority of the academic attention on the impact of traumatic experiences on the journalistic profession.
Traumatic experiences are common. Although distributed unequally, around 70% of the global population is estimated to have experienced a traumatic event serious enough to merit the possible development of PTSD, with an average of around 3.2 events per person.8 PTSD meanwhile, is comparatively rare, with only around 4% of the global population estimated to reach a threshold for diagnosis.9 However, variation between countries, across various demographic variables and the risk associated with the type of trauma is enormous. Interpersonal violence (especially intimate partner sexual violence) is widely regarded as the category of trauma that carries the most risk,8 whilst one study of war-related trauma suggested that of the 1.45 billion people who have experienced war between 1989 and 2015, around 345 million (34%) of those who were adults and still alive in 2015 have PTSD and/or major depression.10
A seminal study by Feinstein and colleagues of 170 experienced conflict journalists working for major news organisations calculated a lifetime prevalence of PTSD of just under 29%,11 a figure in line with the higher end of the estimated range for combat-related PTSD in US military populations (6-31%).12 Equally stark were the study’s estimates for other disorders. Notwithstanding caveats around cultural and sociodemographic variations and influences, the lifetime prevalence of substance abuse in conflict journalists (14.3%) was at the upper margins of the median worldwide general population estimates (1.3-15%)13 and an estimate of 21.4% for major depression exceeded that generally seen in high-income countries (14.6%)14 even after various statistical corrections for age and pre-conflict health conditions were made. Unsurprisingly, all scores were higher than those provided by non-combat-exposed journalists. Whilst striking, these results are not surprising; conflict reporting relies on repeatedly putting oneself in environments where one’s life will almost inevitably be threatened, with considerable similarities in terms of situation and frequency to those experienced by combatants. Epidemiological studies of frontline workers in ‘blue light’ professions15 and those on the COVID frontline frequently dealing with suffering, distress, injury and death show similar elevated rates of PTSD and common mental disorders.16
Rates of PTSD only tell part of the story. In a retrospective analysis of data collected in eight studies over eighteen years across a number of conflicts, Feinstein found the severity of self-reported PTSD symptomology to be low to mild.17 Closer inspection reveals that reporters in Iran and Kenya endorsed higher levels of PTSD symptomology than their Western counterparts. Uniquely, two separate conflict situations in Kenya were examined; the 2007 post-election violence and the 2013 Al-Shabab attack on the Westgate Mall. Those who were engaged in covering the post-election violence reported greater symptom scores than those who did not, but there was no such difference for the Westgate attack.18 A probable explanation is twofold. Firstly, the Westgate attack was an isolated and contained incident, whereas the 2007 violence was not restricted to a single location and lasted for two months. Secondly, the post-election period was characterised by internecine violence, down to an intra-family level. Thus, Kenyan journalists reporting on the crisis were more likely to be inextricably personally connected to and rooted in the story on which they were reporting. The combination of repeated and prolonged exposure, higher rates of personal injury and threat as well as physical or emotional proximity all combined to form a psychologically toxic mix. Comparable conclusions can also be drawn from studies of Iranian journalists many of whom were forced to live in exile,19 Mexican journalists working under the shadow of drug-related violence,20 and the increased rates of depression amongst Western journalists covering the Syrian conflict during which the threat of kidnap, torture and execution were uniquely high.21 Although, little investigation has been conducted into understanding whether cultural attitudes or influences may impact symptomatic variation more widely,22 these findings uncover one of the uncomfortable truths in journalism, namely that the bylines and headlines of the big-name correspondents and their colleagues are built on the foundations laid by indigenous reporters, researchers and fixers. These journalists carry a disproportionate amount of the burden and risk and receive far less of the recognition, praise, remuneration or support compared to their international (often Western) colleagues. Most importantly, unlike their international colleagues, they do not have the option to leave when the story moves elsewhere. Their experiences are of at least equal interest and importance.
Two studies examining the impact of the 2004 Indian Ocean earthquake and tsunami estimated PTSD rates of 33% immediately post-deployment and 6.6% eight months after the event. Such a reduction with time is to be expected, however two points are of major importance. Firstly, the symptoms endorsed in PTSD are considered typical after a traumatic event. It is not unless symptoms are present for around six months after an event (whether enduring or new), that a diagnosis is considered. Secondly, although the index event (covering the tsunami) was the same, the figures are derived from two different groups – 12 Singaporean journalists in the first study23 and 61 German, Austrian and Germanphone Swiss journalists in the second.24 The lack of longitudinal studies with the same cohorts is particularly frustrating, considering the evidence of a complex interplay of risk and protective factors that contribute to risk of developing trauma-related mental health problems.
Ultimately, for conflict journalists trauma exposure is an expected occupational norm, and this expectation is key. The protective effect of psychological preparedness has been implicated in studies of frontline workers such as firefighters25 and victims of torture.26 Personally, when I packed my equipment and got on a flight, I knew that I was going to face a challenging environment and was always immensely grateful for the travel time allowing a chance to switch ‘on’ and ‘off’ from work mode, and prepare myself for what was coming next. It’s worth noting that the cohorts in many studies are journalists with a minimum of a decade’s worth of experience who specialise in conflict work. With some occasional notable and tragic exceptions, news organisations today do not typically force employees to repeatedly work in hostile environments against their will, and those who do are rarely inexperienced. Whilst there is a frequently cited truism from countless studies of different populations that increased trauma exposure correlates with an increased risk of adverse mental health outcomes, other studies have shown that repeated trauma can also have a protective (habituation and experience)27 impact on individuals. Consequently, those often studied are by definition a highly self-selective group and only represent journalists who may have an innate or developed ability to have ‘stayed the course’ for a considerable period of time.
It is also important not to get hung up on definitions. Clinical diagnoses necessarily have thresholds beyond which an individual is considered to be unwell and in need of help. A more nuanced approach to population studies is to also consider sub-threshold scores in line with reported impact on day-to-day functioning. The same study by Feinstein that reported low symptom severity in combat journalists (implying that their daily functioning was not greatly adversely impacted) also reported significantly higher alcohol consumption amongst female conflict journalists compared to their non-conflict colleagues. Whilst clinically sub-threshold, such behaviours could indicate wider health problems whether linked to maladaptive coping strategies, a (now waning) bon viveur culture of forging reporting or other factors.
Of course, the most important point to make is that PTSD and other conditions are treatable with the right support and therapeutic interventions. Undoubtedly, those journalists who put themselves in harm’s way are at elevated risk for PTSD and other mental health disorders, just as with other professions faced with elevated risk and trauma, and their employers have a duty of care to mitigate these risks. Yet not all journalists gallivant around the world’s conflict zones and traumatic experiences are not confined to places once viewed as ‘other’. Although PTSD may still grab the attention of headline writers and those supporting them, the impact of the more mundane but no less challenging news cycle, I believe can be equally if not more perniciously corrosive. It is the risk of vicarious trauma and burnout that will be the focus of part 2…
For information and help:
Samaritans (call 116 123) and Shout (text 85258) – round the clock support via phone, email and text (UK)
Our Frontline – 24/7 emotional support for COVID 19 essential and frontline workers (UK)
Dart Centre – resources on reporting on, dealing with and self-care on trauma (Worldwide)
newsbreak – peer support for journalists (UK)
Film & TV Charity – 24 hour support on a range of issues for anyone in the media (UK)
- 1.Soroka S, McAdams S. News, Politics, and Negativity. Political Communication [Internet]. 2015 Jan 2;1–22. Available from: http://dx.doi.org/10.1080/10584609.2014.881942
- 2.Ahern J, Galea S, Resnick H, Kilpatrick D, Bucuvalas M, Gold J, et al. Television Images and Psychological Symptoms after the September 11 Terrorist Attacks. Psychiatry: Interpersonal and Biological Processes [Internet]. 2002 Dec;289–300. Available from: http://dx.doi.org/10.1521/psyc.65.4.289.20240
- 3.Boukes M, Vliegenthart R. News Consumption and Its Unpleasant Side Effect. Journal of Media Psychology [Internet]. 2017 Jul;137–47. Available from: http://dx.doi.org/10.1027/1864-1105/a000224
- 4.Busso DS, McLaughlin KA, Sheridan MA. MEDIA EXPOSURE AND SYMPATHETIC NERVOUS SYSTEM REACTIVITY PREDICT PTSD SYMPTOMS AFTER THE BOSTON MARATHON BOMBINGS. Depress Anxiety [Internet]. 2014 Jul;551–8. Available from: http://dx.doi.org/10.1002/da.22282
- 5.Johnston WM, Davey GCL. The psychological impact of negative TV news bulletins: The catastrophizing of personal worries. British Journal of Psychology [Internet]. 1997 Feb;85–91. Available from: http://dx.doi.org/10.1111/j.2044-8295.1997.tb02622.x
- 6.Pfefferbaum B, Newman E, Nelson SD, Nitiéma P, Pfefferbaum RL, Rahman A. Disaster Media Coverage and Psychological Outcomes: Descriptive Findings in the Extant Research. Curr Psychiatry Rep [Internet]. 2014 Jul 27; Available from: http://dx.doi.org/10.1007/s11920-014-0464-x
- 7.Simpson J. A Mad World, My Masters: Tales from a Traveller’s Life. London: Pan Books; 2008.
- 8.Kessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet EJ, Cardoso G, et al. Trauma and PTSD in the WHO World Mental Health Surveys. European Journal of Psychotraumatology [Internet]. 2017 Jul 31;1353383. Available from: http://dx.doi.org/10.1080/20008198.2017.1353383
- 9.Koenen KC, Ratanatharathorn A, Ng L, McLaughlin KA, Bromet EJ, Stein DJ, et al. Posttraumatic stress disorder in the World Mental Health Surveys. Psychol Med [Internet]. 2017 Apr 7;2260–74. Available from: http://dx.doi.org/10.1017/S0033291717000708
- 10.Hoppen TH, Morina N. The prevalence of PTSD and major depression in the global population of adult war survivors: a meta-analytically informed estimate in absolute numbers. European Journal of Psychotraumatology [Internet]. 2019 Feb 22;1578637. Available from: http://dx.doi.org/10.1080/20008198.2019.1578637
- 11.Feinstein A, Owen J, Blair N. A Hazardous Profession: War, Journalists, and Psychopathology. AJP [Internet]. 2002 Sep;1570–5. Available from: http://dx.doi.org/10.1176/appi.ajp.159.9.1570
- 12.Richardson LK, Frueh BC, Acierno R. Prevalence Estimates of Combat-Related Post-Traumatic Stress Disorder: Critical Review. Aust N Z J Psychiatry [Internet]. 2010 Jan;4–19. Available from: http://dx.doi.org/10.3109/00048670903393597
- 13.Kessler R, Angermeyer M, Anthony J, DE G, Demyttenaere K, Gasquet I, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry [Internet]. 2007 Oct 1;6(3):168–76. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18188442
- 14.Kessler RC, Bromet EJ. The Epidemiology of Depression Across Cultures. Annu Rev Public Health [Internet]. 2013 Mar 18;119–38. Available from: http://dx.doi.org/10.1146/annurev-publhealth-031912-114409
- 15.Stevelink SAM, Pernet D, Dregan A, Davis K, Walker-Bone K, Fear NT, et al. The mental health of emergency services personnel in the UK Biobank: a comparison with the working population. European Journal of Psychotraumatology [Internet]. 2020 Sep 23;1799477. Available from: http://dx.doi.org/10.1080/20008198.2020.1799477
- 16.Lamb D, Gnanapragasam S, Greenberg N, Bhundia R, Carr E, Hotopf M, et al. The psychosocial impact of the COVID-19 pandemic on 4,378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic [Internet]. Cold Spring Harbor Laboratory; 2021. Available from: http://dx.doi.org/10.1101/2021.01.21.20240887
- 17.Feinstein A, Osmann J, Patel V. Symptoms of PTSD in Frontline Journalists: A Retrospective Examination of 18 Years of War and Conflict. Can J Psychiatry [Internet]. 2018 May 23;629–35. Available from: http://dx.doi.org/10.1177/0706743718777396
- 18.Feinstein A, Wanga J, Owen J. The psychological effects of reporting extreme violence: a study of Kenyan journalists. JRSM Open [Internet]. 2015 Sep 1;205427041560282. Available from: http://dx.doi.org/10.1177/2054270415602828
- 19.Feinstein A, Feinstein S, Behari M, Pavisian B. The psychological wellbeing of Iranian journalists: a descriptive study. JRSM Open [Internet]. 2016 Dec;205427041667556. Available from: http://dx.doi.org/10.1177/2054270416675560
- 20.Feinstein A. Mexican journalists: An investigation of their emotional health. J Traum Stress [Internet]. 2012 Jul 13;480–3. Available from: http://dx.doi.org/10.1002/jts.21715
- 21.Feinstein A, Starr S. Civil War in Syria: the psychological effects on journalists. Journal of Aggression, Conflict and Peace Research [Internet]. 2015 Jan 12;57–64. Available from: http://dx.doi.org/10.1108/JACPR-04-2014-0119
- 22.Levaot Y, Sinyor M, Feinstein A. Trauma and psychological distress observed in journalists: a comparison of Israeli journalists and their Western counterparts. Isr J Psychiatry Relat Sci [Internet]. 2013 Jan 1;50(2):118–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24225439
- 23.Sin S, Chan A, Huak C. A pilot study of the impact of the Asian Tsunami on a group of Asian media workers. Int J Emerg Ment Health [Internet]. 2005 Oct 1;7(4):299–305. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16392274
- 24.Weidmann A, Fehm L, Fydrich T. Covering the tsunami disaster: subsequent post-traumatic and depressive symptoms and associated social factors. Stress and Health [Internet]. 2008;129–35. Available from: http://dx.doi.org/10.1002/smi.1168
- 25.North CS, Tivis L, McMillen JC, Pfefferbaum B, Spitznagel EL, Cox J, et al. Psychiatric Disorders in Rescue Workers After the Oklahoma City Bombing. AJP [Internet]. 2002 May;857–9. Available from: http://dx.doi.org/10.1176/appi.ajp.159.5.857
- 26.BAŞOĞLU M, MINEKA S, PAKER M, AKER T, LIVANOU M, GÖK Ş. Psychological preparedness for trauma as a protective factor in survivors of torture. Psychol Med [Internet]. 1997 Nov;1421–33. Available from: http://dx.doi.org/10.1017/s0033291797005679
- 27.Stein JY, Levin Y, Gelkopf M, Tangir G, Solomon Z. Traumatization or habituation? A four-wave investigation of exposure to continuous traumatic stress in Israel. International Journal of Stress Management [Internet]. 2018 Dec;137–53. Available from: http://dx.doi.org/10.1037/str0000084