The Psychological Health of Missionaries—Adding to the Research

6903821997_e0a95ce498_nHere’s a quick question:

What percentage of returned missionaries and aid workers report psychological disorders during their time overseas or shortly after their return? What do you think? About a quarter, a third, half, two thirds, three quarters?

According to a 1997 study conducted by Debbie Lovell-Hawker of Oxford University, the answer is “about half.” More precisely, Lovell-Hawker’s findings show that among the returned missionaries and aid workers she studied,

46% reported that they had experienced a clinically diagnosed psychological disorder either while working overseas or shortly after returning to the United Kingdom.

Before I went overseas, I would have guessed much lower than half, but after I first heard this statistic referenced in a debriefing I attended, in my mind, the number began to grow much higher than 46%. Statistics have a way of doing that.

Lovell-Hawker’s research included 145 aid and development workers and missionaries from 62 organizations. Though not definitive, the findings are significant as a wake-up call to cross-cultural workers, sending agencies, NGOs, churches, and member-care givers. And they also can assure those repats who are struggling that they are not alone.

Other  findings include

• 18% reported that their problems developed while they were overseas—82% said they began after returning to their home country
• Depression was the most frequently reported problem, occuring in 87% of the cases
• Those who reported having psychological problems had spent significantly longer time overseas than those who reported having none

(Debbie Lovell-Hawker, “Specialist Care: Psychological Input,” Global Connections Member Care Conference, February 18, 2002)

Moving forward from this study, there are some things I’d still like to know: Has anything changed in the 26 years since the findings were published? What would the numbers be for all missionaries and aid workers, not just those who’ve returned? What would the breakdown be among those working in relief and development vs other settings, such as teaching or church planting in developed areas? Are the numbers consistent for workers returning to countries other than the UK? And what about TCKs?

The good news is that there are researchers who are working on these and similar questions.

The Research Continues

One of those researchers is Lynette H. Bikos. Lynette served as a guest editor (along with M. Elizabeth Lewis Hall) of a special issue of Mental Health, Religion & Culture in 2009, titled “Missionaries.” Lynette is director of research and professor of clinical psychology in the School of Psychology, Family, and Community at Seattle Pacific University—and she also happens to be a friend who lived next to me, on an adjoining farm, as we grew up in northeast Missouri. We’ve kept in touch over the years, and she corresponded with my family and me as she worked on her research.

The special issue includes 10 articles dealing with several aspects of cross-cultural adjustment among those whom the editors call “religiously motivated sojourners.” I’d like to highlight four of those articles:

“Social Support, Organisational Support, and Religious Support in Relation to Burnout in Expatriate Humanitarian Aid Workers”
(Cynthia B. Eriksson et al., Mental Health, Religion, & Culture, November 2009)

This assessment found that 40% of expat middle managers in an international faith-based agency were at “high risk” of burnout in one of three areas—lack of personal accomplishment, emotional exhaustion, and disconnection or distance from those being cared for—but less than 4% reported high levels of burnout in all three.

According to the authors of the study, “This suggests that despite intense work and chaotic environments a majority of workers find ways to identify accomplishments, stay connected to others in their work, and rejuvenate. Team relationships, friendships, and positive organisational support may contribute to the resilience for these workers.”

The findings also indicate that younger workers are at a greater risk of burnout, as they register greater negatives in all three burnout areas. But while age was a factor, the number of years serving with the agency was not.

“Resilience in Re-Entering Missionaries: Why Do Some Do Well?”
(Susan P. Selby et al., Mental Health, Religion, & Culture, November 2009)

The authors posed the question ‘‘Why do some re-entering missionaries do well while others do not?’’ and interviewed 15 Australian cross-cultural missionary workers to help find the answer.

All the participants were over 25 years old and had spent at least 2 out of the previous 3 years in a non-Western country. Based on their responses, the researchers divided the missionaries into two categories: “resilient” and “fragile.”

In the interviews, the eight resilient missionaries described having

• flexibility
• higher expectancy and self-determination
• denial in the form of minimization to deal with their distress
• good mental health
• more social support
• a positive reintegration
• a personal spiritual connection to God

In contrast, the seven who were considered fragile described

• less flexibility
• lower expectancy and self-determination
• less use of denial with minimization
• poorer mental health
• less social support
• difficulty reintegrating
• a decreased or fluctuating personal spiritual connection to God

It is interesting that while the results of a questionnaire measuring depression, anxiety, and stress (DASS 21) showed higher levels for the fragile group, the scale showed that only one out of the entire group (including resilient and fragile) had an actual perception of being “personally stressed.”

“Psychological Well-Being and Sociocultural Adaptation in College-Aged, Repatriated, Missionary Kids”
(Michael J. Klemens and Lynette H. Bikos, Mental Health, Religion, & Culture, November 2009)

When the researchers compared a group of MKs to non-MKs at a Christian university, they found that while both groups scored in the healthy range of psychological well-being (PWB),  the missionary kids’ scores were significantly lower.

The missionary kids’ MK status accounted for only 4% of the variance in psychological well-being but was responsible for nearly a quarter (23%) of the difference in sociocultural adaptation (SCA). In this latter area, the MKs reported the most difficulty in “taking a US’ perspective on the culture; seeing things from an American’s point of view; understanding the US’ worldview; understanding the US’ value system; and making yourself understood.”

“Curiously,” report Klemens and Bikos, “neither the age of the participant, nor the number of years abroad, nor the number of years since repatriation was related to PWB or SCA for the MKs.”

“Reduction in Burnout May Be a Benefit for Short-Term Medical Mission Volunteers”
(Clark Campbell et al., Mental Health, Religion, & Culture, November 2009)

This assessment looked at how international short-term mission trips affect burnout among volunteers.

The participants in the study, most of whom were physicians and nurses, travelled to South America for two weeks to provide medical care in a non-disaster-relief setting. Prior to their departure, the group members’ responses to questionnaires showed that they were experiencing moderate burnout. Their burnout levels were again assessed one month and six months after the trip.

“The major finding of this study,” report the researches, “is counter-intuitive: that medical personnel who are emotionally exhausted, have an impersonal response towards their patients, and lack a sense of [personal accomplishments] (moderately burned out) benefit by working hard with numerous patients in an international context.”

They found that levels of emotional exhaustion and perceived personal accomplishments showed significant improvements following the short-term trip and continued in a positive direction in the 6-month followup.

___________________________________________________

All good research builds about what has been learned before and leads to questions for new studies in the future. I join with Lynette and her co-editor in hoping that the information in their special issue of Mental Health, Religion & Culture encourages others to join in the “exploration” of the psychological health of missionaries. There is so much more to be discovered.

(Lynette H. Bikos and M. Elizabeth Lewis Hall, “Psychological Functioning of International Missionaries: Introduction to the Special Issue,” Mental Health, Religion, & Culture, November 2009)

This special journal issue also includes several articles specific to the experiences of female missionaries. I hope to discuss these in a future post.

[photo: “Confused,” by Mary T Moore, used under a Creative Commons license]

Do You Have Compassion Fatigue?

5982590252_cab6303486_nAre you a cross-cultural worker in a “caring profession”? Are you a member-care giver or coach to someone who works cross-culturally? Do you sometimes feel overwhelmed by the needs of those you’re helping, pouring out more and more from a reservoir that is going dry? Has your compassion satisfaction turned into compassion fatigue?

A few weeks ago I attended a day-long workshop entitled “Resilience Strategies for Educators: Techniques for Self-Care and Peer Support.” It was offered to our community in Joplin, Missouri, because of the ongoing effects—felt by educators and students—of the May 22 tornado, two years ago.

I am very interested in how the vocabulary and strategies used by the facilitators, Arthur Cummins (Orange County Department of Education) and Stephen Hydon (University of Southern California), parallel what I’ve heard presented by those in member care for cross-cultural workers. One of their goals was to give us “tools” for our “toolbox,” and I’d like to share one of those tools with you: the “Professional Quality of Life Scale,” or ProQOL.

The ProQOL measures “compassion satisfaction” and “compassion fatigue,” with the latter category further broken down into “burnout” and “secondary trauma.”

I have included the ProQOL Measure below. As you can see, it uses the generic terms help and helper, but they can be substituted with words to better fit a given audience. A printable version, along with scoring instructions, is available here. The ProQOL Measure in 17 non-English languages (versions vary) can be downloaded here. And the 2010 edition of the “The Concise ProQOL Manual,” explaining the background and interpretation of scores is here.

For those interested in more information on compassion fatigue and trauma stress, try these sites:

If you use the scale, I hope that you find you’re doing well, but if the results show that you have compassion fatigue, I hope you can find the rest and help you need.

Professional Quality of Life Scale (ProQOL)

Compassion Satisfaction and Compassion Fatigue (ProQOL) Version 5 (2009)

When you [help] people you have direct contact with their lives. As you may have found, your compassion for those you [help] can affect you in positive and negative ways. Below are some questions about your experiences, both positive and negative, as a [helper]. Consider each of the following questions about you and your current work situation. Select the number that honestly reflects how frequently you experienced these things in the last 30 days.

1=Never    2=Rarely    3=Sometimes    4=Often    5=Very Often

___ 1. I am happy.
___ 2. I am preoccupied with more than one person I [help].
___ 3. I get satisfaction from being able to [help] people.
___ 4. I feel connected to others.
___ 5. I jump or am startled by unexpected sounds.
___ 6. I feel invigorated after working with those I [help].
___ 7. I find it difficult to separate my personal life from my life as a [helper].
___ 8. I am not as productive at work because I am losing sleep over traumatic experiences of a person I [help].
___ 9. I think that I might have been affected by the traumatic stress of those I [help].
___ 10. I feel trapped by my job as a [helper].
___ 11. Because of my [helping], I have felt “on edge” about various things.
___ 12. I like my work as a [helper].
___ 13. I feel depressed because of the traumatic experiences of the people I [help].
___ 
14. I feel as though I am experiencing the trauma of someone I have [helped].
___ 15. I have beliefs that sustain me.
___ 16. I am pleased with how I am able to keep up with [helping] techniques and protocols.
___ 17. I am the person I always wanted to be.
___ 18. My work makes me feel satisfied.
___ 19. I feel worn out because of my work as a [helper].
___ 
20. I have happy thoughts and feelings about those I [help] and how I could help them.
___ 21. I feel overwhelmed because my case [work] load seems endless.
___ 22. I believe I can make a difference through my work.
___ 23. I avoid certain activities or situations because they remind me of frightening experiences of the people I [help].
___ 24. I am proud of what I can do to [help].
___ 25. As a result of my [helping], I have intrusive, frightening thoughts.
___ 26. I feel “bogged down” by the system.
___ 27. I have thoughts that I am a “success” as a [helper].
___ 28. I can’t recall important parts of my work with trauma victims.
___ 29. I am a very caring person.
___ 30. I am happy that I chose to do this work.

(After completing the scale, go here for the self-scoring guide.)

© B. Hudnall Stamm, 2009. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). /www. isu. edu/~bhstamm or www. proqol. org. This test may be freely copied as long as (a) author is credited, (b) no changes are made, and (c) it is not sold.

[photo: “I Think I’ll Start a New Life,” by Noukka Signe, used under a Creative Commons license]