Missionary Care

Ronald L. Koteskey

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You may look at this title and say, "I've experienced some traumatic things as a missionary, but what in the world are PTSD and CISD? Does trauma affect children like it does adults? What happens to those who help the traumatized? Is there anything we can do to help prevent serious problems following trauma?

What is trauma?

People who respond with intense fear, helplessness or horror when they are confronted with something that involves the threat of death or serious injury to themselves or others experience trauma. This may be something people actually experienced themselves or something they witnessed.

Although this can happen to anyone anywhere in the world in the form of accident, assault, rape, etc., missionaries in some cultures are more likely to have such experiences, and less likely to have someone who knows how to help them at the most crucial time. Missionaries are often more likely to experience conflicts, such as guerilla warfare, coups, and evacuations. They may also be more likely to live where natural disasters, such as typhoons, earthquakes, and volcanic eruptions, occur frequently. They may also live through epidemics, such as cholera, typhoid, or malaria. Terrorism, kidnapping, and being held hostage are more common in mission settings. If missionaries do not experience the trauma firsthand, they often witness it in national friends.

What is PTSD?

Although nearly everyone living through such events has some symptoms for a week or two, some have much longer-lasting minor symptoms that do not interfere with their lives. However, some experiencing severe trauma develop Posttraumatic Stress Disorder (PTSD), and their symptoms are.

• Re-experiencing the traumatic event in the form of having recurring images or thoughts, or distressing dreams, feeling as if the event is happening again, and reacting physiologically to stimuli associated with the event or similar to the event
• Avoiding things associated with the trauma, such as conversations, activities, places, people or feeling detached from others, unable to experience emotions, and unable to remember significant parts of the trauma
• Experiencing symptoms of increased arousal, such as being easily startled, unable to sleep, irritable or angry, and having difficulty concentrating

These symptoms may occur immediately or be delayed for months or years. They may last for a few months or for many years. PTSD has been called combat fatigue and shell shock when found among the military in combat.

What is CISD?

Critical Incident Stress Debriefing (CISD) is a method of helping prevent PTSD from developing in someone who has experienced trauma. CISD is a structured group meeting ideally conducted by a trained professional between 24 and 72 hours after the crisis. A day is needed for the shock and numbness to wear off and for the people to rest and attend to immediate needs. After three days people begin to "seal off" emotionally and distance themselves from the trauma. Unfortunately, with airline scheduling problems, needed visas, lack of funds, etc., trained professionals may not be available within 72 hours, so those present but not directly involved in the crisis may want to deal with trying to prevent PTSD. Here are the outlines of a CISD which usually takes two or three hours.

• Introduction. Explain the purpose of CISD, discuss what will and will not be held confidential, make sure that only those directly involved in the crisis are present and that all directly involved are present, give opportunity for questions, and have prayer together. (If some do not want to participate, point out to them that they may not need help, but they may be helpful to others in the group.)
• History. If the people involved know each other well, this step may be omitted. However, if they are not part of an already established group, having each one briefly give a personal testimony, family history, personal background (education, work, marriage, children, happiest times, most stressful times, strengths, and weaknesses) may be helpful.
• Facts. Ask each member of the group to tell about what happened and what his or her role was. This may include anything from watching helplessly as someone died to pulling people from the wreckage and saving their lives.
• Thoughts. Ask members of the group to give the first thought they remember after they stopped behaving automatically. It may be something as simple as worrying about a pet or as complex as wondering what would happen to their child if they died.
• Reactions. Ask each person to talk at a more emotional level about his or her experience, perhaps by asking, "What was the worst part of it for you?"
• Symptoms. Ask members to describe any symptoms they experienced during and after the event, such as disturbed sleep, lack of appetite, or poor concentration.
• Spiritual struggles. Experiencing trauma may impact members' faith in God or concept of God. Indicate that it is safe to report questions about God. You may want to pray with them, even repeat some of the Psalms of David as he questioned God.
• Education. Summarize the meeting and note that their symptoms are normal for anyone who has experienced severe stress; then give them some techniques to help reduce stress. Tell briefly about PTSD and note that common reactions to trauma are feelings of anger, anxiety, denial, depression, guilt, grief, tension, and gastrointestinal problems.
• Referral. Finally, encourage participants who experience continuing problems to see a mental health professional for CISM (Critical Incident Stress Management), because you have just given first aid, not full treatment.

What about children and trauma?

Children are also affected by trauma and need care much like adults. Parents, teachers, pastors, and friends of the family may be most helpful to children.

• The presence of supportive loving adults is the greatest need of traumatized children. Children find the greatest comfort in knowing that they will not be left alone, that someone will be there for them whenever needed.
• Children need to be given enough information to comfort them, but not so many details that it increases the trauma. Always tell children the truth; covering up the facts leads to distrust later on.
• Like adults, children need to be able to process what has happened to them with other children their own age. Also like adults, they need a facilitator present-a supportive, loving adult.

The general health of the family influences how severely the trauma will affect the child. Children from dysfunctional families are much more vulnerable to the effects of traumatic situations.

Does debriefing affect the helpers?

Yes. The debriefers must be debriefed. Leading a debriefing is an emotionally draining experience, and anyone doing it is very likely to experience the very symptoms they have heard others describe. They need some way to process what they have been through themselves, again within 24-72 hours. If not, the debriefers may well experience compassion fatigue and become cynical themselves.

This does not need to be another full CISD but may be an informal way to talk through what has happened to them. They should have people praying for them. They should not schedule other emotionally demanding events after the debriefing so that they will have time themselves to debrief. If possible, the debriefers should work in pairs so that they can get together later and debrief each other.

What can we do to prevent trauma?

Your agency should have contingency plans for potentially traumatizing situations. Decisions should already be made on such questions as to whether or not ransom will be paid, who will go to help people in traumatic situations, who will speak for the mission during crisis times, and so forth.

You should know how to act to minimize danger. For example, you should know where flash floods are likely to occur, and avoid those roads when you see clouds in the mountains. Or how do you tag your luggage? "Dr. Jonathan Q. Smith, PhD, Executive Director, Important Mission International" is a much more inviting target for hostage takers than is "John Smith, 123 The Lane."

You should know what to do if a potentially dangerous situation occurs. For example, what do you do if an earthquake occurs? Running from a brick building is not wise. What do you do if you are taken hostage? Those early minutes of captivity are some of the most dangerous, and resistance in the face of overwhelming odds may result in your becoming a corpse.

We live in a fallen world, and trauma cannot always be avoided. However, by using the best resources that we have available and the spiritual resources that God supplies, we can emerge from the situation only scarred to some extent, but not total casualties.