How People Get Sick and Wounded:

Levels of Prevention

and Intervention

Lois A. Dodds, Ph.D.

Lawrence E. Dodds, M.D., M.P.H.

First Presented at

Mental Health and Missions Conference

November 19-21, 1993

Angola, Indiana

Heartstream Resources, Inc.

101 Herman Lee Circle

Liverpool, PA 17045

Phone: 717-444-2374; Fax 717-444-2574

E-mail: heartstream@compuserve.com

Copyright, 1993 May be copied in entirety for non-profit educational use.

A Brief Outline:

 

1. Public health model of disease development--emphasis on physical disease and a paradigm as well for emotional, spiritual and organizational health.

2. The corollary: developmental process of psychological dis-ease; psychosoma

3. Levels of prevention and intervention (what to look for; how to help & empower)

             a. Level 1: prevention: optimizing development; enhancing growth

             b. Level 2: intervention: screening for early problems not yet symptomatized

             c. Level 3: intervention: treating symptomatized disease and distress; reversal of  disease process

             d. Level 4: intervention in crisis: treating the life-threatening illness; reversal

                                to lesser levels of disease

             Case study, illustrating the dis-ease process with child/family

4. Three interactive dimensions in mission life

 

             a. Basic health status (sum of physical, spiritual and psychosocial  =  underlying life structure)

             b. Predominant issues in the life cycle of missionaries or candidates (by decades)

             c. Stages of the missionary “career” or vocation.

                          Cumulative stress during the mission career.

5. Interactions of these three dimensions

             a. critical intersections of cycle, stage and life events

             b. the role of “unfinished business”

 

6. Summary

References

1. PUBLIC HEALTH MODEL OF DISEASE DEVELOPMENT:

HEALTHY ORGANISM: We are born about as healthy as we will ever be, biologically.

Primary Prevention: After birth we want to nourish for growth and to prevent damage from occurring. Common examples of interventions are immunizations, water treatment, proper nutrition (such as eating low fat/high fiber diet), and exercise.

HEALTHY ORGANISM AT RISK: Because of learned behaviors, habits, environment, etc., we accumulate injuries/insults. For example, eating a high fat/high cholesterol diet will result in elevated blood cholesterol levels. Physical inactivity and smoking also increase cholesterol. Genetics plays a part in the kind of elevated blood lipid levels we may have.

Secondary Prevention: At level two we seek to detect abnormalities or deviations from normal in order to intervene to restore “normalcy”. For example, screening tests can detect elevated levels of cholesterol and triglycerides which indicate the individual has a higher risk of coronary heart disease. Interventions may consist of education about making dietary changes, physical exercise and stress management.

ASYMPTOMATIC ORGANISM WITH SIGNS OF DISEASE: Biochemical and/or tissue changes have accumulated, but no symptoms appear as yet. For example, an individual may have elevated serum cholesterol and perhaps also have elevated blood pressure, which is another risk indicator.

Tertiary prevention: At this level, we seek to prevent further damage and attempt to restore function as much as possible. This usually occurs in a hospital or consulting room.

SYMPTOMATIC ORGANISM: Tissue damage has occurred, but it is not irreparable. For example, the person may experience elevated blood pressure or angina pectoris. Because of pain or decreased function, the individual seeks treatment. Treatment is directed at alleviating symptoms and trying to reverse as much as possible contributing conditions in order to return the person to full function.

Crisis: Intervention to save life. (The hospital is a monument to failure to make good choices.)

RETURN TO ASYMPTOMATIC STATE OR DEATH: Function is seriously compromised and death may overtake the person. For example, heart attack or stroke with paralysis puts the individual at great risk of dying. Often vigorous therapeutic interventions can save the person’s life and he or she is restored to life, although with serious “scars” which reduce function. If the damage is too great, the individual dies.

The goal of each of the interventions made at the different stages of disease is restoration to allow the person to function as close to optimal as possible.

2. PSYCHOLOGICAL COROLLARIES OF THE PHYSICAL DISEASE PROCESS

             Dis-ease in the emotional, spiritual and social dimensions of the person follows the same kind of progressive development as does disease in the physical dimension. Researchers are continually discovering more and more about the immediate and complex interactions between the psychic and the soma. Our minds, emotions, and spirits clearly create conditions in our bodies, and vice versa. (See illustration next page.) We can trace such dis-ease progression by looking at a case study illustrating the perpetual interactions of emotional/social/spiritual dis-ease and physical disease.

             Gina has spent many years preparing for and anticipating a career overseas in a semi-professional role. She has grown up in a family with very high expectations; they expect her to do everything well and to never question authority. She has earned excellent grades and is affirmed by her peers as being inspiring, dedicated, and with “a lot to offer.”

             When Gina arrives at her first field assignment she is dismayed to discover that they don’t know about her professional training and experience. She is assigned to a job which she believes is beneath her abilities, and appears to waste the years of training she worked so hard for. However, she does not question the assignment, assuming the directors have the right to tell her what to do. Organizational values favor unquestioning obedience, self-sacrifice, and serving without expectation of rewards. Gina doesn’t express her disappointment to anyone except her husband. She finds it hard to sleep, wondering why she has been assigned to a job which doesn’t make use of her abilities.

             No one communicates what Gina is expected to accomplish in the job handed her. It is assumed she will know how to do it and will produce the “right thing.” Gina asks for no feedback, and gets no direction until she is criticized: “That’s not what we wanted!” she is told. Gina feels unappreciated and disappointed. She has worked hard, done her best, to get the job done. Why is God allowing her to suffer like this? Doesn’t He see how hard she is working for Him? Gina cries often at night and begins to feel ill many mornings and doesn’t want to go to work. Her supervisor criticizes her further for not being motivated; being late or absent, he says, means she doesn’t care. Older workers comment, “These new recruits just aren’t committed!” Gina internalizes the criticisms and tries harder. Finally she gets the job done, but receives no thanks. “Yeah--that’ll do,” is the only feedback she gets. Gina is handed the next assignment without guidelines, but fears to begin work on it. She is afraid of further criticism and feels paralyzed to accomplish anything.

             At home, Gina’s husband tells her to “snap out of it.” He’s feeling great! Why can’t she? She should try harder, be more spiritual, and not let things slip at home as she has been doing. Gina speaks harshly to the maid, who has grown lax in getting the household tasks done. Later she feels very guilty and finds it hard to speak to the maid at all. When they do overlap time in the house, she stays in her room to avoid having to interact with her.

             Gina becomes ill with hepatitis. During this time she develops severe food allergies, so that even after she recovers she finds it very hard to eat and to find foods that don’t cause intestinal problems or other allergic symptoms. She consults the nurse, who tells her it’s “just stress” and that the symptoms will go away when she feels better.

             A supporter back home writes that it is SIN to feel frustrated; it shows Gina isn’t trusting God. Gina’s level of energy drops even lower. She finds it harder and harder to interact with others, and even on Sundays sometimes avoids going to church so that she doesn’t have to expend the energy to look cheerful and be friendly. She’s afraid someone will see her looking gloomy and exhausted; they’ll judge her to be unspiritual, not victorious. She drags herself to work a few hours a day, but finds work unfulfilling. She prefers to close the door and work alone rather than to interact with anyone else, especially the supervisor.

             Gina becomes increasingly depressed. She loses twenty pounds in the next four months due to her food allergies and the limited food choices available. She knows some people are criticizing her for not “doing her share” and for letting something that “is all in her head” rule her life. She stops going to work, pleading exhaustion and illness. She doesn’t want visitors; it hurts too much to have anyone see her in this depleted and defeated state. She hasn’t got the energy to get out of bed. Her hepatitis flares up; she goes into shock and is hospitalized.

             Comment: In Gina’s case we can trace the pathway and process of how unattended emotional and social wounds contribute to a person developing a style of behavior which contributes further to disease, so that symptoms of illness finally occur. Treatment is usually not sought or offered until the acute or crisis level, after much damage is done. Some of the damage may be irreversible, locked forever into the tissues or organs of the body in the form of scar tissue, non-functional cells, etc. Attempts to treat the symptoms may bring relief to the sufferer, and move the process of decline backwards to a lesser level of damage. However, without help in the psychosocial dimension, to help her learn healthier ways of responding and relating, it is likely that full recovery will not take place. It is important to impart to Gina at this point, as part of the treatment, that her disease is real, that even though it may have begun through damaged emotions and social conflicts, the daily stress has produced very real physical changes which must now be reckoned with. Though these were psychogenic they became physical, starting at the cellular-chemical level and continuing until tissue and organ damage occurred.

             Additional examples might be useful: 1) Early life abuse causes a child to formulate certain mental constructs (such as that authority always betrays one). These lead to certain attitudes, which spawn certain behaviors. These in turn create a relational style, such as aggression to protect one’s self from perceived threat. This creates conflict which causes many kinds of harm. 2) A cold parenting style will influence negatively a child’s self-concept and self-esteem, which foster certain attitudes, such as feeling unacceptable. This leads to isolation, diminished communication and ultimately to a failure to thrive. 

3. LEVELS OF PREVENTION AND INTERVENTION: See chart of levels on page 9.

             The underlying assumption at all levels is that the person seeks homeostasis, to re-gain balance and to be self-healing in order to return to best functioning. The more frequent and the smaller the “adjustments” back to the optimum, the better the level of functioning.

Level 1

 

Note: Prevention is not dramatic: e.g., preventing 20 children from being hit and run over by cars gains less attention than saving the life of one who is run over. Saving 100,000 lives through proper sanitation is less captivating than curing dozens with typhoid. Thus, the importance of prevention is often overlooked and prevention is neglected. Most health and care providers (and missions) overlook and neglect the crucial importance of this level. Care extended at Level 1 is the least expensive; the most cost effective, i.e., securing the most gain for the least investment. (A few insurance companies recognize this; they provide for preventive measures in their coverage.)

Level 2

Note: There are no overtly noticeable symptoms of disease or distress at level 2, but the damaging process has begun. Interventions at this stage are not dramatic; correcting and instructing 20 children who have dashed into the street does not gain attention as does stitching up one who is wounded. Discovering and treating giardia in the water supply doesn’t make the news unless it happens too late and someone becomes ill. At this level trained observers can detect the signs of disease or dis-ease not noticeable to the untrained. (Example: detecting abnormal levels of cholesterol in blood which indicate incipient disease process, putting the person at risk.)

Level 3

Note: Treatment/intervention may become dramatic at this point if symptoms are acute. Efforts are directed towards reversing the disease process and restoring normalcy. Chances are, however, that the optimum can not be fully restored. Lasting damage has likely occurred at the tissue/organ level; scars may remain even after treatment.

Level 4

Note: Crisis level intervention is the most dramatic because the threat to life is manifest. It is also the most costly. Most of the health care dollar is spent at this point, both in physical disease and in emotional dis-ease.

Levels of Intervention

Some examples of methods of prevention and intervention at various levels:

             These levels apply to various dimensions of development: physical, spiritual, relational, emotional, mental--and to the organizational dimension. We include interventions of the organization because individuals function within the organizational system and setting. Ill health or disturbances in the organization leads to ill health in the individual, and vice versa (Smith and Berg, 1987).

1. Primary level (prevention): The importance of this cannot be underestimated. All areas of life warrant preventive measures to promote best functioning. (Example: What would you do to prepare a soldier whom you will send into battle six months from now?)

             a. Personal--psychosocial, spiritual, relational

Teach/train in personal growth areas, such as communication and interpersonal skills.

                       Teach how to create personal support networks, such as care groups.

                       Increase personal awareness, of self, others, impact of culture, etc.

Practice values clarification; conflicting values resolutions (e.g., how does need for “sabbath rest” conflict with value of giving hospitality, feeding the hungry, etc.?).

Teach and practice coping skills and mechanisms; teach about burnout, depletion, over-adaptation, stress management, etc.

                       Teach and practice good spiritual habits and use of resources for coping.

Experience pastoral and other supportive care continually to enable return to optimal as soon as possible after each “insult” or experience which disturbs equilibrium.

                       Spiritual retreats regularly.

             b. Physical 

                       Teach and practice physical fitness via appropriate

                                       nutrition

                                       regular exercise  

                                       avoidance of addictive substances, etc.

Have regular physical examinations for early detection of problems, especially being alert to signs and symptoms of over-stress, such as psychosomatic manifestations.

                       Take regular vacations and mini-vacations as needed.

             c. Organizational

                          Create climate of trust and openness.

                          Provide optimal environments as models and for intentional analysis and direct experience (e.g., in training/candidacy process).

                          Practice conflict resolution; consensus making.

                          Affirm, encourage, build-up to foster maximum growth.

Match jobs and persons appropriately; examine and clarify role expectations and changes.

Examine and correct organizational structures, ethos, culture, attitudes, values, expectations, etc., especially identifying organizational factors which are contradictory to good health. (E.g., not communicating clearly role expectations, confused lines of leadership, hurtful policies.)

                          Teach group dynamics and process and needs of individuals in groups.

 

             Gardner (1987) provides an excellent list of various pro-active means of preventing illness by attending to the needs before overt problems arise.

             Some organizational practices or behaviors constitute “mission malpractice.”

Example 1: Woman sent to field immediately after suicide of mother, with only three days “preparation/training” in New York City for life in Africa.

 

Example 2: Young couple with nursing infant and toddler assigned to parent 23 children, plus supervise a staff of six nationals, keep radio contact with airplanes in flight, and purchase and ship for the organization.

2. Secondary level intervention:

             a. personal

Repeat screening tools at critical times: entry in to candidacy, early training, various stages of training, departure for field, arrival on field, pre-furlough, re-entry time, especially relationship assessment, self-esteem and self-concept levels, communication skills and job satisfaction.

                          Dialogues or interviews to pick up early signs of dis-ease and disequilibrium.

 

             b. physical 

Regular physical examinations and screening, looking for early signs of incipient disease, such as psychosomatic disturbances.

 

             c. organizational

Assess organizational role in budding problems, such as unclear job expectations, confusion about roles and responsibility.

                          Make appropriate changes to support individual in roles, etc.

3. Tertiary level interventions:

             a. personal

                          Provide supportive care to diagnose and attend to problem(s).

                          Mobilize support network and look for alternative behaviors and solutions.

                          Change life style, work habits, schedules, etc., as needed to experience healing.

             b. physical

                          Proper assessment of physical state and disease.

                          Provide appropriate care.

                          Time off for recovery; adjust nutrition and exercise according to need.

             c. organizational

                          Proactive climate of trust, open communication.

                          Communicate care: “You are more important than your work.”

                          Consult; trouble shoot organizational role in problem.

                          Teach on-going skills in conflict resolution, etc.

                          Re-structure job roles, lines of authority, etc.

                          Place positive value on seeking help before crisis occurs;

                                       remove shame or guilt or blame from help-seeking.

                          Allow time out or time off to remedy problems.

                          Provide resources (e.g., insurance, counselors, physicians)

 

4. Crisis level interventions

             a. personal

                          Cry for help! Heed the cry for help of others!

                          Act and respond immediately! You are worth saving!

                          Communicate care: “You are more important than your work or the organization. We want you to be well!”

             b. physical

                          Hospitalize or get emergency care.

                          Time off and time out to restructure life, work, role expectations, etc.

             c. organizational

                         Don’t “punish” person for having or expressing a need.

                         Mobilize resources immediately! Support group, physician, counselor.

                         Always take the cry for help seriously--even if it doesn’t “look” so bad.

Mobilize or send crisis team after disaster, such as terrorist attack.

Reassess organizational issues which helped to create the crisis (e.g., years of failure to confront obesity which has put the individual at risk; authoritarian practices which allow no dialogue or discussion, appeals, etc.)

4. THREE INTERACTIVE DIMENSIONS OF “MISSIONARY DEVELOPMENT”:

             Various dimensions of life interact continually to create a person’s current state and status. O’Donnell (1988) examines the interplay of an individual’s personal development, the family life cycle in relation to the mission career stage. Here we focus on the basic health status (involving physical, psychosocial, etc.) and its interaction with life stages and mission career stages.

a. Basic health status: This is the sum of all dimensions of health. Basic health status is the foundation, or underlying matrix, on which life development and mission career development takes place.

 

1. physical health--any limitations? chronic diseases? at risk behaviors or hereditary pre-dispositions? general level of fitness and energy

 

2. emotional health and maturity--self-aware? level of self-esteem? self-concept? “unfinished business”? mental constructs governing behavior? flexibility, coping power?

 

3. relational status--necessary skills for establishing intimacy? able to confide in others? able to verbalize stresses, etc.?

ways of handling conflict? attitudes to authority? able to create caring, supportive network for self and others?

                          family of origin issues?

 

4. spiritual--concepts of God, of self? grounded in the Scriptures?

able to feed self and others through Word? accustomed to prayer? power of Holy Spirit? aware of Christian standards? able to resolve guilt and shame? feel unconditionally accepted?

 

             5. mental--able to seek stimulation? handle boredom? seeks a challenge?

content to be under-stimulated? able to apply new learning? (even Mensa geniuses lose intelligence when under-stimulated and/or not using their mental capacities regularly.)

b. Predominant or primary issues emerging from life cycle stages, particularly heightened by involvement in missions and cross-cultural life. We have made a special column for financial concerns because these are a continuing part of the matrix of life and a major source of stress.

Life Stages and Critical Issues

C. Stages of missionary career also interact with the basic health status and life cycle stages.

Stages of Missionary Career

Cumulative Stress During Certain Stages of Mission Career

             We believe that one factor in the interactive dimensions of missionary life which needs to be researched and addressed further is cumulative stress. Particularly during the first four phases or stages of the mission career stress may mount up to very significant levels because of the progression of the orientation and training process. In WBT and SIL, for example, individuals and families must move through a series of programs, each of which takes them away from home into a new environment, a new group, a new set of expectations and a new learning challenge. (See graph on stress and missionary career stages.)

             This initial process may take, in WBT and SIL, as long as five or six years. The candidate first attends Quest (the entry level one-month program), returns home, goes on to the Intercultural Communication Course (ICC), returns home, takes special training according to job destination (such as with JAARS), attends one or several semesters of linguistics and translation training, returns home to continue gaining financial support, and eventually goes to the field--only to be faced with more moves as she or he is assigned to learn the national language for a year or two. By the time the linguist/translator has reached the field assignment, several years have passed. He or she has had to make literally hundreds of new acquaintances, learn one or more languages, move every month or two or four, and then arrive on the field--and try to give the impression of starting the field assignment “fresh from home.” At least, that is the expectation of the tired field personnel awaiting his or her coming. We ourselves (Dodds) moved 19 times in two and a half years, with three small children, beginning with the first candidacy program and ending with moving to our own house in the jungle after our national language study program.

             In some missions the cumulative stresses are compounded by the “staged acceptance” process, in which candidates are not fully accepted until they successfully complete all phases of training. We believe this unnecessarily adds to the already high levels of stress; to not feel that one is fully accepted and that the organization is not yet fully committed to one’s success adds an extra burden, keeping the trainee on edge and under scrutiny for as much as five or six years.

             A number of studies have considered the levels of stress which cross-cultural, overseas workers or missionaries experience (Mueller, 1977; Foyle, Lindquist, 1982; Chester, 1988). Our own experience, through living in and teaching in WBT and SIL for 23 years and through regularly teaching missionaries overseas in about 20 countries during the last decade, is that people perpetually live with levels of stress which are astonishing. We have used a “stress event scale” (Holmes-Rahe), altered to accommodate to cross-cultural realities, with many groups in many locations worldwide. Most expatriate groups average 600 points on the scale, three times the 200 points considered to put a person “at risk” in the U.S. In one location with young MK’s recruited to work in a refugee program, we found them regularly averaging 900 points (3 tests over 2 years). We have encountered some individuals coming into a training program or new phase of career with points as high as 1,500.

             What keeps most missionaries healthy enough to live with such stress levels? It appears that for most of them, coping ability gradually increases to meet the demand of the stressors. They learn to use more resources for growth. In general, cross-cultural workers succeed amazingly well in adapting to the challenges they face. However, understanding the levels of stress they habitually carry certainly helps us to see why they do symptomatize over-stress and occasionally are overcome by it. Most mission candidates are disciplined and persevering, and very motivated, factors which contribute significantly to their success (Britt, 1983).

             We must always keep in mind that responses to stress are idiosyncratic; what causes stress and how it is symptomatized varies greatly from person to person, based on personality type, genotype, and many other factors. The threshold from bearable stress into over-stress is highly variable.

             In the graph attached, we trace what seems to be a fairly typical pattern of increasing or cumulative stress during various career stages. The shaded area represents the rather usual, daily levels of stress experienced by ordinary people. The graph illustrates how persons who go across cultures often encounter stress upon stress as each new stage (involving multiple changes) demands adaptation.

             Our observation is that the stress level most often peaks mid-way into the first field term, unless one is a short termer who stays in the “honeymoon” or tourist phase. Mueller, et. al, 1977, found that culture shock and culture fatigue are major causes of dropout. They site several studies, including one of C&MA personnel. They found that 38.1 percent of those who dropped out did so during or at the end of the first field term. Both from our experience and other studies, it appears that half-way into the first field term is a critical period, worthy of extra support of individuals by the organization. The fact that most missionaries “make it” is remarkable, considering what Daniel (1981) writes: “The cost of burnout is high.... The average length of stay in many people-helping professions such as social workers, poverty lawyers, child care workers, pastors, etcetera, is two years or less.” (Chester, 1983).

             For many workers, stress peaks again at furlough time, with the uncertainties of re-entry. Once back on the field there tends to be a decline and leveling out of the stress pattern. However, another researcher found that more personnel left the field half way into the second term than at any other time. This study did not include measures of stress, but we could infer that a long build up of stresses would account for leaving the field at that time.

             For the very long term worker abroad who has successfully made the cultural adjustment, a new threat to well-being arises: that of under-challenge or over-adaptation to an unchallenging situation. If persons are not provided with continued opportunities for personal and professional growth, or are deprived of their primary, significant job role (such as a pilot losing flight status) they may experience a decline in their over-all functioning that is akin to chronic burnout. We see persons manifesting the ashen, grey, prolonged state, which we could call “long term burnout,” characterized by low levels of energy, loss of hope, loss of self-esteem, negative self-concepts, loss of job satisfaction, little sense of meaning, despair, and other negative states. Perhaps such a state is the long term outcome of burnout that was not attended to, so that the total depletion experience earlier on has not been rectified. We need to investigate to what extent organizational values, such as an emphasis on faithfulness and submissiveness to authority rather than on personal growth and continued challenge, influence person’s depleted states.

5. INTERACTIONS OF THREE PROGRESSIVE DIMENSIONS:

              The three processes interact continually. The degree of health or the stage in one process has direct connection to the others. Assessing and understanding the basic level of health at entry level into the mission career is essential, as it is foundational to all further development.

 

a. critical intersections: Certain critical periods or events, when intersecting, increase vulnerability and put the person at greater risk. For example:

                        1) first child bearing with first field years

                        2) empty nest with recovery of memories of early childhood trauma.

3) empty nest with loss of significant ministry role or change of field assignment

4) going to field for first time with unstable or late teen or early adult children remaining at home, or at the onset of one’s parents’ decline

 

b. “Unfinished business:” The heavier the load of disease or dis-ease, whether undiagnosed or known, the extent of unresolved earlier life issues, etc., the sooner the movement to the next level of symptomization when the next round of stresses are encountered. (For example, coming in to mission service just after the suicide of a parent, without taking time for grieving or resolution of issues aroused will hasten the development and outbreak of disease in both the physical and the emotional dimensions. These pre-existing burdens will lower the threshold for sustaining additional stress, use up the person’s energy and thus will lower the adaptability and coping.)

             CAUTION HERE: In assessing a candidate’s basic health it is very important to ask: “What is his/her present level of functioning given their background? Where is she/he now compared to where she/he came from?” It would be highly unfair and unrealistic to eliminate a person based on background if he or she has been able to achieve a healthy level of functioning.

             Some persons are “self-correcting,” self-renewing, self-healing and otherwise resilient so that they change and grow and function well in spite of serious background issues. (See Dodds’ research, 1992.) We need to research what makes the difference between such persons and those who either fail to recover or continue to decline.

SUMMARY

             The public health model of disease progression is helpful for demonstrating and understanding the developmental nature of both physical disease and psychosocial-spiritual dis-ease. The model is easily visualized and readily understood. The levels of prevention and intervention which accompany the levels of disease progression provide a useful and easily applied framework for assessing the needs of a person and for making interventions appropriate to the level of illness. The model also illustrates the need for on-going prevention (or maintenance) to enable the person to return as quickly as possible to the optimal state.

             The basic health status of an individual is the sum total of her or his health in all dimensions of human development, such as the physical, emotional, relational, spiritual, mental and organizational spheres of life. Though the organization exists external to the person, each individual lives and works within the organizational system and setting, which exert direct influence in myriad ways on the well-being of that individual. Thus, we consider that both prevention and interventions must include assessment of the organizational factors related to the person, and the making of appropriate changes by the organization.

             Both the life development stages and the stages of the mission career are taking place upon the foundation or matrix of health of the individual. Thus, understanding and attending to all dimensions of health is essential. These three dimensions, each a progression, interact continually to create the person’s immediate state. Certain intersections of life cycle stage, mission career stages, and health status create particular vulnerability in persons, putting them at high risk for crisis.

References

 

Allen, Frank. 1986. Why do they leave? Reflections on attrition. Evangelical Missions Quarterly, 22, 118-129. Reprinted in O’Donnell and O’Donnell, 1988, p. 421-431.

 

Britt, William G., III. 1983. Pretraining variables in the prediction of missionary success overseas. Journal of Psychology and Theology. 11, 203-212.

 

Chester, Raymond M. 1983. Stress on missionary families living in “Other Culture” situations. Journal of Psychology and Theology. 2, 30-37. Reprinted in O’Donnell and O’Donnell, 1988, p. 164-185.

 

Daniel, A., and Rogers, M. L. 1981. Burn-out and the pastorate: A critical review with implications for pastors. Journal of Psychology and Theology. 9, 232-249. Quoted in Chester, 1983.

 

Donovan, Kath. The pastoral care of missionaries: The responsibilities of church and mission. Melbourne, New Zealand: Bible College of Victoria, Sept. 1992.

 

Gardner, Laura Mae. 1987. Proactive care of missionary personnel. Journal of Psychology and Theology. 15. p. 308-314. Reprinted in O’Donnell and O’Donnell, 1988, p. 432-443.

Hart, Archibald. 1991. Adrenalin and stress. Waco: Word, Inc.

 

Hawkins, Don; Minirth, Frank; Meier, Paul; Thurman, Chris. 1990. Before burnout: Balanced living for busy people. Chicago: Moody Press.

 

Horowitz, Mardi Jon. 1992. Stress response syndromes. Northvale, NJ and London: Jason Aronson, Inc.

 

Kobasa, S. C. 1979. Stressful life events, personality, and health: An inquiry into hardiness. Journal of Personality and Social Psychology. 37, 1-11.

 

Lindquist, Stanley E. 1982. Prediction of success in overseas adjustment. Journal of Psychology and Christianity. 1, 22-25.

Maslach, Christine. 1982. Burnout: The cost of caring. NY: Prentiss Hall.

 

Mueller, D., Edwards, D. W., and Yarvia, R. M. 1977. Stressful life events and psychiatric symptomatology: Change or undesirability. Journal of Health and Sociology. 18, 307-316.

 

O’Donnell, Kelly S. and Michele L., eds. 1988. Helping missionaries grow: readings in mental health and missions. Pasadena: William Carey Library.

O’Donnell, Kelly S., ed. Missionary Care. 1992. Pasadena: William Carey Library.

_____: Developmental tasks in the life cycle of mission families. Missionary Care. p. 148-163.

Schein, Edgar. 1992. Organizational culture and leadership. San Francisco: Jossey-Bass.

 

Smith, Kenwyn K. and Berg, David, N.: 1987. Paradoxes of group life. San Francisco: Jossey-Bass.

 

Thoits, P. A. 1981. Undesirable life events and psychophysiological stress. A problem of operational confounding. American Sociological Review. 46, 97-109.

 

Vinokur, A. & Selzer, M. L. 1975. Desirable versus undesirable life events: their relationship to stems and mental distress. Journal of Personality and Social Psychology. 33, 329-337.

Winter, Ralph, and Winter, Roberta. 1992. Foreword to Missionary Care. O’Donnell, ed. p. ix.