Trauma and traumatic stress among missionaries.

Research was conducted to determine the extent and nature of traumatic events experienced by missionaries and the extent to which missionaries reported Posttraumatic Stress Disorder (PTSD) symptoms due to traumatic exposure on the mission field. Ninety-four percent of missionaries reported having been exposed to trauma on the field, with 86% reporting exposure to multiple incidents. This was considerably higher than their exposure when off the field and could be attributed primarily to an increased risk of exposure to civil unrest and violent crime. Less than half of the missionaries reported symptoms at a level necessary for a diagnosis of PTSD at their most difficult period of adjustment to their most distressing traumatic experience. No missionaries reported current symptoms at a level necessary for a diagnosis of PTSD. The data suggests that missionaries from North America have a greater resilience to trauma than is found in the general North American population.

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In 1993, Miersma drew parallels between the experiences of Vietnam veterans dealing with the trauma and stress of combat and the experiences of missionaries dealing with trauma and stress in missionary life. Miersma concluded that research conducted with combat veterans could provide guidance to missionaries and mission agencies to help "reduce the impact of stress for missionaries both at the prefield and on-the-field level of experience" (1993, p. 95).

Many American soldiers who fought in Vietnam returned home with deep psychological wounds. The prevailing wisdom of the time was that they were suffering from "shell shock" or "combat fatigue," and if given space and time, their mental wounds would soon heal and life would return to normal. Unfortunately, that was not the case for many. The struggle of veterans led the psychological community to reexamine the impact of overwhelming traumatic experiences on individuals. Thus, in 1980, the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) listed Posttraumatic Stress Disorder (PTSD) as a diagnosable disorder.

Early research into PTSD focused primarily on combat veterans. However, soon it was recognized that many people who had never been in combat but who had experienced significant trauma were liable to experience the same symptoms of PTSD as the combat veterans. For example, studies made of rape victims (e.g., Foa, Rothbaum, Riggs, & Murdock, 1991), assault victims (e.g., Foa et al., 1999), armed robbery victims (e.g., Harrison & Kinner, 1998), motor vehicle accident victims (e.g., Ursano et al., 1999), and victims of natural disasters (e.g., Beck & Franke, 1996) revealed similar response patterns to those observed in combat veterans.

Researchers also began to identify certain populations at high risk for the development of PTSD. At-risk populations not only included combat soldiers (Mamar et al., 1994), but also groups such as law enforcement officers (Harvey-Lintz & Tidwell, 1997), firefighters (Wagner, Heinrichs, & Ehlart, 1998), disaster workers (Fullerton & Ursano, 1997), nurses (Clark & Gioro, 1998), and international relief and development workers (Eriksson, 1997). The obvious commonality between these high risk groups is that their members are frequently exposed to dangerous or even life threatening situations, or that they are part of a profession that works closely with trauma victims (Clark & Gioro, 1998; Cornille & Meyers, 1999; Figley, 1995a).

Psychologists working with missionaries warn that missionaries fir the profile of a high risk group. Goode (1995) warns that, "As the missionary community continues to focus upon unreached peoples, continued exposure to life-threatening, crisis situations can be expected" (p. 211). Grant (1995) makes the following observation: "Being a missionary can be very dangerous.... Overseas ministry can be peppered with years of direct experience with an exposure to crime, psychological intimidation, military and terrorist threats, kidnappings, armed coercion, torture, rape and murder. Repeated robberies and home invasions by burglars, soldiers, and terrorists are not uncommon" (p. 72).

Not only are missionaries often located in places that many would consider dangerous, they also tend to work closely with victims of trauma, making them susceptible to secondary traumatic stress (STS; Clark & Gioro, 1998; Cornille & Meyers, 1999; Figley, 1995a; Stamm, 1997). STS is defined by Figley (1995b) as "the natural, consequent behaviors and emotions resulting from a knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" (p. 10). In Stamm's (1997) summary of research into STS she notes that, "Clergy receive little attention but may be exposed to a great deal of traumatic material as a result of their work" (p. 2); thus, placing them at risk for developing STS. Obviously, missionaries are exposed to similar risks.

Unfortunately most of the literature dealing with issues of trauma and traumatic stress in the missionary community is based on anecdotal evidence rather than empirical research. Mission agencies may be tempted to respond by treating such incidents as isolated occurrences and so do little, or they may view them as signs that an extensive response is necessary. By providing research based information, this research was conducted to help mission agencies to respond responsibly to issues relating to trauma and traumatic stress among their missionary personnel.

Trauma Exposure

Within the general population between 66.8% (Bernat, Ronfeldt, Calhoun, & Arias, 1998) and 89.6% (Breslau et al., 1998) of individuals report being exposed to at least one traumatic event in their lifetime. Up to half of the general population is likely to have experienced multiple traumatic events in their lifetime (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Stein, Walker, Hazen, & Forde, 1997). Men are more likely than women to have experienced a traumatic event (Breslau et al., 1998; Kessler et al., 1995), and among those who have experienced an event men are likely to have experienced a higher number of events than women (Stein et al., 1997). Literature addressing the issue of trauma among missionaries generally assumes that missionaries are at high risk for encountering traumatic events (Carr, 1994, 1997; Goode, 1995; Grant, 1995; Jensma, 1999; Lindquist, 1982; Miersma, 1993).

Some types of traumatic events are much more common in the general population than others. For example, the sudden unexpected death of a close friend or loved one was experienced by 60% of the general population, while only 1.5% of the general population were exposed to military combat (Breslau et al., 1998). Research also showed that some types of traumatic events were more common among men than women, whereas others were more common among women than men (Stein et al., 1997). Those writing about trauma in the missionary community suggest that missionaries may be at higher risk of exposure to "war, violence, evacuations, kidnappings, and even torture" (Jensma, 1999, p. 130) than individuals in the general North American population.

PTSD Prevalence

Between 7.8% (Kessler et al., 1995) and 9.2% (Breslau, Davis, Andreski, & Peterson, 1991; Breslau et al., 1998) of the general North American population can be expected to have PTSD at some point in their lifetime. At any given point in time, between 4% (Bernat et al., 1998) and 6.2% (Norris, 1992) of the general North American population can be expected to have PTSD. No studies of the prevalence of PTSD among missionaries has been reported in the literature, but Eriksson (1997) reported that 10% of returning Christian relief and development workers had PTSD upon their return (p. 14).

The Research Focus

The focus of this project was to determine the extent to which North American missionaries report experiencing trauma on the field, identify the nature of the traumatic experiences they report, and determine the extent to which they report PTSD symptoms upon returning from a term of service.

METHOD

Participants

Participants in this study were drawn from career missionaries originating in North America who were under appointment by Wesleyan World Missions, the denominational mission agency of The Wesleyan Church. Wesleyan career missionaries usually serve terms of three to four years followed by a one year furlough back in North America. During the period in which data was being collected for this project, The Wesleyan World listed 157 North Americans under appointment as career missionaries (The Wesleyan Church, 2000). The sample (n=31) for this study consisted of all career missionaries who were in North America in January 2000 and who had returned from the field in the previous 12 months. This included missionaries on regular furlough as well as those who were discontinuing missionary service.

Questionnaire

A three-part questionnaire was sent by mail to the sample. The responses to the questionnaire were returned anonymously by mail. A separate response card was returned by respondents at the same time as the questionnaire so that the researcher could determine which subjects had not responded and follow up on non-respondents to encourage their participation.

Demographic section. The first section asked for general sociodemographic information such as age, gender, marital status, ministry assignment, years spent on the field as a missionary, geographic area of service, and whether or nor the individual had ever received training in stress management.

Trauma inventory section. The second section consisted of a modified version of the Trauma Events Questionnaire (TEQ) as developed by Scott Vrana and Dean Lauterbach (1994). Although the TEQ was developed just prior to the publication of the DSM-IV, it is clear that the authors were greatly influenced by the research and thinking that led to the changes in the DSM-IV in the definition of what constituted a traumatic event. In their evaluation of the TEQ, Norris and Riad (1997) concluded that the TEQ "is consistent with the present wording of Criterion A in DSM-IV" (p. 13).

In this project, the TEQ was modified in order to bring it in line with more recent research on traumatic stressors by expanding the category "combat" to "combat/civil war/violent civil unrest, or evacuation due to any of these" (Gardner, 1991; Ihrke, 1993, p. 5); changing "serious industrial/farm accidents" to "serious industrial, farm, or car accidents" (Hobbs, Mayou, Harrison, & Worlock, 1996; Ursano et al., 1999); and defining "violent crime" as "assault, robbery or hold up" (Brewin, Andrews, Rose, & Kirk, 1999; Riggs, Rothbaum, & Foa, 1995; Stein et al., 1997). In addition, the two catchall questions at the end of the TEQ were combined to create one question relating to traumatic events not reported elsewhere in the questionnaire. Also, instead of asking simply about the occurrence of these events in their life time, subjects were asked to identify when these events occurred. This enabled a comparison of the life time prevalence and year span prevalence of trauma among missionaries with studies of other populations over similar time spans. It also enabled the distinguishing between on the field and off the field traumatic experiences.

PTSD symptom section. The third section of the questionnaire asked questions to identify the prevalence of PTSD symptoms related to the traumatic events identified in the previous part of the questionnaire. This is a version of the Posttraumatic Stress Disorder Checklist, Civilian Version (PCL-C) as developed by Weathers, Litz, Herman, Huska, and Keane (1993), a measure used frequently in PTSD research. The PCL-C is a seventeen item measure in which respondents are asked to reflect on the impact of "stressful life experiences" and report if they have experienced symptoms in the past month. Respondents are asked to indicate the degree to which they have experienced each symptom on a five point Likert scale, ranging from "nor at all" to "very much." The seventeen questions correspond directly with the seventeen symptoms of PTSD as described in DSM-IV specifically criteria B (5 questions), criteria C (7 questions), and criteria D (5 questions).

Subjects were asked to identify the most traumatic event they have experienced on the mission field and respond to the questions in this section in relation to this event. They were asked to respond to the questions twice: first, for "your most difficult period of adjustment" (Vrana & Lauterbach, 1994, p. 293); and second, "within the past month." The score on this section provided an indication of the level of PTSD symptoms both at their maximum level as well as currently.

Reliability and validity of the Traumatic Events Questionnaire. According to Vrana and Lauterbach, the TEQ has been shown to have very high reliability (.91) over a two-week test retest interval in a sample of 51 college students (Lauterbach & Vrana, 1996; Vrana & Lauterbach, 1994). In their review of the TEQ, Norris and Riad (1997) suggest that the use of the two catchall questions at the end of the instrument raises a possible problem with content validity, though overall they view the TEQ as having acceptable validity. They conclude that the use of catchall questions is a necessity because it is impossible to anticipate and, thus, catalog all possible traumatic experiences, even though these questions allow for the inclusion of rather ordinary events that would not be generally considered traumatic by most people. In this study, by combining the two catchall questions originally in the TEQ into one, an effort was made to reduce the number of invalid responses.

Reliability and validity of the PTSD Checklist. The PCL-C is a widely used instrument and has shown itself to have high test-retest reliability (.96) over a 2-3 day period and a coefficient alpha of .97 (Weathers et al., 1993). In research designed to assess the reliability of psychological tests administered by computer, the PCL-C was shown to have a test-retest reliability of .88 over a week when administered by computer (Campbell et al., 1999). In convergent validity tests with other PTSD scales, the PCL-C has also demonstrated high reliability (Andrykowski & Cordova, 1998; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers et al., 1993; Weathers & Ford, 1996).

The designers of the PCL-C suggest two possible methods for interpreting PCL-C scores (Weathers et al., 1993). The first method simply takes a cumulative score of 50 as a cutoff point, so that a score of 50 or above would be indicative of a probable diagnosis of PTSD. The second method involves interpreting scores more closely in lines with the standards of DSM-IV by dividing the scores into three categories corresponding to the three symptom categories listed in DSM-IV. Accordingly, to be diagnosed with PTSD, an individual must have one or more symptom within the first category, three or more in the second category, and two or more within the third category.

Procedure

In December 1999, contact information for career missionaries who returned to North America during 1999 was obtained from Wesleyan World Missions. At the beginning of January 2000 the questionnaire, response sheet, and response card were mailed to the members of the sample along with a letter explaining the nature of the study, including it's goals, risks, and benefits. Individuals were assured that their participation was voluntary and confidential. When response sheets were received, the data was transferred from the response sheets to a computerized database for analysis.

RESULTS

Demographic Characteristics

All 31 missionaries completed and returned the questionnaire, for a return rate of 100%. The sample consisted of 18 females (58%) and 13 males (42%). Two (6.5%) were under age 35; 21(67.7%) were between 35 and 50 years of age; and 8 (25.8%) were between 51 and 65 years of age. Five (16%) missionaries were unmarried and 26 (84%) were married. All 26 married missionaries reported having their children living with them on the field at some point.

Three (10%) missionaries reported having received some type of stress management training, whereas 28 (90%) reported no such training. Given the high levels of stress common to missionary life and the high levels of exposure to trauma found in this research, such low levels of stress management training are noteworthy.

Due to the small sample, statistically significant differences between various demographic groupings, other than gender groups, could not be calculated.

Traumatic Exposure

From the data it is possible to determine the percentage of missionaries who were exposed to trauma: (a) at some point during their lifetime, (b) at some time when they were not on the field, (c) at some time while on the field, and (d) during their most recent year on the field. The percentage of missionaries exposed to specific types of traumatic events for each of these time periods can also be calculated.

Lifetime traumatic exposure. Twenty-nine (94%) missionaties reported exposure to at least one traumatic experience in their lifetime. Of those reporting exposure, 25 (86%) reported exposure to multiple incidents. The least number of incidents reported was 0 (by two respondents) and the greatest number of incidents reported was 32+. The median number of incidents reported was 7 with a mean of 8.48+ incidents. (1)

The most common traumatic event reported by missionaries was exposure to natural disaster, reported by 16 missionaries (55% of those reporting exposure to some type of incident). On the other extreme, none of the missionaries reported exposure to sexual assault.

Although males and females were equally likely to be exposed to a traumatic event in their lifetime, men were found to be 5.56 times as likely as women to have been exposed to "life endangerment" (95% confidence interval = 1.16-25.0). A summary of the lifetime trauma prevalence of missionaries in the sample is presented in Table 1. (In this report odds ratios are used to compare between groups. In an odds ratio, if the 95% confidence interval is completely above or below 1.00, then the difference is significant at a probability level of 0.05.)

Non-Field traumatic exposure. Twenty (65%) missionaries reported exposure to at least one traumatic experience that did not occur on the mission field. Of those reporting exposure, 14 (70%) reported exposure to multiple incidents. The least number of incidents reported was 0 (by 11 respondents) and the greatest number of incidents reported was 12+.

Men were 14.29 times as likely to experience a non-field traumatic event than women (95% confidence interval = 1.59-100.00) as well as being 1111 times as likely to experience multiple non-field traumatic event (95% confidence interval = 2.13-100.00). Table 2 gives a summary of the prevalence of non-field traumatic events.

On-Field traumatic exposure. Twenty-nine (94%) missionaries reported exposure to at least one traumatic experience on the mission field. Of those reporting exposure, twenty-four (83%) reported exposure to multiple incidents. The least number of incidents reported was 0 (by 2 respondents) and the greatest number of incidents reported was 20+.

The most common types of traumatic events reported by missionaries to have been experienced on the field were combat/civil unrest/evacuation and violent crime, both types reported by thirteen missionaries (45% of those reporting exposure to some type of incident). On the other extreme, none of the missionaries reported exposure to sexual assault.

No significant differences were observed in the prevalence of exposure to traumatic events on the field between male and female missionaries. A summary of the prevalence of traumatic events experienced by missionaries on the field is presented in Table 3.

Comparison of non-field and on-field traumatic exposure. Missionaries were found to be 7.69 times as likely to experience exposure to a traumatic event while on the field than elsewhere (95% confidence interval = 1.59-33.33). They were also 4.17 times as likely to experience multiple traumas on the field as opposed to elsewhere (95% confidence interval = 1.39-12.50).

Missionaries were 10 times more likely to be exposed to violent crime on the field than anywhere else (95% confidence interval = 2.13-50.00). Missionaries are also more likely to be exposed to combat/civil war/evacuation on the field, though statistical odds cannot be calculated since no missionaries reported such exposure other than on the field. A comparison of the prevalence of trauma exposure on the field with exposure away from the field is given in Table 4.

Most recent year traumatic exposure. During their most recent year spent on the mission field 20 (65%) missionaries reported exposure to at least one traumatic incident and 13 (42%) reported exposure to more than one such incident during the year. No significant differences were observed between male and female missionaries. The prevalence of exposure to specific types of trauma during their most recent year on the field is given in Table 5.

PTSD Symptoms

Two methods can be used for interpreting the scores on the final section of the questionnaire, as explained earlier.

PTSD symptoms using the "cutoff" method. Of the twenty-nine missionaries reporting exposure to trauma on the field, seven (24%) missionaries reported symptoms above the cutoff level at their most difficult period of adjustment. However, since the questionnaire does not identify the duration of symptoms (criterion E), it would not be correct to say that these respondents could be diagnosed with PTSD, but simply that at that point in time they had a level of symptoms necessary for a diagnosis of PTSD.

None of the missionaries reporting exposure to trauma on the field reported current symptoms above the cutoff level. Twelve (41%) reported no current symptoms at all.

PTSD symptoms using the "cluster" method. At their most difficult period of adjustment to trauma experienced on the field, eleven (38%) missionaries reported symptoms above the level necessary for a diagnosis of PTSD using the symptom cluster method. Since the questionnaire does not identify the duration of symptoms (criterion E), it would be incorrect to say that these respondents could be diagnosed with PTSD. All seven respondents who were identified using the cutoff level were also identified using the symptom cluster method.

None of the missionaries reporting exposure to trauma on the field reported current symptoms above the level necessary for a diagnosis of PTSD using the symptom cluster method.

DISCUSSION

Trauma Exposure

Close to 94% of missionaries surveyed reported having been exposed to at least one traumatic event at some time on the mission field, whereas 65% reported exposure some place other than on the mission field. Seventy-seven percent of missionaries reported exposure to more than one traumatic event on the field, with 45% reporting multiple exposure some place other than on the mission field. Sixty-five percent of missionaries reported exposure to a traumatic event during their most recent year spent on the mission field, with 42% reporting exposure to more than one event during the year.

The lifetime prevalence of trauma exposure among Wesleyan missionaries is higher than that found in any study of trauma prevalence in the general population. The highest trauma prevalence found in a general population survey was that of 89.6% in a study of young adults in Detroit (Breslau et al., 1998). Other studies have reported prevalence rates of 84.3% (Vrana & Lauterbach, 1994), 77.6% (Stein et al., 1997), and 69% (Norris, 1992), all less than the rate of 93.6% for Wesleyan missionaries found in this study. During their most recent year on the field 64.5% of Wesleyan missionaries reported having a traumatic experience, while only nine percent of U.S. college students reported a traumatic experience in the space of a year (Vrana & Lauterbach, 1994). The difference between Wesleyan missionaries and the general population is more striking when looking at the prevalence rate of exposure to multiple traumatic events. The study by Stein et al. (1997) showed a multiple exposure rate of 50.4%; the National Comor bidity study reported a multiple exposure rate of 28.8% (Kessler et al., 1995); whereas this study showed Wesleyan missionaries with a multiple exposure rate of 80.7%. Though only 21% of American adults reported exposure to seven or more events (Norris, 1992), well over half (54.8%) of Wesleyan missionaries reported seven or more traumatic incidents.

That the high prevalence of exposure to trauma among Wesleyan missionaries is related to their missionary service is made clear when one compares their exposure to trauma off the field with their exposure on the field. Although all the missionaries in the study have spent less time on the field than they have off the field, they are 7.7 times more likely to have been exposed to a traumatic event on the field (95% confidence interval 1.6-33.3), and 4.2 times as likely to have been exposed to multiple traumatic incidents (95% confidence interval = 1.4-12.5) than when somewhere else.

The Nature of Traumatic Events Experienced by Missionaries

Missionaries' increased risk of trauma exposure appears to be due primarily to an increased risk of exposure to two types of traumatic events. Wesleyan missionaries are ten times as likely to be exposed to violent crime on the mission field as compared with being somewhere else (95% confidence interval = 2.1-50.0). They also have a much higher risk of being exposed to civil unrest or war or evacuation due to such events. None of the missionaries surveyed reported exposure to such events off the mission field, while 42% reported such experiences on the field. Compared with studies of the general North American population, Wesleyan missionaries also appear to be at higher risk for exposure to natural disasters and to have a lower risk of exposure to sexual assault.

Interestingly, the missionaries surveyed reported a higher level of exposure to childhood abuse (22.6%) than American college students (6%; Vrana & Lauterbach, 1994) or adults in Winnipeg (12.18%; Stein et al., 1997) as reported in two studies that assessed this type incident in a manner similar to this research. Since a history of childhood abuse has been associated with higher levels of PTSD due to exposure to subsequent trauma (Kessler et al., 1995, p. 1053), this is a finding that deserves further investigation.

The Extent of PTSD Symptoms in the Missionary Community

It was expected that because of the high levels of everyday stress under which missionaries commonly live (Dodds & Dodds, 1993, 1997), they would have few reserves upon which to draw to cope with trauma, and thus exhibit higher levels of PTSD symptoms than comparable populations. The findings of this research suggest that this expectation was not valid.

During the most difficult period of adjustment to their "most stressful experience on the mission field," 24% of missionaries reported symptoms above the cutoff level for a PTSD diagnosis, and 38% reported a level of symptoms necessary for a diagnosis of PTSD using the symptom cluster method. Recognizing that "the most difficult period of adjustment" for many or most of the missionaries would likely be immediately following an incident rather than over a month later as is necessary for a diagnosis of PTSD, the symptom levels are much lower than one might expect. By comparison, 75% of Korean-American victims of the Los Angeles riots reported symptoms diagnosable as PTSD four months following the event (Kim-Goh, Suh, Blake, & Hilley-Young, 1995); 34.4% of motor vehicle accident victims reported symptoms diagnosable as PTSD one month after the event (Ursano et al., 1999); 76.1% of female assault victims reported a similar level of symptoms two weeks after the assault (Zoellner, Foa, & Brigidi, 1999); and 94% of sexual assault victims reported symptoms at a level necessary for a diagnosis of PTSD one to two weeks post-assault (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992).

Equally noteworthy was the finding that the missionaries surveyed reported relatively few current PTSD symptoms. None reported current symptoms at a level necessary for a diagnosis of PTSD. In fact, none met either criterion C (i.e., numbing symptoms) or criterion D (i.e., arousal symptoms), whereas only 9.7% met criterion B (i.e., reexperiencing symptoms). Remarkably, 72.4% of missionaries reported not to have experienced any of the seventeen symptoms at a level of moderate or above during the past month. Considering missionaries' high level of exposure to trauma and the current prevalence of PTSD in the general population of 4% (Bernat et al., 1998) to 6.2% (Norris, 1992), such low symptom levels must be considered unusual.

The reasons for the seeming greater resilience of missionaries cannot be determined from this research, but some possibilities may be suggested. It is possible that constantly living under high levels of stress has caused missionaries to develop ways of coping that are different from those which are common within the general population of North America. Carr (personal communication, July 11, 2000), a psychologist who works with missionaries in crisis situations, noted about the missionaries with whom she has worked, "that because of their exposure to stressful situations (a la stress inoculation theory) they have developed more resilience and hardiness than the average American."

Another factor that could lead to a lower report of symptoms is that missionaries can be assumed to have chosen their career with some level of understanding of the potential dangers involved. Traumatic events do not take them fully by surprise. They are anticipated. That in essence makes them, to some degree, "master of their fate" and in turn could create a higher level of determination and resilience in the face of trauma.

Missionaries generally are people who have demonstrated a high level of religious commitment by their decision to pursue missionary careers. The limited research on the impact of religious faith on trauma indicates that religious faith may have a buffering effect from the negative effects of trauma (Card, 1987; Kulka et al., 1990; Nixon, Schorr, Boudreaux, & Vincent, 1999) and that faith-based resources may be helpful in dealing with such events (Drescher & Foy, l995; Jamieson, 1999; Nixon et al., 1999; Pargament, 1997; Pargament et al., 1990, 1992, 1994; Weaver, Koenig, & Ochberg, 1996; Wilson & Moran, 1998). It may well be that the high level of religious commitment of missionaries gives them some protection against the impact of trauma as well as providing them with spiritual resources for handling the emotional and mental disruption trauma brings. This may be especially so when missionaries view exposure to trauma as an extension of their commitment to serve God in a missionary vocation.

On the other hand, it may be that missionaries may underreport PTSD symptoms in an effort to deny emotions inconsistent with their concept of spirituality. In that case, it may be that missionaries actually experience a greater number of PTSD symptoms than this research suggests, but that the symptoms have been suppressed or denied.

The findings of this study should not be interpreted to suggest that following exposure to traumatic events missionaries do not need debriefing, counseling, or some other form of psychological intervention. Even if symptom levels are as low among missionaries as this research suggests, efforts to identify and treat such symptoms as they appear are important. Carr's (1994) assertion that "any missionary who experiences any type of trauma should receive an immediate response which is designed to enhance his or her coping and to prevent the development of stress-related illnesses" (p. 136) is appropriate.

Limitations

Findings of this study should be generalizable to career missionaries serving with Wesleyan World Missions with a fair degree of confidence. Since short-term personnel are not included in the sample, generalization of the findings to persons serving for periods of less than two years cannot be made with confidence. Generalization to missionaries beyond Wesleyan World Missions should only be done with caution since variables with possible impact on the findings such as mission ministry focus, geographic focus of the mission, mission support structures, prefield training, and missionary qualifications will vary from agency to agency.

Recommendations For Further Research

As introductory exploratory research, this project raises more questions than it answers. Further research is recommended in several areas.

First, this research has been limited by its focus on a single mission agency and by its use of a small sample. For example, a larger sample would have made it possible to analyze the findings based on ministry assignment, geographic area of service, length of service, and marital status. Similar research with other agencies and larger samples would be helpful in making it possible to generalize the findings to the broader missions community.

A helpful approach in further research would be to make use of a comparison sample of national people from the country or countries in which the missionaries are serving. Differences (or lack thereof) between missionaries and nationals in trauma exposure and reported PTSD symptoms could help in interpreting the findings of this study.

One of the surprising findings of this research is that the missionaries surveyed reported amazing low PTSD symptom levels considering the level of trauma exposure. Further research to identify variables responsible for the low symptom levels would be helpful indeed. It would be helpful to make use of a clinical evaluation rather than a self report measure in assessing symptoms to try to ascertain if the low report of symptoms may have in fact been in part due to a denial coping strategy.

Similarly, noting that missionaries seemingly have developed adaptive strategies to cope with high levels of chronic stress and trauma, research to identify the components of such strategies could be of great benefit. Particular attention should be given to the ways and degree to which missionaries utilize religious coping strategies identified in research conducted by Pargament and others (Pargament, 1997; Pargament et al., 1990, 1992, 1994).

Critical Incident Stress Debriefing (CISD) has been highly recommended in the literature for use with missionaries in the wake of trauma (Carr, 1994, 1997; Jensma, 1999). However, research into the effectiveness of CISD has produced results that are hard to interpret, with some research suggesting CISD has a beneficial impact, others reporting no effect, and still others indicating a negative outcome. Further research into the effectiveness of crisis intervention strategies with missionary populations would be very helpful.

The nature of trauma is such that the ripple effect from a traumatic event can touch the lives of many people. Anecdotal evidence suggests that at times those hit by the ripples feel a greater impact from the trauma than the person who experienced the trauma directly. Further research into the impact of traumatic events on family members and coworkers of a missionary who has gone through a traumatic event would be beneficial.

A further surprising finding of this research was the high level of exposure to childhood abuse reported by missionaries in the sample. Further research should be done to verify if this is in common in missionary populations, and if so what the implications are for missionaries and mission agencies.

Table 1

Lifetime Prevalence of Traumatic Events

                            All missionaries              Women
                                (n = 31)                 (n =18)

Type of traumatic
event                    n          %             n          %

Combat/civil unrest     13        41.94           9        50.00
Fire/explosion           4        12.90           2        11.11
Serious accident        10        32.26           4        22.22
Natural disaster        16        51.61          10        55.56
Violent crime           14        45.16           8        44.44
Childhood abuse          7        22.58           5        27.78
Sexual assault           0         0.00           0         0.00
Abusive relationship     3         9.68           1         5.56
Witness injury/killing   6        19.35           2        11.11
Life endangerment       12        38.71           4        22.22
News of injury/death     8        25.81           5        27.78
Other trauma            13        41.94           6        33.33
All types of trauma     29        93.55          17        94.44
Multiple traumas        25        80.65          13        72.22

                                Men                Men vs. Women
                              (n = 13)
                                                          95%
Type of traumatic                            Odds     Confidence
event                    n          %       ratio      interval

Combat/civil unrest      4        30.77      0.44     0.10-2.00
Fire/explosion           2        15.38      0.69     0.18-12.50
Serious accident         6        46.15      3.03     0.63-14.29
Natural disaster         6        46.15      0.68     0.16-2.86
Violent crime            6        46.15      1.08     0.26-4.55
Childhood abuse          2        15.38      0.47     0.08-2.94
Sexual assault           0         0.00       **          **
Abusive relationship     2        15.38      3.13     0.25-33.33
Witness injury/killing   4        30.77      3.57     0.54-25.00
Life endangerment        8        61.54      5.56 *   1.16-25.0 *
News of injury/death     3        23.08      0.78     0.15-4.00
Other trauma             7        53.85      2.33     0.54-10.00
All types of trauma     12        92.31      0.70     0.04-50.00
Multiple traumas        12        92.31      4.55     0.05-50.00

* p<0.05

** cannot be calculated

Table 2

Prevalence of Traumatic Events not Occurring on the Mission Field

                            All missionaries              Women
                                 (n=31)                   (n=18)

Type of traumatic
event                    n          %            n           %

Combat/civil unrest      0         0.00          0          0.00
Fire/explosion           2         6.45          0          0.00
Serious accident         5        16.13          0          0.00
Natural disaster         9        29.03          4         22.22
Violent crime            2         6.45          2         11.11
Childhood abuse          7        22.58          5         27.78
Sexual assault           0         0.00          0          0.00
Abusive relationship     0         0.00          0          0.00
Witness injury/killing   2         6.45          0          0.00
Life endangerment        5        16.13          1          5.56
News of injury/death     5        16.13          2         11.11
Other trauma             5        16.13          2         11.11
All types of trauma     20        64.52          8         44.44
Multiple traumas        14        45.16          4         22.22

                                Men                Men vs. Women
                               (n=13)
                                                           95%
Type of traumatic                            Odds      Confidence
event                    n          %        ratio      interval

Combat/civil unrest      0         0.00       **           **
Fire/explosion           2        15.38       **           **
Serious accident         5        38.46       **           **
Natural disaster         5        38.46      2.17      0.45-11.11
Violent crime            0         0.00       **           **
Childhood abuse          2        15.38      0.47       0.08-2.94
Sexual assault           0         0.00       **           **
Abusive relationship     0         0.00       **           **
Witness injury/killing   2        15.38       **           **
Life endangerment        4        30.77      7.69      0.73-100.0
News of injury/death     3        23.08      2.38      0.34-16.67
Other trauma             3        23.08      2.38      0.34-16.67
All types of trauma     12        92.31     14.29 *    1.59-100. *
Multiple traumas        10        76.92     11.11 *    2.13-100. *

* p<0.05

** cannot be calculated

Table 3

Prevalence of Traumatic Events Occurring on the Mission Field

                            All missionaries              Women
                                 (n=31)                   (n=18)

Type of traumatic
event                    n          %             n          %

Combat/civil unrest     13        41.94           9        50.00
Fire/explosion           3         9.68           2        11.11
Serious accident         8        25.81           4        22.22
Natural disaster        12        38.71           7        38.89
Violent crime           13        41.94           7        38.89
Sexual assault           0         0.00           0         0.00
Abusive relationship     3         9.68           1         5.56
Wirness injury/killing   5        16.13           2        11.11
Life endangerment       10        32.26           4        22.22
News of injury/death     5        16.13           4        22.22
Other trauma            11        35.48           5        27.78
All types of trauma     29        93.55          17        94.44
Multiple traumas        24        77.42          13        72.22

                                Men                Men vs. Women
                               (n=13)
                                                          95%
Type of traumatic                           Odds       Confidence
event                    n          %       ratio       interval

Combat/civil unrest      4        30.77     2.00       0.44-9.10
Fire/explosion           1         7.69     1.50       0.12-18.54
Serious accident         4        30.77     0.64       0.33-1.85
Natural disaster         5        38.46     1.02       0.24-4.41
Violent crime            6        45.15     0.74       0.18-3.15
Sexual assault           0         0.00      **            **
Abusive relationship     2        15.38     0.32       0.03-4.01
Wirness injury/killing   3        23.08     0.42       0.06-2.95
Life endangerment        6        46.15     0.33       0.07-1.58
News of injury/death     1         7.69     3.43       0.34-34.99
Other trauma             6        46.15     0.45        0.1-2.01
All types of trauma     12        92.31     1.42       0.08-24.95
Multiple traumas        11        84.62     0.47       0.08-2.93

** cannot be calculated

Table 4

Comparison of the Prevalence of Exposure to 'Frauma: On the Field vs.
Away from the Field

                               Nonfield             On the field
                                (n=31)                 (n=18)

Type of traumatic
event                    n            %        n          %

Combat/civil unrest      0           0.00     13        41.94
Fire/explosion           2           6.45      3         9.68
Serious accident         5          16.13      8        25.81
natural disaster         9          29.03     12        38.71
Voilent crime            2           6.45     13        41.94
Sexual assault           0           0.00      0         0.00
Abusive relationship     0           0.00      0         0.00
Witness injury/killing   2           6.45      5        16.13
Life endangerment        5          16.13     10        32.26
news of injury/death     5          16.13      5        16.13
Other trauma             5          16.13     11        35.48
All types of trauma     20          64.52     29        93.55
Multiple traumas        14          45.16     24        77.42

                            Field vs. nonfield

                                        95%
Type of traumatic       Odds         Confidence
event                   Ratio         interval

Combat/civil unrest      **              **
Fire/explosion           1.56        0.24-10.00
Serious accident         1.81        0.52-6.25
natural disaster         1.54        0.53-4.55
Voilent crime           10.00 *      2.13-50.00 *
Sexual assault           **              **
Abusive relationship     **              **
Witness injury/killing   2.78        0.50-16.67
Life endangerment        2.63        0.77-9.09
news of injury/death     1.00        0.26-3.85
Other trauma             2.86        0.85-10.00
All types of trauma      7.69 *      1.59-33.33 *
Multiple traumas         4.17 *      1.39-12.50 *

* p<0.05

** cannot be calculated

Table 5

Prevalence of Exposure to Traumatic Incidents During Missionaries' Most
Recent Year on the Field

                             All missionaries                Women
                                 (n = 31)                   (n = 18)

Type of traumatic
event                    n            %             n            %

Combat/civil unrest      2           6.45           2          11.11
Fire/explosion           2           6.45           2          11.11
Serious accident         5          16.13           2          11.11
Natural disaster         7          22.58           4          22.22
Violent crime            6          19.35           3          16.67
Sexual assault           0           0.00           0           0.00
Abusive relationship     0           0.00           0           0.00
Witness injury/killing   3           9.68           1           5.56
Life endangerment        2           6.45           1           5.56
News of injury/death     1           3.23           1           5.56
Other trauma             6          19.35           2          11.11
All types of trauma     20          64.52          12          66.67
Multiple traumas        13          41.94           7          38.89

                                 Men                 Men vs. Women
                               (n = 13)
                                                            95%
Type of traumatic                             Odds       Confidence
event                   n             %       ratio       interval

Combat/civil unrest     0           30.77      **            **
Fire/explosion          0            7.69      **            **
Serious accident        3           30.77     0.42       0.06-2.95
Natural disaster        3           38.46     0.95       0.17-2.95
Violent crime           3           46.15     0.67       0.11-3.99
Sexual assault          0            0.00      **            **
Abusive relationship    0           15.38      **            **
Witness injury/killing  2           23.08     0.32       0.03-4.01
Life endangerment       1           46.15     1.03       0.04-12.43
News of injury/death    0            7.69      **            **
Other trauma            4           46.15     0.28       0.04-1.85
All types of trauma     8           92.31      125       0.28-5.53
Multiple traumas        6           84.62     0.74       0.18-3.15

** cannot be calculated

(1.) Note that the instrument asked respondents to specify if a specific type of incident had occurred once, twice, or three or more times, and that when a response of "three or more" was given, for statistical purposes it was treated as three occurrences

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AUTHOR

BAGLEY, ROBERT W. Address: P.O. Box 3457, Dalview 1544, South Africa. Title: Southern Africa Mission Director, Wesleyan World Missions. Degrees: BA, Southern Wesleyan University; MA, Columbia International University; PhD, Trinity International University. Specializations: Intercultural education; higher education administration; leadership development; missionary member care.

Requests for reprints may be sent to Robert W. Bagley, PhD, P.O. Box 3457, Dalview 1544, South Africa.