by Becky Thorson

A guide to help agencies and churches make decisions and plan for contingencies when workers may need to leave the field early.

Falling through the Cracks
We had just finished our first term in Nepal and were waiting outside the door to meet with our mission council to be approved to return. We had gone to Nepal with great enthusiasm about how God might use us to minister to the Nepali people. But adjustment to life inNepal was hard, work in the hospital taxed our emotional and spiritual reserves, and we realized we had failed in many ways. We had been honest about our struggles in our lengthy debriefing session. What was the council going to say?

Imagine our shock when we walked into the room—and everyone stood up! “We honor you who are serving on the front lines,” they said. I will never forget the wave of healing love and grace that washed over me through these people I highly respected. We returned to Nepal feeling thankful and loved, that our mission had heard and understood our struggles, that they encouraged us to continue to serve, and that were upholding us in prayer. I would desire that every person returning from the field would be received and healed like this.

Cross-cultural adjustment stress is almost guaranteed to stretch us to the limit. It did that for me. We have to deal with many new things: isolation, sickness, difficult and demanding working conditions, danger, new relationships, different customs, language learning, spiritual attack, and new living situations. Most people eventually adjust to the new culture and grow through their new experiences, as I believe we did.

But when the overseas assignment is finished, people must traverse more hurdles when returning to their home country. Packing and moving, saying goodbye, changing cultures again, a new job, financial pressures, discerning God’s will, and especially loss of identity and community can cause emotional upheaval (Kimber 2012, 332-338). Some recent studies have shown that as many as forty to fifty percent of cross-cultural workers develop a psychological disorder such as depression, burnout, or post-traumatic stress during their time overseas or after returning to their home country (Levin 2008, 10; Hay et al 2007, 386).

Most mission organizations know this and support their workers well in pre-field preparation, on-field training, ongoing pastoral care, preparation for re-entry, and debriefing after assignments. But in my experience, I have found one area where we need to improve: when people have to return home prematurely for any reason: difficulties adjusting to the culture, living conditions, political unrest, the work or job description, moral failure, illness, family issues, etc. Ron Kotesky says this is more difficult than a scheduled return because (1) it is sudden, giving little time to prepare and (2) because other people will expect an explanation, which can be awkward if it involved something like interpersonal conflict or moral failure (Kotesky 2011, 1-2).

One young woman arrived very excited about the work she would be doing after her time of language study and cultural orientation. She studied diligently and seemed well adjusted. Up until that time she had seemed a strong survivor of an unsettling childhood: her parents had their own deep mental health issues and had separated. After that, she had been pushed and pulled between her parents, grandparents, aunts and uncles.

But the coping mechanisms that had worked for her before didn’t work in this strange new place. When the time came to begin work, she just couldn’t do it. She simply didn’t show up for work. In fact, she didn’t even inform others of her whereabouts! She met a few times with our counselor, who highly recommended that she have further counseling back home. She needed to deal with what had come to the surface while she had been struggling in Nepal. When she returned, however, the stress lifted and she felt no need for counseling. Her organization said they had no right to insist she get counseling, so she was on her own.

This is not the only time this has happened. Individuals and families have left the field early, and were strongly recommended to obtain professional counseling, but it did not happen. They were making critical decisions at an inopportune time—when they were psychologically compromised but not aware of it. The stress subsided, the issues that had surfaced went back into hiding, and everything seemed fine. However, the individuals missed the chance to process their experiences: to come to terms with their fears or perceived failures or anger at their organization, and to experience real freedom from the burdens of the past.

Counseling could have helped these individuals and families work through present and past issues, find value and meaning in their experiences on the field, and continue on stronger, knowing themselves better, trusting God more, and having greater coping ability. Without processing their experiences, there is a real danger that the problems will surface later on, potentially causing even more distress than if they had been dealt with immediately after returning home.

The sending agencies were keen to help their returning staff, but when these individuals refused the offer of counseling, the agencies felt there was nothing they could do. They could not force them to get counseling, and once they resign, the organization no longer had responsibility for them or a channel for advising them. Sending agencies need to be prepared for situations such as this by having a policy in place that will ensure the best possible care for their workers.

Situation in International Staff Care of Returning Workers
Studies have shown that sending organizations are doing very well in preparing people to work cross-culturally and helping them adjust to the culture when they arrive. But most organizations do not do as well when helping people return to their home countries, especially when there have been problems on the field. Medical checks are often routine, but psychological reviews are not required by most organizations surveyed (Porter and Emmens 2009, 37-44; Knell 2006, 64; Hay et al 2007, 386).

Organizations that do have procedures in place can serve as models for agencies which desire to design a policy in this area. Below are some good examples.

Tearfund has a mandatory post-assignment medical and opt-out confidential psychological debriefing with a professional psychologist or specially-trained counselor. If workers choose to opt out, they must sign a waiver. It is normal post-assignment procedure for all staff, and ninety percent take advantage of it (Porter and Emmens 2009, 38).

Medecins Sans Frontieres-UK staff members are required to participate in a confidential “returner’s talk” with a qualified psychological practitioner who understands the unique pressures of the international work environment. This practitioner is also available for clinical counseling if requested. MSF also requires a debriefing in the office, and returnees are contacted six to eight weeks after returning by a “volunteer link” who has previously worked with MSF and is trained in listening skills. This person also provides information on additional support that is available (Porter and Emmens 2009, 41; Moore 2008, 31).

Mennonite Central Committee staff debrief returning staff. The latter also participates in a four-day re-entry retreat with other returning staff, run by their staff care worker and at least one psychologist. The debriefing and the retreat provide opportunity where issues that may require additional psychological support can be identified. Counseling is available, encouraged, and paid for (Porter and Emmens 2009, 42; Williamson 2011).

Evangelical Fellowship of Canada’s Code of Best Practice is considered the “benchmark” by the member care international community. They consider their organizational responsibilities to extend to reentry and retirement from the field. This responsibility includes required debriefing (physical, psychological, ministry, and pastoral), opportunity to attend transition seminars, and resources (human and financial) for follow-up care. In case of a crisis (organizational, family, disasters, kidnapping, medical, spiritual battles, etc.), any care deemed necessary, such as post-traumatic stress care and counseling, is made available. (O’Donnell 2002, 272- 276)

BMS World Mission-UK offers debriefing to all returning staff. A reentry weekend is offered and paid for, and further debriefing is available, although few staff take advantage of it. BMS also refers people for counseling to the Church Ministerial Counseling Service, and cover the costs of up to ten sessions (Gibbs 2011).

Best Practice
Many sources concerned with good management and care of cross-cultural workers agree on the need for support at the end of an assignment. All recommend debriefing, and most recommend a confidential psychological assessment by a professional, with continued counseling support, if necessary. Many note that premature departure from the assignment for any reason is uniquely stressful and will require additional care. Good resources include:

• People in Aid’s “Code of Good Practice” (Wallace 2003)
• Antares Foundation’s Managing Stress in Humanitarian Workers: Guidelines for Good Practice (van Pietersom et al 2006)
• Doing Member Care Well’s “Flow of Care and Caregivers” model (O’Donnell 2002)

In a publication about stress management for staff, Monday Developments magazine states that “humanitarian relief and development organizations have a moral imperative to look after the health and well-being of their team members” (Levin 2008, 12). They point out that this obligation applies to all stages of the staff person’s employment: “before they are deployed, when they are in the field and after they return” (Ehrenreich 2008a 27; Ehrenreich 2008b, 14).

People in Aid and Interhealth note that returning staff have sometimes complained to insurance providers that they were not properly supported by their international employers, and that litigation is increasingly becoming an issue. Because of this, they suggest that comprehensive debriefing should be part of a “due-diligence” process for returning staff (Porter and Emmens 2009, 43-44).

The Antares Foundation’s Managing Stress in Humanitarian Workers: Guidelines for Good Practice states that in addition to an “operational debriefing,” all staff members should have access to a confidential “personal stress assessment and review” by someone outside of the organization at the end of their assignment. They understand that unplanned endings can create unique problems, and therefore recommend that psycho-social services and help in developing a peer support network should be made available for staff after any kind of premature termination of an assignment. This can help staff members to assess their own needs, and make personal plans to address these needs, thus reducing the stress (van Pietersom et al 2006, 20-21).

A People in Aid/Interhealth proposal says that, “The end of an assignment or contract period is an ideal time for staff members to ‘take stock’ of their physical and psychological state.” They mention that a physical examination (required by many organizations for returning staff) is done to identify and treat any diseases a person may have picked up overseas. Why not a psychological review for the same reason? They state that “psychological reviews enable staff to process their experience, receive advice on dealing with reverse culture shock, learn and give meaning to their time abroad, as well as prepare them for the next assignment” (Porter and Emmens 2009, 43).

The Doing Member Care Well “Flow of Care and Caregivers” model includes “Reentry” as Stage 8 and “Ongoing Support” as Stage 9. It points out that there are “consequences to our kingdom work, and often times there are significant injuries.” For those who have returned injured, whether physically, psychologically, or spiritually, they advise this: “We must thus prioritize, budget, and take the time necessary to walk mission personnel through the healing process and see them restored” (O’Donnell 2002, 31).

The importance of personal debriefing for all returning workers (including children) is also emphasized in Worth Keeping (Hay et al 2007) and Burn up or Splash Down (Knell 2006). Good debriefing will allow free expression of feelings without judgment, allowing returning workers to feel listened to and valued. Debriefing can help individuals to view their mission experiences as meaningful and valuable parts of their whole life stories and be ready for the next chapter. This can help prevent psychological disorders such as depression or anxiety from developing.

Stress symptoms can be identified and coping strategies developed. Adjustment issues, feelings of failure or guilt, or any other symptoms of stress can be brought up at this time and dealt with, thus preventing them from simmering below the surface and erupting later on in life. The debriefer can recommend further professional help if needed (Hay et al 2007, 386; Knell 2006, 66).

To summarize, talking about one’s experience with a trained counselor who understands the special stresses of cross-cultural work can provide a chance to:

• Talk about the experience and process it
• Give meaning to one’s time abroad
• Receive advice on dealing with reverse culture shock
• Look forward to the next chapter in his or her life journey
• Assess one’s own needs and create a personal management plan
• Highlight any issues that require follow up
Receive recommendations for further counseling, if needed
• Prevent or minimize psychological consequences of any stress experienced

What Should We Do?
It is better to work together to make decisions and plan for contingencies when people are feeling healthy and have time to think things through. The ability to weigh choices, see the situation and their own needs clearly, and make wise decisions is compromised when people are in the midst of a crisis and, to some degree, psychologically impaired. I strongly agree with this statement from Worth Keeping: “Only providing debriefing for those that ask usually means that those who really need it won’t get it!” It is better to arrange it for all (Hay et al 2007, 386).

Sending agencies should include something about this not only in the policy guidelines, but also in their agreements with new cross-cultural workers before they leave their home country. Sending agencies should:

• Include debriefing as a standard, required procedure for all staff on home assignment after a term overseas. Debriefing by a confidential counselor is highly recommended.
• Provide a confidential psychological assessment by a professional who understands the special issues related to cross-cultural living as a standard and required procedure for all staff returning prematurely from the field.
• Have candidates sign an agreement as part of their application process, stating that they will agree to this psychological assessment and counseling, if recommended (see sample agreement on page 475). A few notes:
* This should be done when they are feeling well and thinking clearly
* They must “opt out” against recommendations of the agency if they refuse to have the assessment and subsequent counseling
• Assist returnees in finding a counselor if a period of counseling is recommended.
• Provide financial assistance for any counseling that is recommended.
• Prioritize, budget, and take the time necessary to walk mission personnel through the healing process and see them restored (O’Donnell 2002, 31).
• Ensure that all returning staff be embraced by a loving faith community (Williamson 2011).

References
Ehrenreich, John H. 2008a. “Lest We Reinvent the Wheel: Guidelines Do Exist for Good Practice in Managing Stress in Humanitarian Workers.” Monday Developments Magazine 26(9): 27.

_____. 2008b. “Social Support: Is staff Care an Individual or an Agency Responsibility?” Monday Developments Magazine 26(9): 14.

Foyle, Marjory. 2001. Honourably Wounded: Stress among Christian Workers. Rev. ed. London: Monarch Books.

Gibbs, Margaret. 2011. BMS World Mission, Didcot, U.K. Personal email November 1.

Hay, Rob, Valerie Lim, Detlef Blöcher, Jaap Ketelaar, and Sarah Hay. 2007. Worth Keeping: Global Perspectives on Best Practices in Missionary Retention. Pasadena, Calif.: William Carey Library.

Kimber, Thomas. 2012. “Healthy Reentry: The Shared Responsibility of Missionary Care.” Evangelical Missions Quarterly 48(3): 332-338.

Knell, Marion. 2006. Burn Up or Splash Down: Surviving the Culture Shock of Re-entry. Atlanta: Authentic Publishing.

Kotestky, Ron. 2011. What Missionaries Ought to Know about Premature Departure from the Field. Wilmore, Ken.: New Hope International Ministries. Accessed June 3, 2011, from www.missionarycare.com.

Levin, Joshua. 2008. “Why Bother with Stress Management?” Monday Developments Magazine 26(9):10-12.

Moore, Christina. 2008. “Taking Care of Each Other. Peer Support in Humanitarian Organizations: Peer Support Network.” Monday Developments Magazine 26(9):31

O’Donnell, Kelly, ed. 2002. Doing Member Care Well: Perspectives and Practices from around the World. Pasadena, Calif.: William Carey Library.

Porter, Benjamin and Ben Emmens. 2009. Approaches to Staff Care in International NGOs. London: People in Aid and Interhealth.

van Pietersom, Tineke, John Ehrenreich, and Winnifred Simon. 2006. Managing Stress in Humanitarian Aid Workers: Guidelines for Good Practice. 2nd ed. Amsterdam: Antares Foundation. Accessed May 13, 2013, from www.antaresfoundation.org/guidelines.htm

Wallace, Ian. 2003. People in Aid Code of Good Practice in the Management and Support of Aid Personnel. London: People in Aid.

Williams, David. 2010. “Pastoral Care of Missionaries: Turning Theory into Practice.” Evangelical Missions Quarterly. 46(4): 426-432.

Williamson, John. 2011. Mennonite Central Committee area director, Kathmandu, Nepal. Personal email. November 22.

….

Becky Thorson has been sent by World Mission Prayer League to work with the United Mission to Nepal (UMN) since 1984. She has been part of the human resources team of UMN since 2003 as coordinator for the UMN Language and Orientation Program, as well as holding roles in recruitment and pastoral care for part of that time. She holds an MA in intercultural studies and an MA in clinical psychology, and is a licensed professional counselor.

__________________________________

SAMPLE AGREEMENT

Agreement for applicants to SENDING AGENCY (replace with your agency name)

Member care experts and those experienced in personnel issues related to overseas assignments are well aware that people may have to return to their home country prematurely (before they or SENDING AGENCY had originally planned). There may be many reasons, such as: physical illness, miscarriage, psychological stress, misfit of person to assigned role, problems related to family back home, death of a family member, children’s education, marital relationship, moral failure, political unrest, accidents, adopting a child, etc.

In any case, it has been found that talking with an experienced counselor can help the individual and the family to process the situation and come to terms with what has happened. Often, after returning home, the need for this may seem less apparent to the individual or family affected. But later on, sometimes even years later, memories, hurts, grieving over losses can still be affecting the person.
Therefore, before going to the field, while in a healthy and calm state, let us all agree that if you have to come back home early (either the worker or the agency can determine what ‘early’ means), you will see a confidential professional counselor for a psychological assessment and follow up with counseling as recommended by the counselor. The SENDING AGENCY will cover the cost of up to ___ sessions of counseling through SENDING AGENCY’s health insurance provider, or by SENDING AGENCY self-insurance if the health insurance provider will not cover it fully. This is in addition to the regular debriefing by the SENDING AGENCY that all returning workers will have, as stated in the policy manual.

Candidate (both husband and wife sign separately):

I agree to the following:

If for any reason I (or my family) have to leave the field of assignment suddenly and/or significantly earlier than what was stated in the assignment agreement, I agree to see a confidential professional counselor for a psychological assessment and follow up with counseling as recommended by the counselor. This counselor will be chosen by the SENDING AGENCY personnel director, or chosen by me and agreed to by SENDING AGENCY personnel director.

_____________________________________________________ Date:____________
Signature of Candidate

SENDING AGENCY agrees to the following:

If for any reason ______________________ (name of candidate) has to leave the field of assignment suddenly and/or significantly earlier than what was stated in the assignment agreement, SENDING AGENCY agrees to arrange psychological assessment with a confidential professional counselor. This counselor will be chosen by the SENDING AGENCY personnel director, or chosen by the worker and agreed to by the SENDING AGENCY personnel director. SENDING AGENCY will ensure that the cost of up to ___ sessions of counseling is either covered by SENDING AGENCY’s health insurance provider, or by SENDING AGENCY self-insurance if the health insurance provider will not cover it fully.

___________________________________________________________ Date _______

Signature of SENDING AGENCY personnel director or other SENDING AGENCY home office staff

Catch Me if I Fall: Premature Departure from the Field

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