Mental Health and Missions Conference
November 16 - 19, 1999 Angola Indiana Texas

Love and Survival: In Life, In Missions
Lois A. Dodds, Ph.D.
Lawrence E. Dodds, M.D., MPH.

Presenters:

This paper serves two related purposes: 1) to provide research data about stress levels in missionaries, and to illustrate the data with real life examples, and 2) to assess the relevance of our data in the light of other research about stress and mental health, particularly the findings of Dr. Dean Ornish, as related in his new book Love and Survival. 

 

We hope that in reporting our findings, along with the insights of Dr. Ornish, we can motivate the mental health and missions community:

1.  To have a greater consciousness of the cumulative effects of stress which result in a chronic high stress lifestyle for missionaries.

2.  To recognize the many threats to health, well-being and effectiveness created by chronic high stress, especially isolation and lack of social support.

3.  To motivate all of us involved in missions to reduce the levels of stress through pro-active planning and training.

4.  To teach stress management as one of the essential aspects of missionary training, both pre-field and on the field.

5.  To provide higher levels of support and more continuous nurture and care for missionaries.

 

                                                    Methodology

 

We have been collecting data for about twenty years from missionaries around the globe.  The sample reported on here have been mostly collected in the last five years.  (A larger set from previous years is still not fully analyzed.)  The contexts in which we have collected data have been primarily missionary field conferences and workshops, graduate level courses overseas serving missionaries, and some U.S. based courses or programs for furloughing missionaries.  This report includes reports from 582 missionaries originating from more than twenty countries and serving in about forty countries.  These cross-cultural workers work in more countries than the number in which we collected the data, as some traveled to the sites where we collected the data.  Those listed as serving in the USA or home country have usually served abroad at earlier times; their scores are for their current year at home.

 

Stress levels scores were collected using a modified version of Holmes-Rahe Life Event Stress List.  The original list was changed by adding events typical of cross-cultural and foreign-soil life and work.  The points attributed to the various events were arrived at by comparisons with other events on the list.  The committee which created this modified list was part of the Quest program staff of Wycliffe Bible Translators, consisting of several persons who are acquainted with cross-cultural, overseas life, as well as mental health issues.  We acknowledge that to assign points was a subjective process, and that the list is not comprehensive.  (For example, women sometimes have asked, “Why don’t you include menopause on the list?”  We did not, because the original study done with sailors did not include menopause, and we did not regard it to be an event typical of cross-cultural life.)  (The stress events list is appended.  Starred items were added to the original list.)

 

The participants were volunteers from many nations of origin who speak English; they made self-reports.  We made no attempts to change or alter scores, even when obvious over-sights were made by the participants.  We assume that if a person did not check an item he or she did not perceive it to be stressful even though he or she may have actually experienced it.  It is likely that reported scores are actually an under-estimate of actual stress experienced, in that the list is not comprehensive and many people overlook some stressors.  Nevertheless, the levels reported are significant.

 

The largest set of data are the Holmes-Rahe scores.  A smaller set includes stress event scores plus personality type (based on Myers-Briggs Type Inventory) and symptoms and stressors which the person experiences.  Participants could choose between about 100 symptoms and stressors, and were asked to rank order the ten they most frequently experience.  This sub-set will be reported in a separate paper.

 

 

                                               Results and Trends

 

For an N of 582 the mean score was 439.5, including participants from many countries who were career missionaries.  Table I shows the countries with an N more than 5 with the mean, median, mode, minimum and maximum scores.  Table II shows the means by years of service abroad.

 

Predictably, the highest scores were reported by people in the first five years, usually coinciding with the period of candidacy, training of various kinds, language learning, and first field term.  Table II reports scores for 487 participants who indicated length of service in their questionnaire.  The first five years includes 208 persons, with a mean score of 541.  Between six and ten years, mean scores drop to 398, and between eleven and fifteen drop further to 373.  Scores peak again between sixteen and twenty years, to a mean of 451.  This peak likely coincides with the “empty nest” years, mid-life crisis and the needs of aging parents. 

 

We assume the years of service represented in the sample are typical of the range of persons serving abroad.  We made no attempts to select out those in the earlier years.  It appears that there is a drop off or attrition rate of 80 percent between the first five years and the sixteen to twenty year period.  This becomes even steeper after the twenty year mark, with few persons remaining beyond twenty years.

 

 

                                                    Implications

 

We have reported in earlier papers that the amount of stress experienced among cross-cultural workers averages around 600 points on the Holmes-Rahe modified scale, with levels peaking up to 900 and beyond for people in their first field term.  These earlier estimate were primarily based on U.S. expatriate cross-cultural workers in Latin America.  Our current sample is more diversified by nation of origin, nation of service, and organization.  Even with the lower mean score, however, the results are still highly significant for missions, both in the impact upon individuals and families, and for the agencies themselves.

 

In Holmes and Rahe’s original study, they found that when people scored 200 points during a given year, the cumulative stress had an impact well beyond that year.  They found that 50% of those scoring 200 points were hospitalized within the subsequent two years for heart attacks, diabetes, cancer, or other severe illness.  When the scores reached 300 points, 90% were hospitalized for these illnesses within the subsequent two years.  Holmes and Rahe demonstrated that high stress is cumulative, and that it has a “tail,” that is, the effects of it continue long after the event itself has passed.

 

We have been analyzing the cumulative effects of stress in the missionary life style for about thirty years.  Typically the effects of stress have been overlooked by mission agencies in their “processing” of candidate, trainees and appointees.  There has been very little, if any, awareness that each phase of the process adds additional stress to the individual and family.  The usual progression for missions includes some years of preparation (such as Bible school or seminary), a period of seeking, the stress of uncertainty about choosing a mission, the uncertainty of being found acceptable, and a host of other uncertainties.  These psychological uncertainties are usually accompanied by several changes of location for various training periods and programs, often interspersed by temporary housing and being on the speaking (support raising) circuit.  The candidate may be conditionally accepted, based on performance in future training modules.  Support raising, packing, planning, etc., all consume huge amounts of energy, and are stressful.  Leaving home, family, friends, church, and all that is familiar precedes adapting to a new language, home, culture, set of people, and all the adjustments inherent in a new field setting.  (See “Stressed from core to cosmos: the needs and issues arising from cross-cultural ministry,” by Dodds, Dodds, and Schaeffer.)

 

In typical missionary life, the stresses keep mounting up at a pace far faster than one can assimilate.  Seldom is there time to fully adjust to one change and regain equilibrium before the next demand for adaptation hits.  This means the life style itself becomes chronically full of high stress.  The “tails” from stress-upon-stress stretch out for years.  Physiologically, this means living for years with increased adrenalin, which leads to physical changes in the brain and other body systems.

 

The positive side, for those who survive, of the chronic high stress is that most missionaries do adapt over time, becoming more resilient and enlarging their repertoire of coping skills and attitudes.  Even with such high stress scores, we don’t find 90% of cross-cultural workers in the hospital.  People stretch and grow.  However, it is also just as likely that many drop out (see table two) because they don’t receive sufficient support in developing more coping skills and strategies.  They may become either ill or discouraged with the chronic high stress life style and give up in the face of insufficient support or guided recovery.

 

We can apply this crucial knowledge about chronic high stress in several ways.  It is essential to support mission workers more consistently, particularly at the predictable high points of stress, such as the first five years, and again at the mid-life peak.   It is also crucial to take into account the spiritual, emotional and physical impact of a chronic high stress life style.  As the world of missions increasingly focuses on more hostile environments (such as those in Muslim settings) and more isolated allocations, we must consider the stressful effects of isolation, loneliness, and inadequate social and spiritual support.  We must make every effort to provide sufficient peer support, as well as loving and caring oversight.  Otherwise, we are sending people into spiritual war zones unequipped and unsupplied with what they need to become productive and remain healthy.

 

                                    A Look At Dean Ornish’s Work

 

Dr. Dean Ornish has pioneered research on heart health, specifically about diet, and how emotional health, attitudes and communication either help to restore the heart after an attack, or how they hasten the death of the patient.  In this current book he expands on what he has previously reported.  He relates the incredible discoveries, literally rolling in from multiple sources, that show the power of love and intimacy in survival and longevity.  Immediate death and immediate recovery are directly influenced by the emotional states of ill patients.

 

Dr. Ornish’s thesis is that loneliness and isolation kill people, quite literally.  Without love, intimacy, and a strong sense of connection and community, the body ceases to function in an optimal way.  The immune system is depleted and many other physiological changes take place to prevent or diminish healing.  Without love and the positive feelings it generates, the body simply cannot work to produce healing.   Concerning one study of 10,000 heart attack patients, he says, “...the greater the anxiety and stress, the more important was the love of a spouse in buffering against these harmful effects” (p. 25).  He found that patients who did not feel loved and connected, and who had no religious faith, were seven times more likely to die within six months than those who felt loved and connected and who exercised faith (p. 51)!   In another study, researchers reported a four times higher risk of death when people felt unloved and unconnected and when they were isolated and had a high stress life (p. 44).

 

Dr. Ornish says, “...anything that promotes feelings of love and intimacy is healing; anything that promotes isolation, separation, alienation, loneliness, loss, hostility, anger, cynicism, depression, alienation, and related feelings leads to suffering, disease, and premature death from all causes” (p. 29).  Hostility, suspicion, cynicism and conflict create havoc in the immune system and other bodily functions which lead to disease and death (p. 59, 60, 61, 63).

 

Many of the research studies have discovered truths which have direct bearing on our policies and behaviors in mission selection and member care.  For instance, in a longitudinal study, researchers found that the positive or negative feelings and perceptions of college students about their parental bonds had direct results in their health status thirty five years later (p. 33, 34) (See Table III).  In other studies researchers found that weekly support groups, for almost any illness, dramatically increased the length of survival from the cancer or other illness (p. 50). 

 

Love and Survival is full of vital information, both about the positive attitudes and practices which promote well-being and the negative ones which erode life.  Dr. Ornish’s insights are born out by other researchers.  Especially notable are the works of Horowitz (1964), Lazarus (1999), and Miller (1997).  The recommended reading list cites some additional key works.  Other authors relate the same implications of stress.  “There is elegant work showing that stress, whether environmental or social, actually changes the shape, size and number of neurons in the hippocampus,” (Marano, 1999, quoting Dumas, p 36.)  Glaser, et al., report on many of the effects of stress on the immune system and point to the need for life style changes to improve health (1999, p. 3 in article reprint).

 

 

                           How can we apply this research to missions:

 

1.  We must do very careful selection, training and placement. 

 

We know from Ornish’s report, and others, that early life and family of origin, particularly the quality of parental bonds, relate to life-long health and longevity.  We know that isolation, separation, loneliness and such common experiences of first term missionaries also diminishes health, producing illness and delaying healing.  Almost all the stressors we have identified which are common to first-term missionaries are debilitating, and because they are continuous, unrelenting, and cumulative, we put first term people at high risk.  This is especially true of young and idealistic people.  They are already “set up” for burnout.  Allocating them to isolated, difficult situations without sufficient support almost dooms them to depression, illness, and failures of some kind due to maladaptive coping.

 

In general, people inadequately loved as children are more likely to feel empty and to lack resilience and good coping.  They have fewer emotional resources and lower reserves of energy.  They are less likely to develop a strong ego, or basic personality structure.  The home of origin does matter because both the degree of love received and the patterns of relating which the person has learned shapes development.  We know that some children become resilient in spite of early deficits, and go on to develop good resources and highly effective lives.  (See “Children of the garden island,”  Werner, 1989.)  Thus, persons should be assessed in the light of how far they have come, given their origins, rather than just on the basis of their families of origins.  Some of our most productive missionaries started out in unhealthy homes, yet grow well beyond the usual outcomes.  They are atypical, however.  (See Dodds, “The role of the holy spirit in personality growth and development.”)

 

Let me give some examples of missionaries with troubled backgrounds and how they fare in difficulty.  These are all real people, in real places, sent out by real missions or churches.  I only change the names and places to protect the privacy of these precious persons.

 

A.  Bob and Susie both came from very dysfunctional families, both with addictions to alcohol or other habits.  Neither had much nurture.  They had poor parental models, both for parenting and for marriage.  After becoming Christians in college they felt called of God to serve in missions.  Knowing little of their personal histories, their mission assigned them to work in a remote Muslim country, in a setting where no one else spoke their language, and without any other expats.  The setting was dangerous.  Most people carried weapons.  There were frequent political and tribal fights.  They received many taunts, great distrust, and suspicion.  Their housing was very substandard, with no indoor toilet or bath.  They had to bathe outdoors, which brought crowds staring at their white bodies.  This was extremely stressful for the little girls.  Every word they spoke could be heard through the thin walls by their neighbors.  There was little to do for diversion.  To escape their situation for a break meant hours or days of difficult travel and high expense.  Bob and Susie found they did not know how to create a positive marriage, and they did not know much about how to parent, lacking both parental and current models for both.  They became increasing dysfunctional in their own relationship.  The husband became very hostile, the wife very depressed.  Finally they withdrew from their setting in order to get help.  Their situation precipitated severe spiritual crisis as well as depression, hostility and illness.

 

B.  Jim and Anne came from more positive home backgrounds, but still had some unhealthy messages about their own adequacy.  They too were placed in an isolated Muslim setting, in which it took them two years to discover any other expats who spoke their language.  The wife spent most of her time in the mud house with the little children, who were always ill.  The open sewer outside their door hardly made going outside much better.  The husband at least escaped to work, but even there experienced considerable rejection and sometimes hostility.  They felt so unsupported by their mission that they eventually concluded they had been sent to country X just so their mission could add another country to its letterhead.  We can not say whether this was true, but it is tragic that they perceived it to be so.

 

C.  Bill and Carol also both came from unhealthy homes, having suffered abuse and neglect.  They found great love in each other, and both came to Christ during college years.  They too lacked healthy models for marriage or parenting.  When they felt called to missions, their church sent them out, with no training, along with three other couples, to be a team in a closed country.  Within two months, three couples left the field.  Bob and Carol stayed, living in a city with no other foreigners, under constant surveillance and living in harsh physical surroundings.  They were constantly vigilant, knowing that anyone they were seen talking with would become suspects to their government.  They attempted to love the people while learning the language.  By the end of two years they met their goal of “walking out” of the country (rather than being carried out on stretchers), but both had Post Traumatic Stress Disorder and multiple physical problems.  They were nearly incapacitated and barely functional when we saw them.

 

D.  Roger and Kathy both grew up in home that left them damaged and immature in many respects.  Neither knew how to love or to resolve conflicts in positive ways.  Though they became Christians and missionaries, none of their family of origin issues had ever been talked about, let alone addressed in ways that would bring them healing.  They actually knew little about Christian standards for right living.  They were placed as a young couple, alone, in a hardship setting, with the closest colleagues hundreds of miles away.  Not knowing how to create a close relationship, faced with unending work and distorted priorities, they grew farther and farther apart until each had an affair.  They left the field, devastated and shamed, when someone reported on their situation.

 

We could cite many other cases like these, where young, inexperienced and idealistic young people were sent out with little if any support, and lacking positive models of how to live healthy lives, especially in marriage and parenting.  Our conclusions based on many such situations are these:

 

2.  Missions would best not send first term people into isolated and difficult allocations, such as Muslim countries or others closed to the gospel and grudging towards foreigners.  The strains from adaptation to a foreign language and culture are intensified in young, idealistic, and inexperienced people, and compounded in the religious or political setting typified by hostility, suspicion, paranoia, and severe danger or political control.  How much effective ministry is accomplished through a young couple who crashes before they ever become fluent in the language and able to relate fully to the people?

 

Lest we conclude that only couples from dysfunctional homes suffer, we have also seen the “cream of the crop” young families, with very solid backgrounds and personal formation severely affected by stresses of life in hostile environments.  Some “jewels”–those your candidate personnel would vote “most likely to succeed”–have encountered such difficulty they have been debilitated to the point of severe illness, marital crisis, and crises of faith.  We know first hand because we are committed full time to the restoration and healing of such spiritual warfare casualties.

 

3.  Missions would best not send young couples in child rearing years into such situations because they so often result in isolation and depression for the mothers.  Husbands who are themselves not yet mature and are unsupported are not good supporters of wives and children!  They more often become the source of additional stresses to the wife and children.  (Note: recent research in the U.S. shows that fifty percent of mothers with pre-school children suffer from depression.  This is here, in their own language, culture, and familiar setting, with friends, family and telephones available!  How much more so when isolated from any other mother-tongue speakers, in a strange culture, a foreign land, and with an immense accumulation of stress, including frequently ill children!)

 

4.  Missions would be better served by assigning experienced, middle-aged couples (or singles) to difficult, isolated allocations.  By age forty-five or fifty couples are more likely mature in their relationship, have reared their children, and are more experienced in cross-cultural life.  Wives can more easily endure the isolation imposed by culture by virtue of greater maturity and self-direction.

 

5.  Selection and training should include the following:

 

A. Know the person!  Careful assessment of the individual’s background: family of origin issues, degree of nurture as children, patterns of relationships in the family and since conversion, number of models for godly, mature living, etc.  Time in community is needed for spiritual formation and learning healthy patterns of life.  Our Catholic brothers and sisters can teach us much about this.  Persons with wounded backgrounds ESPECIALLY need to be placed in allocations with an ample supply of on-going support and love, because they are likely to lack the inner reserves and resources to sustain themselves emotionally and spiritually in isolation.  Feelings of emptiness are typical of people who were unnurtured in childhood.  If they themselves feel empty they are not much able to sustain a spouse or others.  Two empty spouses cannot nurture children or a fledgling ministry.

 

B.  Careful assessment of the person’s actual ability to love and to interact in loving, non-defensive ways.  These should be observed first hand over a period of time by mission trainers, and be reflected in the references collected about the person.  Individuals who are still defensive, emotionally cold, tight or angry, and who are immature in self-giving really will not communicate much of the love of God (which is done relationally, not through teaching theology).  We often work with individuals who have head level knowledge of the Gospel but who do not experience it, and are thus ineffective in actually communicating it.   Lacking personal warmth, loving communication, and heart-felt acceptance by God leads them to ineffectively living out the Gospel.  Loving requires maturity and skills for building community and intimacy, such as self-knowledge, self-disclosure, conflict resolution, heart-level sharing, acceptance and respect.

Ornish says, “If you grew up in a family in which love, nurture and intimacy were in short supply, then you are more likely to view your current relationships with mistrust and suspicion.  If your family experiences were filled with love and caring, then you are more likely to be open and trusting in your on-going relationships” (p. 39).  “The perception of love itself...may turn out to be a core biopsychosocial-spiritual buffer, reducing the negative impact of stressors and pathogens and promoting immune function and healing” (p. 34).

 

C.  Training should include personal growth matters, such as how to develop self-knowledge and self-awareness, skills for loving communication, intimacy, conflict management, stress training, parenting and marriage skills.  Each person needs to learn how one got to be who one has become, to identify pitfalls from the past which create vulnerabilities, personal habits and patterns which may be obstacles to relating, and so on.  How to create and sustain small groups for support of one’s self and ministry is another vital tool to increase the likelihood of love and intimacy and reduce the likelihood of isolation and loneliness.  Some of the discoveries of the research include the benefits available in community, such as the importance of telling life stories, having support groups, the power of the group process, the power of being touched, the power of family “heart messages,” being open-hearted, being vulnerable, feeling close, the power of prayer and meditation, the power of unconditional love received from a parental figure, and the value of writing, journal writing, telling about trauma to friends, disclosing feelings, especially about difficulty.  Having friends is not sufficient in itself–people must be given skills for heart-level sharing. 

 

One statistic cited by Ornish is unforgettable.  In a study of childbirth, mothers who labored alone had an average of 19.3 hours of labor.  Mothers who labored with a caring attendant, even if that person had been a stranger to them before labor, averaged 8.7 hours of labor (p. 65).  If something so physical, so physiologic, is altered so greatly just by the presence of a loving person, how much might all of our experiences of difficulty and pain be altered by the presence of a loving, caring person?

 

D.  Training should include teaching on spiritual warfare, a theology of suffering, and the role of the Holy Spirit as our vital power source.  He is our energy for living godly lives instead of living out of our old patterns of life and thought.  Understanding the big picture of God’s battle with His enemy, Satan, helps us gain perspectives on the doubts, attacks, and other ravages of Satan.  Seeing our role as participants in the battle gives meaning to our sufferings, and helps to explain why ministry can be so difficult.  Understanding the role of suffering, both as a result of the spiritual war and as one of God’s means for shaping us and creating His image in us, is crucial to our endurance.  Learning how to live daily, hourly, minutely, by the power of the Holy Spirit within us is essential for righteous living.  Without His prompting, teaching, exhorting, encouraging, comforting and empowering we will remain stuck in the lies we believe and ineffective or destructive patterns of life we gained in early life.

 

Recent studies on the sequelae of torture underscores the point of having a meaningful structure (religious or idealogical) in which to interpret such horrors as torture.  Miller (1997, p. 58) reports on several studies including one by Basaglu and Menika.  They found that torture victims with prior knowledge were psychologically more prepared and thus suffered less intense consequences (such as less severe PTSD).  Those without a means to “make sense of” the torture, or without prior knowledge that they might experience it, had more severe and lasting sequelae.

 

6.  First term assignments should be made to teams or groups with warm and supportive leadership, so that new missionaries can learn first hand, through instruction and by models, how to relate to nationals, how to form a good marriage, how to parent well.  Though most missions give lip service to “teams” the reality is widely disparate.  Some consider anyone in the same country a team, yet the individuals may be hundreds of miles apart, and are functionally separate.  Even in a city, teams may be so far separated by traffic or transport that there is no daily or weekly functioning together or mutual support.  Can you imagine any professional sports team who never even PRACTICED together before playing a public game?  Placement of missionaries “on teams” is often so haphazard and ill defined that it is in reality an empty phrase.  Would it not be better to consolidate people into larger, genuine teams where nurture can be provided rather than scatter them out?  We know one couple who said that no one in their mission knows them or their work well enough to be able to do an annual performance review for them.  Is that appropriate?  Another missionary, a pastor, told us that his mission only puts one couple in any given country, as a matter of policy.  He said that is because two couples or more can never get along!  What role does such a policy play in preventing missionaries from modeling the life of Christ, the body of Christ?

 

Giving priority to appropriate nurture and care means taking more seriously the preparation and training of team leaders at all levels.  Leaders need training to function optimally.  Longevity and other job competencies do not imbue leaders with the interpersonal skills and loving attitudes needed for caring for people.

 

Just as it is crucial to know the person, leaders must also know the places and roles to which they allocate the person.  How isolated is this place?  How hostile (or friendly) is the

environment?  Will there be support available through team members, mature local Christians with a common language, or others?  How often can you visit or send a member care facilitator or pastor to visit?  Is there a genuine team there, or a phantom team?

 

 

7.  Have designated member care facilitators and nurturers, trained and educated about human needs, cross-cultural adjustment, stress and coping (and maladaptive coping).  Provide continuous support through these and other personnel, such as pastors on the field.  Teach administrators how to extend love, care and nurture which will help to sustain people, especially those who work without team support.

 

                                                       Summary

 

Understanding the impact of the chronic high levels of stress under which cross-cultural workers live is crucial to the selection process, to designing training programs and to providing on-site support systems.  The research presented here specific to persons who work cross-culturally indicates sustained, high levels of stress, well beyond those which researchers in the U.S. found to be highly detrimental to the health of individuals.  This conclusion is supported by a huge amount of research, mostly based on U.S. samples of population.

 

We recommend that personnel in organizations who are responsible for overseas selection, training and placement become thoroughly familiar with the literature and research about the impact of high, chronic stress on all types of well-being.  This will enable them to better design programs, placements and support systems to allow people to succeed and thrive over the long haul, and it will reduce the drop-out or attrition rate, resulting in both human and financial savings.