Crisis intervention for missionaries
By Karen Carr
(Vol. 33, No. 4)

The impact of trauma

When someone commits his or her life to the Lord to serve as a missionary, there is an understanding and acceptance that this choice may involve suffering and trial. We accept this as part of the Christian life. Scripture tells us, "Dear friends, do not be surprised at the painful trial you are suffering, as though something strange were happening to you. But rejoice that you participate in the sufferings of Christ, so that you may be overjoyed when glory is revealed" (1 Pet. 4:12).

We also know that the Lord works good from suffering. James 1:2-7 tells us to "Consider it pure joy, my brothers, whenever you face trials of many kinds, because you know that the testing of your faith develops perseverance. Perseverance must finish its work so that you may be mature and complete, not lacking anything."

So, suffering is predicted. In fact, it is guaranteed. But, does this knowledge prepare the missionary for its impact and consequences?

Many do not realize that the impact of trauma can go very deep, be far reaching, and last a long time. This lack of understanding often leads the victim to circumvent the healing process by denying the impact, speeding up the process, or using poor coping mechanisms. It also leads those around the victim to impede healing often through well-intentioned words that communicate an impatience with the process.

In a previous article, I described the normal reactions to a crisis or trauma.1 They are: intense levels of shock, anxiety, denial, guilt, anger, shame, and grief. Each person is unique in how he or she responds to a crisis and in how long the recovery phase takes. Comparison with others may set up unrealistic expectations, which can lead to discouragement and despair. Some people may experience long-lasting complications, such as major depression or post-traumatic stress disorder following a trauma. Personal history, genetics, current coping mechanisms, and the nature of the trauma all affect the development of complications. Talking about the event in detail in a supportive context will not necessarily prevent complications, but it is a powerful tool for assisting in recovery.

I've heard many missionaries who went through trauma say things like, "No one ever asked me how I was doing with this," or "I have never talked about this with anyone." The impact of trauma goes much deeper than what is visible immediately after the event. But we can lessen the impact and facilitate the healing process. We can be part of the work of perseverance, which has as its goal that we be mature and complete, not lacking anything. If we ignore missionaries who have suffered trauma, or fail to follow up with them, they may develop serious symptoms and experience a lack of fruitfulness, as the Scripture says happened with Tamar. She was raped, told to be quiet, and "lived in her brother Absalom's house, a desolate woman" (2 Sam. 13:20).

Some traumas missionaries experience on the field are life threatening, such as rape, armed robbery, shootings, evacuations, murders, kidnappings, torture, imprisonment, natural disasters (i.e., earthquakes), and medical emergencies. Other types of trauma, which aren't necessarily life threatening or dramatic, include government opposition, false accusations, betrayal of friends, saying multiple goodbyes, significant family events in the home country (death, marriage, illness), cancellation of a long-term project, serious team conflicts, and changes in roles.

All of these crises involve loss and result in grief. This grief may be compounded if there is unresolved grief from the past or if multiple losses occur in close proximity and time. The hardiest and most enduring of missionaries still has emotional limits and must have mechanisms for processing and coping with trauma. If these mechanisms are established on the field, the result will be increased endurance and longevity of service. I also believe that the result will be more joy, lightheartedness, and peace (Psalm 126:5-6).

Response to trauma, a model for missionaries

One mechanism for helping individuals process the impact of a trauma is the use of the Critical Incident Stress Debriefing (CISD) model, developed by Jeffrey Mitchell.2 It has been used successfully with emergency personnel, and has been adapted for missionaries. The essential components of this model are: (1) a trained de-briefer meets with the traumatized individual or group within 24 to 72 hours following the trauma; (2) the debriefers facilitate a discussion of the traumatic event in which they cover the facts, the mental and emotional reactions to the incident, and the symptoms experienced both during and after the event; and (3) the debriefers educate the victims on normal responses to crises in order to normalize their response and to give them increased understanding about what they are currently experiencing and what they might experience in the future.

A number of unique factors must be considered when applying this model to missionaries. These include time frame and availability of counselors, spiritual issues and resources, cross-cultural issues, confidentiality, systems issues, and follow-up.

Time frame and availability of counselors

The CISD model asserts that the ideal time for debriefing is 24 to 72 hours after the trauma. This allows enough time for the numbing and shock to wear off, but catches the person before the sealing over and distancing process begins. On the mission field, however, this may not be a reasonable time frame. Complications such as flight times, visas, finances, and availability may prevent a trained counselor from arriving on the field until a week or more has passed. In some cases, administrators may decide that the benefit of bringing a counselor to the field will not outweigh the cost. This decision might be made on the basis of how many missionaries are involved or on some assessment of the visible emotional impact on the affected missionary.

At other times, an administrator might want to bring a counselor on the field, but the missionary may insist it is not necessary. How does one decide when to bring a counselor to the field? The decision must be made on a case by case basis. Field leaders can plan ahead by setting up guidelines or a flow chart of factors to consider. For example, certain events (i.e. life threatening ones) might always warrant an immediate CISD regardless of the apparent impact on the missionaries. The impact of such events on family members and colleagues is often overlooked as well, and we must consider what other missionaries on the field need.

If a person does not receive a debriefing in the 24 to 72 hours following the trauma, he or she may still benefit from debriefing later. As time passes, it becomes more difficult to access the memory and feelings related to the event. However, symptoms such as nightmares, depression, flashbacks, poor sleeping, impaired performance, and withdrawal indicate that the trauma is unresolved and the person could benefit from debriefing or therapy. Even without symptoms, certain types of trauma may not be resolved without some form of debriefing.

A young missionary woman was referred to me by her mission board one year after she experienced a significant trauma. While on furlough, she began experiencing nightmares regarding the event. She had never been debriefed. While on the field, she was interviewed by field administrators, but no attention was given to her emotional response.

During two counseling sessions, which lasted two hours each, she had the opportunity to talk in detail about the trauma, her emotional reactions to it, her symptoms, and her coping style. She worked through a plan for bringing some closure to her grief, and developed some additional coping resources.

A letter I received from her just before she returned to the field indicated she was feeling optimistic and positive about her return. A number of personal and spiritual resources made her adjustment prognosis very good. Although she may continue to have difficulties, she had the opportunity to talk about the event, and to gain deeper insight into its impact. She also gained a better understanding of her own reactions to trauma and of her ability to cope. She also knows there is someone she can talk to if she ever feels the need. Her experience and feelings were validated. She knows that she is not crazy or unusual. She feels she has the strength to continue in her service to the Lord.

Spiritual issues and resources

One of the key questions that comes up for missionaries who experience trauma is, "Why did God allow this to happen?" It is a difficult question that each believer must wrestle with. Certainly there are many examples where it seems the Lord miraculously delivered a person from a terrible tragedy. So, why do some suffer terribly? It is normal for a missionary who has suffered trauma to ask, "Where was God?" Resolving this question will be different for each person. But each one will need support getting through it. Support involves allowing the person to ask questions and search God and Scripture for the answer, without giving him or her pat answers. It also involves the mission administration communicating a position of acceptance during this time of ambiguity.

There is something particularly terrible about suffering at the hands of another person. Perhaps it is the violation of a deeply held belief or conviction that compassion or decency is inherent to human beings. If so, this belief is shattered, or at least challenged, when one is the victim of another's choice to do evil. Whatever our beliefs about what humans are capable of, one is rarely prepared to be the victim of evil. A new set of assumptions, which initially may feel like paranoia or extreme suspiciousness, will be developed. One becomes more cautious and less willing to trust, which may be counter to the original world view and self-image.

Missionaries do have a set of spiritual resources available to them. They have a body of believers who can support and pray for them. They have their own prayer life and the Bible. They have worship and praise. They have faith, a perspective on the world, and eternal truths that nonbelievers do not. All of these are invaluable in the healing process and can be encouraged and further developed.

Cross-cultural issues

Some traumas missionaries experience may be directly related to cultural norms. For example, the missionary may witness an infant being killed because of birth defects or a woman being beaten and mistreated by her husband. Feelings of helplessness, horror, or guilt may be pervasive and long-lasting.

The coping process is also affected by cultural norms. Grieving rituals, verbal expressions of pain and suffering, and social support networks are culturally defined coping mechanisms. Missionaries who have acculturated to their place of service may accept or adapt to these norms and face misunderstanding from those in the home country.

Other missionaries may attempt to cope using norms from their home country, which are not understood or accepted in the culture where they are serving. In the United States, when someone is robbed, the police are called, a report is filed, and the victim expects that the case will be investigated. It is hoped that the perpetrator will be arrested and held accountable for his action. There is an expectation of justice and fairness. However, in many countries, where the legal system is corrupt, or where there is apathy or lack of resources, one has little recourse in the face of victimization.

Confidentiality

Sometimes, certain aspects of a trauma remain secret or confidential, further complicating the debriefing process. This may happen for a number of reasons:

• A missionary who was held hostage and then released may have been instructed to keep parts of his release confidential so as not to further endanger those still in captivity. Yet some of those details may be painful for the victim to carry alone.
   

• A missionary may be advised by the mission agency that it would be detrimental to his or her ministry if the supporting church back home learned the details of the trauma. The missionary may be asked to reveal some aspects of the trauma, but not others.

• Someone may have been indirectly affected by another personØs trauma, but unable to talk about it because he or she wants to honor the victimØs privacy or confidentiality.

• Certain parts of a trauma, such as rape, might not be discussed by the victim because of a sense of shame and exposure.

While these reasons may be quite legitimate and understandable, it is more difficult to process and resolve a trauma when restrictions are placed on what can be discussed. When weighing the cost of allowing details to go public, the administration must carefully consider what impact the mandate for silence may have on the trauma victim. Certain information may be detrimental to the organizationØs image and ultimately to the ministry. Therefore, it may be prudent to carefully control who has access to this information. However, these things should not be considered apart from what might hinder the victim from adequately processing and resolving the trauma.

Systems issues

The relationship the trauma victim has with his or her family, colleagues, mission administration, nationals, and supporting church all have an impact on the recovery process. Ideally, each of these relationships will be supportive and empathic. Realistically, however, there may have been tension or problems in one or more of these relationships prior to the trauma, which can be exacerbated at this time.

Follow-up

A victim receives the most attention and care immediately following a trauma. Friends, family, and colleagues are most likely to be sensitive and ask questions that allow the victim to process the event. Administrators are most likely to seek counseling assistance for their members. Furthermore, symptoms and visible distress are most likely to be linked to the trauma now.

However, many missionaries may experience the worst impact much later onßweeks, months, or even years later. It all depends on a number of factors, such as trigger events, other crises, and the personality of the victim. So a plan should be put into place following any missionary trauma and debriefing.

At the point of the CISD, the counselor can assess who might need further assistance. Counseling sessions may be recommended. These could be provided intensively on the field while the counselor is still there. Or, the counselor may recommend that the missionary leave the field to receive treatment. Some missionaries may chose to receive counseling when they go home on furlough. This decision can be made on the basis of the missionaryØs current ability to function, his or her future prognosis, and the available support systems.

Even those who appear to be doing very well at the debriefing should receive follow-up from a designated person, someone the individual sees as caring and competent. The follow-up can be through phone calls, letters, e-mail, or visits. This contact gives the individual an opportunity to talk about the impact of the trauma.

The timing and frequency of the follow-up contacts will vary depending on individual circumstances. Someone who experienced the death of a loved one may need particular attention on key dates such as holidays, birthdays, and the anniversary of the death. Others may need follow-up contact when they experience a trigger event. For example, those returning to where they were robbed or raped may need debriefing before and after their return. Sights, sounds, or smells similar to any aspect of the trauma may also trigger very intense feelings which need to be debriefed.

Debriefing the debriefers

Another important aspect of debriefing, often neglected or overlooked, is giving the debriefers supportive listening following a debriefing session. Debriefings are, by nature, intense. The debriefers cannot help but be emotionally impacted by what they have heard. They may experience sympathetic crisis reactions, such as numbing, depression, anxiety, nightmares, sleep loss, and appetite disturbance. To preserve the longevity and mental health of the debriefers, a system should be in place for them to talk through what they have heard and processed. This should be done within 24 to 72 hours of the debriefing. Failure to do this can result in cynicism and the depletion of compassion in the debriefers.

This doesn't have to be complex. Recently I was called out to assist in a police negotiation with a man who had just killed his wife. Before the negotiations began, the man killed himself. When I arrived at the police station, about 10 family members were gathered there. They had just gotten the news of the two deaths. I was asked to speak with them and help them. I spent about an hour just being present for themßlistening, assisting them in making decisions about informing other family members, and setting up support for each other. When I went back to the mental health center, several colleagues gathered around me and started asking me how I was doing. As I began talking about what I had heard and how it impacted me, I realized how deeply I had been affected. My colleagues' timely and simple questions of "How are you doing?," and their empathetic statements such as "That must have been awful" allowed me to debrief and process the experience in a way that felt very supportive and helpful.

Emotional and spiritual preparation is invaluable. First, debriefers should have several people pray for them consistently. Second, they should be well rested so they can be focused and enduring. The debriefer should avoid scheduling any emotionally draining or demanding events just before and after a debriefing. Third, if possible, the debriefer should have a partner or co-leader. Doing a debriefing alone should be the exception, even though it is more costly to do it in pairs.

Intensive debriefing

Counselors may also offer intensive debriefing for individuals, couples, or families following a trauma. This seems particularly useful for missionaries who have been through extreme trauma, multiple traumas, or for those who have experienced a trauma which triggered past unresolved memories. This intense debriefing may last several hours to several days, and may be done on or off the field.

It should be done only by a trained counselor who has experience with trauma, cross-cultural issues, and mission work. Individuals who do not have this training should not attempt to do an intensive debriefing, which may be more harmful than helpful.

The questions and interview process are not complex. The complexity lies in the interpretation of what is said and the subsequent recommendations made to the missionary and mission administration. Often, these recommendations dramatically affect a person's future. For example, should the missionary return to the field? The recommendations must be based on carefully gathered information incorporating the missionary's preferences and strengths.

Clearly define from the start what the missionary wants to keep confidential and what might be reported back to the administration. In general, the report should address the missionary's current coping and functioning level and the resources he or she will need to successfully adjust, such as further counseling, financial help, or decreased responsibilities. The report does not need to include personal details. When debriefing missionary couples who have been referred to me following kidnappings and robberies, I have used a format which includes history taking, trauma processing, and planning for the future (see box on page 456). This format allows the counselor to develop a foundational understanding of the trauma victim's baseline of coping and relating. It can then be used to develop a strategy for future coping.

Conclusion

Trauma is inevitable for many missionaries. But, by formulating a compassionate and comprehensive response plan, we can perhaps lessen its painful impact. The result will be missionaries who are strengthened and encouraged to continue their service on the field—a goal which is shared by missionaries, administrators, and counselors.

Endnotes
1. Carr, K.F. "Trauma and post-traumatic stress disorder among missionaries," in Evangelical Missions Quarterly, July, 1994, pp. 246-255.
2. Mitchell, J., and Everly, G. Critical Incident Stress Debriefing: An Operations Manual for the Prevention of Traumatic Stress Among Emergency Services and Disaster Workers. Ellicott City, Md.: Chevron Publishing Corporation, 1993.

Recommended reading
Figley, C.R. Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized, New York, N.Y.: Brunner/Mazel Publishers, 1995.
Herman, J.L. Trauma and Recovery. New York, N.Y.: Basic Books, 1992.
Matsakis, A. I Can't Get Over It: A Handbook for Trauma Survivors. Oakland, Calif.: New Harbinger Publications Inc.
Terr, L. Too Scared to Cry. New York, N.Y.: Basic Books, 1990.

KAREN CARR (Ph.D., clinical psychology, Virginia Commonwealth University) is manager of emergency services ats Henrico Mental Health Center, Richmond, Va. Her article is based on a paper she gave at the Mental Health and Missions Conference, Angola, Ind., in November, 1996.

Copyright © 1997 Evangelism and Missions Information Service. This article originally appeared in the October, 1997 issue of EMQ. All rights reserved