Trauma and Traumatic Stress in Cross-cultural Missions: How to Promote Resilience

by Karen F. Carr and Frauke C. Schaefer

Results from a research study explores the relationship between traumatic events and psychological symptoms.

John, Marta, and their three children were church-planting missionaries living in West Africa. Like many living in this area of the world, they experienced several traumatic events, including an armed robbery, a car accident, malaria, and the death of family members in their home country. One day they woke up to the sound of gunfire and explosions. They, along with their teammates, managed to leave the village in their vehicle, but as they drove along the road they saw dead bodies and were stopped several times by rebels who had guns and threatened to shoot them.
 
These traumatic experiences are common scenarios for missionaries in certain settings. As we send missionaries into high-stress environments, it will be helpful to understand the types of trauma they might face and their potential impact. This will allow us to prepare and support them, thereby strengthening their resilience as they face these challenges.

In 2005, the Mobile Member Care Team (MMCT), Greater Europe Mission, and Duke University collaborated to conduct a research study of missionaries. The goals were to better understand the frequency of trauma, explore the relationship between traumatic events and psychological symptoms, and identify factors that would mitigate those symptoms (Schaefer, Blazer, Carr, et al. 2007). The study found that missionaries in West Africa and Europe had encountered more severe trauma than the general U.S. population. Missionaries in West Africa experienced significantly more trauma than missionaries in Europe and those in Europe experienced significantly more trauma than the general U.S. population (see table 1).

The most common traumas for the West Africa missionaries were serious illness (61%); car, train, or plane accidents (56%); unexpected death of family member or close friend (51%); immediate exposure to fighting, civil unrest, or war (48%); burglary (41%); serious threat or harm to family member or close friend (38%); seeing another person seriously injured or dying as a result of accident or violence (34%); and evacuation (31%). For missionaries from Europe, the most common traumas were car, train, or plane accidents (66%); unexpected death of a family member or close friend (54%); and burglary (38%).  

The Impact of Trauma
When John, Marta, and their children arrived in the capital city, they felt physically safe, but were emotionally exhausted. John felt very angry about the injustice he had seen. Marta had trouble sleeping and felt jumpy and nervous. Although the kids mostly acted like nothing was bothering them, the youngest left the light on at night and sometimes came into his parents’ room to sleep during the night. They didn’t know when they could go back to their village and found it hard to concentrate or be productive. They also felt guilty about the people they had left behind and grieved the many losses they and others faced. Both John and Marta had a strong sense of calling to the people group with whom they were working and wondered why God allowed this to happen just when the church was starting to flourish.    

Some missionaries will leave their ministries because of the impact of these kinds of traumas. Some will stay despite ongoing pressure and stress. What are the factors that help people stay on the field? What type of peer, organizational, and member care support would make an impact on whether or not a person leaves prematurely or perseveres in his or her call and finishes well?  

If stress levels exceed the person’s normal coping strategies and resilience, post-traumatic stress, depression, burnout, or anxiety can result (see table 2). The distress can negatively impact the missionary’s relationships and ministry. Missionary communities are often small and tightly knit. If one missionary faces hardship, the whole community is affected. When a friend or colleague experiences a traumatic incident, fellow missionaries will come face to face with their own vulnerability.

Although most people meet the challenges of trauma with resilience, a certain percentage will develop Post-traumatic Stress Disorder (PTSD). PTSD symptoms can include flashbacks, nightmares, difficulty sleeping, emotional numbing, increased startle response, and avoidance of things that remind the person of the event. In a survey of the general U.S. population, Jonathan Davidson (Davidson, Tharwani, and Connor 2002) found that about two percent were suffering from Post-traumatic Stress Disorder (PTSD). A less severe reaction with similar symptoms is called Post-traumatic Stress Symptoms (PTSS) and about four percent of the U.S. population suffers from this at any point in time. The study among missionaries (Schaefer, Blazer, Carr, et al. 2007) showed that despite higher trauma rates among the missionaries sent to Europe, only two percent had PTSD and four percent had PTSS. Much higher trauma rates among West Africa missionaries resulted in significantly higher rates of PTSD (5%) and PTSS (15%), but not as high as one might expect given the high incidence of traumatic events (see table 2).

In fact, given the extremely high incidence of trauma in West Africa, we might have expected a much higher rate of PTSD and PTSS. Why were these rates not so high? Perhaps missionaries in West Africa had characteristics that made them more stress resilient: a strong sense of call, tough-mindedness, a willingness to face adversity, and well-developed support systems. It should be noted, however, that missionaries who lived in high-risk areas such as Ivory Coast, Guinea, and Nigeria had a total PTSD/PTSS rate as high as twenty-eight percent. It appears that regardless of coping strategies, extremely high rates of trauma will result in higher levels of post-traumatic stress.

Missionaries who experienced higher numbers of traumatic events suffered from much higher levels of post-traumatic stress, depression, and more difficulties at work and in relationships. This implies that effective strategies to prepare missionaries for high-risk countries and effective care after traumatic events are needed to maintain the well-being and effective ministry of missionaries.

The study also showed that the level of depression was strongly linked to more severe post-traumatic stress. Missionaries with lingering depression, therefore, are more vulnerable to the impact of trauma. Also, missionaries with post-traumatic stress symptoms which are not sufficiently addressed will likely become increasingly depressed.

Certain types of traumas were most closely associated with post-traumatic stress or depression. These included immediate exposure to fighting, civil unrest, and war; and serious threat or harm to or unexpected death of family member or close friend. Missionaries facing these types of traumas are at a higher risk for experiencing post-traumatic reactions and therefore would benefit from specialized member care on the field provided by a trained counselor or peer responder.

Resilience
John, Marta, and the children waited in the capital city, hoping for news that they could return to the village. During that time, they often talked together as a family, and in devotional times they focused on the Psalms and God’s promises. They enjoyed a strong network of friends from many different mission organizations and took time to renew and strengthen relationships. As a couple, they took time to share their fears and needs. They talked with their leadership and felt supported by them. A missionary (who had been trained as a peer responder) with another organization spent time helping them to understand that their emotional reactions were typical and expected, given the traumas they had been through. Eventually, they were able to return to the village and resume their ministry, thankful for the support they had received and strengthened by a renewed sense of call.

The missionary study also found factors, such as resilience and marital satisfaction, that were linked to decreased severity of post-traumatic stress. Particular resilience characteristics that buffered the impact of trauma in missionaries included a sense of control of one’s life, not easily being discouraged by failure, the ability to handle unpleasant feelings, and a strong sense of purpose.

An encouraging finding was that the more traumatic events missionaries experienced, the higher their levels of resilience over time. This suggests that under certain conditions, along with the psychological distress of trauma, a strengthening effect may happen. Recently, researchers have found that in the midst of post-traumatic distress, emotional and spiritual growth can occur (Calhoun and Tedeschi 2006). This growth may result in strengthened resilience. Prior research (reviewed in Schaefer, Blazer, and Koenig 2008) reports that people who are well supported handle crises and trauma much better. Persons who follow God for his own sake rather than for the benefits of their spiritual pursuits show higher long-term resilience despite their deep spiritual struggles. Those who have a healthy theology of suffering seem to be less affected and have a better chance to grow in the midst of adversity. People who are faithful in their spiritual practices and are generally predisposed to forgive seem to be less affected by the impact of trauma.

A Strategic Response to Trauma
A strategic member care plan includes spiritual, organizational, training, peer, and professional or specialized support. While this does require budget planning, it does not need to be inordinately expensive, especially if there are collaborative efforts between mission agencies.  Another way to save costs and maximize resources is to train peers to provide basic crisis assessment and response to one another. Proactive, preventative care will ultimately reduce costs by preventing serious psychological consequences, ministry failure, and attrition.  

Effective spiritual support includes helping people to develop a stronger, deeper relationship with the Lord, a sturdy theology of suffering, and access to pastoral care. Through pastoral care or counseling, missionaries can be accompanied during the spiritual struggle common after trauma, and spiritual growth can be nurtured. Helping missionaries in understanding the forgiveness process could enhance not only spiritual growth, but also emotional and physical health.

Organizational support refers to the relationship between leaders and their staff. Leaders can make a crucial impact by communicating support, concern, and a commitment to stay involved. During crisis debriefings, missionaries will often comment on whether or not their leader has made personal contact with them in the days following a crisis. Those who have heard directly from their leader speak of it as a key aspect of their recovery; those who have not seem to have higher levels of distress. Leaders will feel more competent to handle the emotional reactions of missionaries during and after crises if they have had their own training in crisis management. One example of a training opportunity is the “Member Care while Managing Crisis” workshop facilitated by MMCT (www.mmct.org), which helps leaders learn normal responses to crises; support those in grief; respond to sexual assault; deal with one’s own stress in the midst of crisis; and understand policies, procedures, and protocols for providing member care in crisis situations. Policies and procedures that promote resilience might include allowing for additional time away after a trauma, providing specialized care following prolonged stress, and making phone calls and visits following a crisis.

Resilience-building training resources currently available on the field include interpersonal skills trainings such as the “Sharpening Your Interpersonal Skills” workshop (information at www.itpartners.org and www.mmct.org). Crisis Care and debriefing trainings that boost trauma-specific community support are available for missionaries who have natural helping skills. One example of a training opportunity is the “Peer Response Trainings” by MMCT, in which participants learn about the typical impact and effects of crisis and its potentially pathological effects, how to make initial contact with a person in need, how to provide debriefing, how to make referrals, and how to deal with ethical issues such as confidentiality and boundaries. An ongoing mentoring and coaching relationship ensures ongoing learning and quality control. The beauty of a peer support model is that care can be provided across organizational and cultural lines rather than each individual organization trying to place its own member care personnel on the field.

Simple surveys of the types of trauma missionaries experience in specific countries of service could inform focused safety training during orientation. This can include thinking through or role-playing protective behaviors during a carjacking or armed robbery. Crisis Consulting International (www.cricon.org) is a resource for crisis preparation training for missionaries. New appointees to high-risk countries will benefit from knowledge about the possible impact of trauma such as post-traumatic stress or depression. They would then experience the impact as a “normal” part of missionary life and be more willing to address concerns as soon as they arise rather than ignoring them until they are unable to function. Training resources for missionaries related to trauma and resilience are also available online www.mmct.org and www.headington-institute.org.

Even resources shared from a distance can have a powerful impact. A recent letter from a missionary who accessed the trauma resources on the MMCT website illustrates the value of this information. She wrote,

I just wanted to thank you for your website. We experienced a trauma a month ago. We had our home broken into by three men. I woke up with a man in my room and my husband had a physical encounter with him as we tried to get him out. All the while, my children were screaming. My family has processed this in many different ways, but my 7-year-old daughter and I have suffered quite a bit from this ordeal. Had I had this information sooner, I probably would have spared myself at least twenty-five percent of the agony from just the questions and responses I was facing. Thank you for addressing the reality of what many suffer on the field.

Peer support comes through member care practices that result in building healthy, loving communities of missionaries who care for each other. Trained member care personnel or peer responders can provide practical support; relief from stress; interpersonal contact; normalizing of reactions; and the opportunity to express emotions such as grief, guilt, and shame. Since the level of social support and perceived organizational support significantly impact the ability to cope, our goal should be to improve and affirm social support systems and the relationships between missionary leaders and peers. This will not only contribute to longevity on the field, but will also enhance the work of the kingdom. 

Specialized support can be provided through member care personnel or counselors who are aware of high-risk trauma, familiar with the signs of post-traumatic stress and depression, and available to provide early interventions before further distress or burnout occurs. Member care personnel can actively follow up with these missionaries immediately after the event and then periodically for several months. They can encourage and offer voluntary debriefings and facilitate community support after severe trauma. For more severe traumatic reactions or depression, specialized missionary counseling centers such as the Tumaini Counseling Center (Kenya), Cornerstone Counseling Center (Thailand), the Budapest Care Center, and the Barnabas Zentrum (Austria) have been established.

Final Comments
Research confirms that missionaries are experiencing many traumatic incidents. Depending upon the frequency and severity of traumatic events, up to one-third of missionaries may experience post-traumatic stress that could affect their personal relationships and ministries. Promoting personal and spiritual resilience factors can buffer the impact of trauma. Those who report supportive relationships with peers and leaders tend to cope better with trauma. Higher levels of marital satisfaction are linked to lower levels of stress.

An effective strategy for reducing post-traumatic stress and enhancing the missionary’s ability to cope with inevitable traumatic stress has many components. Some include:

•  providing member care resources that focus on the development of interpersonal skills,
•  managing conflict,
•  team building,
•  marriage enrichment,
•  crisis preparation, and
•  stress management through training, consultation, pastoral care, and appropriate counseling interventions.

The reduction of post-traumatic stress starts before the trauma occurs by fostering behaviors that enhance stress management and increase the quality of social supports and marriages. Member care has sometimes been seen as an optional or expendable service. However, missionaries sent to the final and high-risk frontiers of missions will be more resilient and able to continue to thrive, grow, and do the work of the kingdom if they are well prepared, receive timely crisis support, and live in a ministry environment equipped to provide relational support that communicates agape love among the redeemed of the Lord and to the world. Just ask John and Marta.

References
Calhoun, Lawrence G. and Richard G. Tedeschi. 2006. “The Foundations of Posttraumatic Growth: An Expanded Framework.” In Handbook of Posttraumatic Growth: Research and Practice. Eds. Lawrence G. Calhoun and Richard G. Tedeschi, 1-23. Mahwah, N.J.: Laurence Erlbaum Associates.

Davidson, Jonathan R. T., Haresh M. Tharwani, and Kathryn M. Connor. 2002. “Davidson Trauma Scale (DTS): Normative Scores in the General Population and Effect Sizes in the Placebo-controlled SSRI Trials.” Depression and Anxiety 15: 75-78.

Kessler, Ronald C., Amanda Sonnega, Evelyn Bromet, Michael Hughes, et al. 1995. “Post-traumatic Stress Disorder in the National Comorbidity Survey.” Archives of General Psychiatry 12: 1048–1060.

Schaefer, Frauke C., Dan G. Blazer, Karen F. Carr, Kathryn M. Connor, Bruce Burchett, Charles A. Schaefer, and Jonathan R. T. Davidson. 2007. “Traumatic Events and Posttraumatic Stress in Cross-cultural Mission Assignments.” Journal of Traumatic Stress 20: 529-539.

Schaefer, Frauke C., Dan G. Blazer, Harold G. Koenig. 2008. “Religious and Spiritual Factors and the Consequences of Trauma: A Review and Model of the Interrelationship.” International Journal of Psychiatry in Medicine 38: 507-524.

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Karen Carr is a missionary psychologist serving in Accra, Ghana, with the Mobile Member Care Team. She has lived in Africa for ten years and enjoys living in community with her teammates and serving missionaries through training and counseling. Frauke C. Schaefer served as a German missionary doctor in Nepal and then trained in counseling and psychiatry in Germany and the USA. She conducted research about missionary trauma and resilience at Duke University and presently works in private practice supporting missions.

EMQ, Vol. 46, No.3, pp. 278-285. Copyright  © 2010 Evangelism and Missions Information Service (EMIS).  All rights reserved. Not to be reproduced or copied in any form without written permission from EMIS.