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War & Peace - Saving Lives on the Front Lines and at Home

Dr. Anthony Feinstein (left), producer of the Oscar short-listed documentary "Under Fire: Journalists in Combat", and Dr. Homer Tien, National Practice Leader in Trauma for the Canadian Forces.

©Tim Fraser, 2012

It has long been understood that the atrocities of war don't always remain on the battlefield when soldiers come home, but a Sunnybrook psychiatrist is proving journalists suffer much the same damage as those behind the gun.

"If you're a journalist going off to war, you can experience horrible things that will lead you to be vulnerable to post-traumatic stress disorder [PTSD]" explains Dr. Anthony Feinstein, producer of Under Fire: Journalists in Combat, a documentary about the mental health risks these journalists face. "This is an issue that is clearly not going to go away. The world is in a big mess, and there's enough conflict in the world to make sure a lot of journalists are going to get hurt."

The documentary, short-listed for a 2012 Oscar nomination, examines the horrors of war through the stories of journalists sent to cover it – and these stories are indeed horrific. Viewers meet Jon Steele, for example, author of War Junkie and a cameraman for Independent Television Network, who describes a little girl injured in Sarajevo while waiting for him to bring her candy. He tries to visit her in hospital, but is brought to her dead body stretched out on the floor instead.

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There is Ian Stewart, who was head of the Associated Press' West Africa bureau in 1999 when a young rebel – a boy, really – fired his AK-47 into Stewart's vehicle, killing another journalist and lodging a bullet in Stewart's brain. Partially paralyzed, he says he still pictures the screaming and agonized faces of war when he closes his eyes.

And there is the Toronto Star's Paul Watson, author of Where War Lives, who is probably best known for his 1994 Pulitzer Prize-winning photograph of a dead American soldier being dragged through the streets of Mogadishu, Somalia. Interviewed in Under Fire, he says he is still haunted by his decision to take that photograph, feels like a participant in the desecration of a body and longs for forgiveness.

"Every front-line journalist deals with these issues," says Dr. Feinstein. "I've spoken with many war photographers who tell me they have trays and trays of photographs that will never see the light of day. No newspaper will ever show them because they are unspeakably horrible, but they've seen them. They're part of their memories."

As these front-line journalists attempt to combat the fallout from their experiences, the results can be devastating: substance abuse, depression, thoughts of suicide or a sense they no longer fit within society. Relationships crumble and sleep suffers.

"When I started out covering conflicts almost 25 years ago, few journalists spoke openly about the psychological risks," Paul Watson, Toronto Star journalist

"We self-medicated with drugs and alcohol," Paul says. "Talking about something like post-traumatic stress disorder would have been seen as a weakness. That has changed. And Dr. Feinstein's work must have helped make that change happen."

To be sure, the idea that journalists could suffer from PTSD (once called shell shock, battle fatigue and other names) was unheard of until a patient was referred to Dr. Feinstein in 2000. She presented with recurring neurological symptoms such as incoherence, agitation, sweating, occasionally lapsing in and out of consciousness, but her chart showed no physical abnormalities. Her personal history was typical of those he would hear from other journalists in the coming years: a decade-plus of cumulative stress, near-death experiences and conflict coverage, followed by self-medication with drugs and alcohol. It was an issue that no one – not journalists, their employers or trauma researchers – was addressing.

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"Not only had most of the news organizations neglected to provide for the psychological welfare of their war reporters, but trauma researchers had ignored them too," Dr. Feinstein writes in his 2006 book Journalists Under Fire: The Psychological Hazards of Covering War. "Trawling through the literature, I could not find a single reference to the subject – no articles, chapters or abstracts. I had stumbled on a virgin topic, lying unrecognized within a larger literature devoted to the emotional consequences of traumatic events."

And so, backed by financial support from the Freedom Forum, a Washington-based organization focused on protecting freedom of speech, Dr. Feinstein interviewed 140 war correspondents by the end of 2001 and published his first book on the subject, Dangerous Lives, in 2003. He later received funding from CNN, the BBC and the Dart Foundation to further his work. "Journalists who develop symptoms of PTSD can suffer greatly," explains Dr. Feinstein. "It's an occupational hazard, and the ones who are good know that and accept it. If they can't accept that, they simply can't do this work."

He is quick to point out that not all journalists who cover conflict are suffering; some return from the battlefield largely unscathed. That 29 per cent of war journalists develop PTSD, Dr. Feinstein notes, leaves more than 70 per cent who don't. Likewise, 76 per cent of journalists do not develop depression. Many do not develop drinking problems. But the rates are still significantly higher than those in the general population and higher, for example, than rates for police officers, fire fighters and veterans who have not seen active combat.

It is truly a dangerous time for journalists: 900 have been killed covering combat in the past two decades compared to just two killed covering the First World War. "Iraq has been by far the most lethal conflict for journalists, with close to 200 members of the press killed so far. This number exceeds the mortality rate for journalists from World Wars I and II and the Vietnam War combined," says Dr. Feinstein.

Whether steered by confidential help lines established by news outlets, or encouraged by Dr. Feinstein's books, his documentary or his reputation, journalists are turning to him in increasing numbers. He responds, depending on the severity of their symptoms, with an array of treatment options including cognitive behavioural therapy, cautious use of medication and counselling. For those with full-blown PTSD or depression, taking a break is often his first recommendation. "If someone is acutely traumatized and in a war zone, my advice to them is, 'You need to take a break from this and look after yourself,'" he explains. "That's common sense; if you're a long-distance runner and you've developed a fractured leg, you're going to take a break from running."

For those in remote areas, he will set aside an hour a week to counsel them remotely, over the phone; he has treated journalists this way for several months at a stretch. (The opening scene in Under Fire, for example, shows Reuters photographer Finbarr O'Reilly preparing for an assignment in West Africa by packing his flak jacket and calling Dr. Feinstein in Toronto.) For those whose problems turn out to be more acute, he recommends returning home – wherever home might be – to seek local expertise.

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Graeme Smith, who covered the war in Afghanistan for The Globe and Mail from 2005 to 2009, visited Dr. Feinstein at his Sunnybrook offices as a precaution. "I wanted to get my head checked, to put it bluntly, and he assured me I'm not suffering from PTSD or depression," says Graeme, adding that the session gave him a clear picture of what he should be watching for: changes in sleeping habits, relationships or appetites for food or sex. "He also told me to watch for any irrational avoidance behaviour, a tip-off that somebody can be scarred by a particular experience and unwilling to repeat it."

But much of Dr. Feinstein's work is more proactive than reactive, working with news outlets and journalists before problems arise.

In 2007, Dr. Feinstein designed and helped launch a confidential online self-help resource ( that allows journalists to complete self-assessments of PTSD symptoms, depression, general psychological well-being and alcohol and substance use. Users receive immediate feedback that can be used to facilitate access to a family doctor or an employee assistance program for therapy, if needed.

And Dr. Feinstein spreads the word through in-depth educational seminars, such as the one he led at the New York offices of CNN in December. There, he offered a series of two-hour sessions in which he presented data from his research; explained PTSD, depression and substance abuse; and facilitated a Q&A. The format benefits journalists who cover conflict far from home, he says, but also those who cover domestic events such as 9/11 and Hurricane Katrina.

Perhaps the most unusual seminar he led was in Boston, by invitation from National Public Radio, which involved Israeli and Palestinian journalists across from one another at one table. "Interestingly, the issue of PTSD was very familiar to the Israelis, but it was a completely new issue among the Palestinians; they were fascinated by it," recalls Dr. Feinstein.

He was a keynote speaker at the 2008 Journalism in a Violent World conference, part of the Canadian Journalism Forum on Violence and Trauma, of which he is director.

His message is sinking in, and Under Fire should help spread that message with screenings in New York, Los Angeles, England and Toronto. Canadian media are behind the curve, Dr. Feinstein admits, while organizations such as CNN are leading the way. "It's people's personal responsibility whether they want to look after themselves or not. The way you break through the barrier and convince people to take the issues seriously is through education," he says. "And the culture is changing – and that's been very rewarding."

Changing, but still with far to go, as one journalist points out. "I'm stunned to hear that media professionals who have seen the film are shocked," says the Toronto Star's Watson."Which tells me that even people in the business, who I assumed knew what we were going through, largely didn't."

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