Stress and burnout often affect missionaries working cross-culturally. Member care providers can do much to prevent or lessen the damage caused by mismanagement of cumulative stress. Best practices in missionary care call for self-care by the missionary and intentional care by the sending church or organization. The author suggests essential member care interventions that will help maintain the health of the missionary.

Introduction

In twenty odd years of providing pastoral care for missionaries, the critical issues that have surfaced most often in my experience are problems related to stress management and personal burnout. In addressing these issues, I have found several critical issues that must be addressed in order for the missionary to maintain a life balance: stress levels, awareness of stressors, and maintenance of emotional and physical reserve levels. How well one manages stress affects not only the individual but their family, their co-workers, and their ministry.

Stress is normal. It is our body’s reaction to an emotional or physical life challenge. Stress can be positive if it activates our body and our mind. When we encounter stress, we marshal every resource the body has to react quickly and sufficiently to the stressors. However, if stress is prolonged, physical and emotional energy reserves will be exhausted, resulting in the development of harmful or negative forms of stress reactions.

Experiencing stress does not mean we are lacking in strength, professionalism, or spirituality. It means we are finite human beings created to need fellowship with God and relationships with other finite humans. We also require work, rest, sleep, exercise, and food. In the same way, missionaries need an understanding of what stress is, an ability to identify the symptoms of stress, and coping skills for managing stress.

Understanding Stress

If we define stress at the most rudimentary level as a transaction between the missionary and the environment, any event that cannot be managed by the available resources becomes stressful. Stress is, therefore, what we experience as we adjust to our continually changing environments.

Recently, during a debriefing of a couple returning stateside that had experienced several troubling events, I learned that only one had been severely traumatized. The other spouse was coping quite well. The couple’s response was different because of their perception and interpretation of the events that brought them home. How an individual appraises a situation will determine whether it is stressful. Our behaviors are shaped by many factors including our core values, beliefs, expectations, culture, and subculture. Likewise, our range of coping skills and strategies is determined by the same factors. How we think about stress matters.

Stress can be understood developmentally by beginning with common, basic stresses that occur at work or within a family. If the basic stress level is not addressed adequately, the stress moves to another level defined as cumulative stress. Burnout occurs when all resources for dealing with the cumulative stress are exhausted. Traumatic stress or critical incident stress is caused by situations outside the range of everyday experiences, when the missionary’s life is perceived to be under immediate danger. Traumatic stress can develop into Post Traumatic Stress Disorder (PTSD), a pathological condition requiring professional mental health care.

The Holmes and Rahe Social Readjustment Rating Scale is a standardized measure of the impact of common life events over a period of a year. The scale is based on the observation that important life changes, positive or negative, will induce stress. Because stress is cumulative, by adding the values assigned to the life events, one is able to obtain a rough estimate of how stress is affecting one’s health. Nine items on the scale are life events at which a missionary moving to a new field would likely experience stress. Adding the values assigned to those events results in a mid-range score indicating a 50% chance of a major health breakdown within two years. Yet, the Holmes and Rahe scale does not include the factors most common to cross-cultural workers—adjusting to a new culture, language learning, maintaining financial support, maintaining a devotional life, and spiritual warfare. Add these to the Holmes and Rahe scale, and one would have an even higher risk of health breakdown.

Why does cumulative stress appear to be the most frequent form of stress encountered by missionaries? Missionaries often bring to the field qualities of selflessness and idealism. With high personal standards, a divine call to make a difference, and a results-oriented philosophy, they become vulnerable to stress when the needs are overwhelming and they are facing limited resources. Although cumulative stress is, to a large extent, inherent in missionary work, measures can be taken to ensure that it remains within reasonable and manageable limits.

The reality in our American church culture is that we rarely admire and encourage those who maintain a margin of time and energy, nor do we appreciate and encourage those who create healthy boundaries for themselves and their families. There appears to be an admiration and support of the “it’s better to burn out than rust out” attitude. Such an environment, which pressures one to prove one’s worth and success, can establish a drive that destroys a healthy balance in ministry. When missionaries are thought of as super-human, they can become driven by unrealistic expectations that threaten their physical and emotional health.

Symptoms of Stress and Burnout

When a missionary experiences chronic stress, and demands exceed their coping resources, burnout will likely occur. Burnout is an exhaustion of normal stress coping mechanisms. The difference between normal stress and burnout is one of intensity. For example, fatigue becomes exhaustion or irritability becomes unmanaged anger. If not addressed, burnout will play havoc with relationships, ministry, and personal health.

There is no formal assessment that provides the diagnosis for burnout, unlike depression or other mood disorders. Recognizing the symptoms is the first step in assessing this destructive challenge to one’s health and ministry. There is a wide range of symptoms. Three areas that appear to be principal signs of burnout are:

1. Emotional exhaustion.
2. Disengagement from work and family.
3. Reduced performance in everyday tasks.

One does not suddenly burn out. The person undergoes a process marked by physical, emotional, and behavioral indicators that can be identified and addressed at an early stage if one is aware of the symptoms.

Signs of stress:

• Physical symptoms: overtiredness, headaches, sleeping disorders, changes in appetite, and back pains.
• Emotional signs: anxiety, mood swings, crying spells, apathy, irritability, frustration, and guilt.
• Mental signs: forgetfulness, loss of motivation, negative self-talk, poor job performance, and negative attitude.
• Relational signs: loneliness, social isolation, resentfulness, anti-social behavior.
• Spiritual signs: feeling of emptiness, feeling unforgiven, loss of life purpose, loss of prayer life and worship.

The most common symptoms of burnout are feelings of isolation and lack of support from teammates, family, or organization; loss of enthusiasm; increased rigidity; and negativity. Emotional exhaustion constitutes the main characteristic of burnout. Becoming familiar with the following symptoms will enhance one’s facility for self-care.

Symptoms of cumulative stress that have become chronic:

• Chronic sleeping disorders
• Somatic problems and exhaustion
• Deterioration of mental capacities
• Loss of memory and efficiency
• Loss of self-esteem
• Focus on failure
• Profound disillusionment
• Rejection of values or faith
• Unwillingness to take leave
• Risk taking

The systemic causes of burnout can come from a lack of support and, if a person has a high need for feedback or affection, a lack of recognition. Working in a high-risk, unstable environment requires exceptional vigilance and readily accessible resources both internally and externally. The loss of control in a high-risk situation can generate burnout quickly. Competitiveness, unforeseen changes in team organization, and changes in work strategies can be additional systemic causes. Finally, missionaries that have few protocols for self-care, are experiencing poor physical, mental, or emotional states, and sustain a high degree of perfectionism are extremely vulnerable to burnout.

Coping with Stress

Preventatives Generated by the Missionary

Learning new coping skills is critical to maintaining health. The effects that stress has on us can be positive or negative. As a positive influence, stress can move us to action and allow us to evaluate a situation from a different viewpoint. The negative impact can result in a rollercoaster of emotions and moods.

Much can be done to decrease cumulative stress and make it manageable. Learning to take care of oneself and recognizing the importance of an adequate support system is a major step in the right direction.

Start with “Who am I?” Know who you are and what you will allow to be changed about you. Recognize that you are fallible, will make mistakes, and that you cannot fulfill everyone’s expectations. Learn to write your own life script. If you do not, there are plenty of well-intentioned people who will gladly do it for you.

Stop comparing yourself to others. No matter what they act like, everyone else is also human and fallible.

The Myers-Briggs Type Indicator (MBTI) can be very helpful by identifying your personality preferences. The MBTI will show how you are energized, take in information, make decisions, and orient yourself to the world around you.

Share and communicate clearly. Find someone to share your fears, doubts, and disappointments with. Especially at times of physical danger, take time to talk and share your emotions. Spend intentional time with co-workers that share your culture. It is important to relax and be yourself around those that understand you in the context of a common culture.

Sabbath rest is critical for maintaining balance in life. You need daily, weekly, and annual breaks that provide time to replenish your emotional and physical reserves. God made the Sabbath rest for people. Our bodies have a divine rhythm of work and rest. The Sabbath is a picture of the rest and care we have all been designed to need in order to maintain health and productivity. Practice it without guilt.

One life-long missionary attributed her longevity in a highly stressful mission work to the practice of Sabbath rest. She reportedly practiced the weekly Sabbath, a week-long Sabbath every seven weeks, a month-long Sabbath every seven months, and a year-long Sabbath every seven years. While that may appear excessive, she was able to maintain a long and effective ministry that few can claim.

Take relaxation seriously and cultivate margins in your life. Plan for physical sports activity, an exercise program, or active games with family or friends to reduce stress. Unplug from technology and build margins that exclude cell phones and the Internet.

Stay attuned and take notice of what factors cause you the most stress. Be sensitive to precursors that indicate you might be under too much stress. If you are struggling, seek the help and support of co-workers, family, or friends. Listen to them if they recommend that you may need to seek professional attention.

Know the internal and external sources of stress.

Internal: Health Spiritual struggles Emotional struggles Life stages Unrealistic expectations Negative attitudes Emotional pain

External: Marriage and family Major changes Social relationships Living situation Work/ministry situation Unsettled future Situational crises

Are you getting enough sleep? Recovering from chronic stress and burnout requires replenishing your resources by removing or reducing the demands. Sleep can help replenish your energy and reserve.

How is your spiritual life and practice? Ron Koteskey states:

The factors that help you cope with stress are summarized in the three enduring things mentioned by Paul at the end of 1 Corinthians 13.

Faith. In addition to faith in God, faith in yourself as a person created in God’s image and called into his service will help you cope.

Hope. Rather than feeling helpless, having not only the hope of eternity with God, but also hope in your future, knowing that he has good plans for you, will help you cope.

Love. Finally, having both God’s love and the love of his people to give you support in the stressful situation you face daily, will help you cope.1

“For the Son of man also came not be ministered unto, but to minister, and to give his life a ransom for many” (Mark 10:45; ASV). Jesus was both the Son of God and Suffering Servant. In his earthly ministry, Jesus experienced unimaginable stress. How did he cope with stress? First, there was the primacy of prayer. In his deepest times of stress, Jesus went to the Father in prayer. Second, he affirmed he affirmed that he could do nothing without the Father (John 5:19; 8:28). In his servanthood, Jesus served without drivenness or compulsion. He knew that God, the Father, loved him so that he could serve the multitudes without the need for recognition. Like Jesus, we are to find the fulfillment of our deepest needs in relationship with the Father.

Preventatives Generated by the Supporting Church
or Sending Organization

Do proper pre-field training. Be preventive by determining that the candidate is healthy and prepared to meet the challenges of the cross-cultural assignment both physically and emotionally. With the abundant resources and support systems stateside, it is easier to address problems and bring resolution before departure.

If a walking path comes near the edge of a cliff, a warning sign and a safety fence can protect hikers from falling over the edge, or a first-aid station at the bottom of the cliff can tend to the unfortunate person who wanders off the path. Prevention is obviously the rational measure. Sending healthy missionaries to the cross-culture assignment is the first step in prevention. Individuals experiencing depression, anxiety, or other unresolved issues will leave their home support systems and, to their dismay, will find only an exacerbation of their personal issues in their new environment.

In particular, pre-field psychological assessment can help identify and address problems before departure. The MMPI-2, 16PF, and FIRO-B are standard assessment tools that can be beneficial to the pre-field preparation of the missionary.

Sending a candidate ill-prepared mentally, emotionally, and spiritually is like throwing a non-swimmer into the pool for his first swimming lesson. He may dog-paddle for a while, but he will not learn to be an Olympic swimmer until he has a coach and proper training. Training candidates in interpersonal skills, communication, conflict management, team development, decision making, language learning techniques, and rest and renewal is critical to the “basic training” of the front-line worker. The provision of a Personal Development Plan (PDP) for the new missionary as well as the seasoned missionary provides additional sources for managing personal and cultural stress. On-field and post-field development plans can strengthen the worker and assure longevity. Lifelong learning and re-tooling are necessary to meet the demands of expanding ministry challenges that create stressors.

Maintain regular check-ups by member care personnel or pastors to missionaries. Planned, consistent use of assessments like the CernySmith Assessment (CSA) will measure progress and provide a voice for the missionaries. Using the CSA periodically after arrival on the field, then annually, will assure the missionaries that they have someone to tell their story to in full confidentiality. Everyone needs a confidant. The CSA can also be used for debriefing following a critical incident or on return to the missionary’s passport country. Member care personnel should not assume that long-term missionaries have less need for similar attention and investment of time. The reality of spiritual warfare is that even the most experienced missionary can be wounded, requiring the need of immediate care.

Member care visits on-field establish a pastoral bond with the missionary. Regular on-field visits by a member care professional provide the missionary another safe outlet to share personal or group concerns. Utmost effort should be made to establish trust and confidentiality. Such a climate may take multiple visits to create. Someone has said the first visit response is, “Thank you for dinner,” the second visit, “Oh, it’s you again,” and finally, the third visit, “Okay, here’s what it’s all about.”

On-field team members can play a vital role in the prevention of cumulative stress in co-workers. When becoming aware of negative trends, the team should provide the missionary an opportunity to rest and talk about the causes of stress being experienced by the missionary. Team members are the first responders and can provide important immediate care.

Recommended Tools for Member Care Providers for Pre-field, On-field, and Post-field Assessment2

The CernySmith Assessment (CSA) is a comprehensive online questionnaire developed by Leonard J. Cerny II and David S. Smith that queries the degree of stress a person is experiencing regarding personal, social, cultural, and organizational experiences (http://cernysmith.com). The CSA provides a snapshot of current stress-management skills and adjustment. This assessment can be taken pre-field as a way to create baseline data that can be compared to any later CSA taken on-field or post-field.

The GoCulture Assessment (GCA), developed by Carley Dodd of Abilene Christian University identifies sixteen intercultural factors called the Cultural Readiness Indicators and five Leadership Style Indicators that show strengths and challenges (http://gocultureinternational.com). The assessment provides self-improvement worksheets for developing stronger skills in cultural adaptation. The assessment developer claims that use of these coaching questions can improve cultural adaptation by as much as 85%.

The Myers-Briggs Type Indicator (MBTI) assessment is a psychometric questionnaire designed to measure preferences in how people perceive the world and make decisions. The Linda Berens Institute (http://lindaberens.com) uses the insights of the MBTI to help individuals shape a stress-resilient work environment.

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is the most widely used psychometric assessment of adult personality and psychopathology. An alternative version of the test, the MMPI-2 Restructured Form (MMPI-2-RF) is a streamlined version with fewer questions. The MMPI-A version of the test is designed for adolescents, ages 14 to 18. It is recommended that the test be used in addition to other assessment tools.

Unlike the MMPI-2, the Sixteen Personality Factor Questionnaire (16PF) is a measure of normal-range personality. The 16PF measures sixteen personality traits, which can predict a person’s behavior in a range of contexts.

The Fundamental Interpersonal Relations Orientation-Behavior (FIRO-B) assessment provides insights into how an individual’s needs for inclusion, control, and affection can shape his or her interactions with others within a group setting. This is an excellent tool for coaching and team building.

The Thomas-Kilmann Inventory (TKI) is designed to measure a person’s behavior in conflict situations. The inventory measures five conflict-handling modes: Competing, Accommodating, Avoiding, Collaborating, and Compromising.

The Team Performance Inventory (TPI) is a resource for assessing a team’s stage of development and performance. The inventory provides insights into the dynamics of the team with evaluations of the team members’ commitment and the tasks needed to improve performance at each stage of team development. The inventory also identifies the appropriate leadership style and the tasks needed to lead the team to high performance.

Stress Questionnaire

Because everyone reacts to stress in their own way, no one stress test can give you a complete diagnosis of your stress levels. This stress test is intended to give you an overview only.

Answer all the questions, but just check one box that applies to you, either yes or no. Answer yes, even if only part of a question applies to you. Take your time, but please be completely honest with your answers.

		Yes	No
I frequently bring work home at night.
Not enough hours in the day to do all the things that I must do.
I deny or ignore problems in the hope that they will go away.
I do the jobs myself to ensure they are done properly.
I underestimate how long it takes to do things.
I feel that there are too many deadlines in my work/life that are difficult to meet.
My self-confidence/self-esteem is lower than I would like it to be.
I frequently have guilty feelings if I relax and do nothing.
I find myself thinking about problems even when I am supposed to be relaxing.
I feel fatigued or tired even when I wake after an adequate sleep.
I often nod or finish other people’s sentences for them when they speak slowly.
I have a tendency to eat, talk, walk, and drive quickly.
My appetite has changed, have either a desire to binge or have a loss of appetite/may skip meals.
I feel irritated or angry if the car or traffic in front seems to be going too slowly/I become very frustrated at having to wait in a line.
If something or someone really annoys me I will bottle up my feelings.
When I play sport or games, I really try to beat whomever I play.
I experience mood swings, difficulty making decisions, concentration and memory is impaired.
I find fault and criticize others rather than praising, even if it is deserved.
I seem to be listening even though I am preoccupied with my own thoughts.
My sex drive is lower, can experience changes to menstrual cycle.
I find myself grinding my teeth.
Increase in muscular aches and pains especially in the neck, head, lower back, shoulders.
I am unable to perform tasks as well as I used to, my judgment is clouded or not as good as it was.
I find I have a greater dependency on alcohol, caffeine, nicotine, or drugs.
I find that I don’t have time for many interests/hobbies outside of work.
A yes answer score = 1 (one), and a no answer score = 0 (zero).	TOTAL:

Your score:

Most of us can manage varying amounts of pressure without feeling stressed. However, excessive pressure, often created by our own thinking patterns and life experiences, can overstretch our ability to cope, and then stress is experienced.

4 points or less: You are least likely to suffer from stress-related illness.

5–13 points: You are more likely to experience stress-related ill health, either mental, physical, or both. You would benefit from stress-management counseling to help in the identified areas.

14 points or more: You are the most prone to stress, showing a great many traits or characteristics that are creating unhealthy behaviors. This means that you are also more likely to experience stress and stress-related illness (e.g., diabetes, irritable bowel, migraine, back and neck pain, high blood pressure, heart disease, strokes, or mental ill health such as depression and anxiety). It is important to seek professional help or stress-management counseling.

Tips to help improve your score:

• Review the questions that you scored yes.
• See if you can reduce, change, or modify this trait.
• Start with the ones that are easiest and most likely to be successful for you.
• Only expect small changes to start with; it takes daily practice to make any change.
• Support from friends, family, and colleagues will make the process easier and more enjoyable.

Willard Walls is the director of A Lamp Unto My Feet (http://lampmembercare.org), a member care ministry of Missionary Health Care and Training International. Will has served as pastor in local churches in the US, Canada, and the United Kingdom, and for twenty-three years he worked as a state university campus minister. He and his wife Ruth were church planters in England from 1995 to 2004. For the next ten years Will served as Member Care Division Director and then Director of Pastoral Care for Christian Missionary Fellowship International (http://cmfi.org), where he continues to serve as a member care consultant.

Bibliography

Koteskey, Ronald L. “What Missionaries Ought to Know about Culture Stress.” http://missionarycare.com/brochures/br_culturestress.htm.