Mental and Emotional Self-Care for the Cross-Cultural Medical Worker

1. Mental and Emotional Self-Care for the Cross-Cultural Medical Worker JWRichardson MD GMHC 2014 Nothing to Disclose

2. Abstract and Objectives Cross-cultural medical workers are under multiple levels of stress peculiar to their professional roles. They often serve as mental health resources to colleagues and other cross-cultural workers, have difficulty limiting the hours of work with minimal reprieve for rest and restoration. This session will focus on cognitive and behavioral tools that can improve mental and emotional self-care.

3. Objectives: 1- Participants will be able to describe the main sources of challenge to mental health of cross-cultural medical workers 2- Participants will be able to describe at least three cognitive-behavioral strategies that can be utilized to improve mental self care

4. Objective 1: Participants will be able to describe the main sources of challenge to mental health of cross-cultural medical workers Cognitive Strategy. -Specifically know the sources of challenge

5. Primary Sources of Mental Health Challenges of Cross Cultural Medical Workers • Those common to all cross cultural workers • Gish • Foyle • Those unique to cross cultural medical workers • PRISM • Other sources

6. Sources of Missionary StressDorothy Gish in 1970s 1-Confronting others when necessary 2-Other missionaries 3-Separations, transitions, rootlessness 4-Cultural adjustments 5-Physical stress and risk 6-Spiritual problems 7-Administrative and organizational problems 8-Developmental and accumulated “bruises” and “baggage” 9-Avalanche of Change 10-Choice, choice, choice 11-Not enough “No”s 12-Pretending/Masks- “the search for the real self”

7. Most recent study:Stresses now are much the same as per Gish but different ranking-Foyle 99 1-Occupational stress was #1 in the 1990s 2-Marital 3-Singleness 4-Parental 5-Home country 6-Child-education related 7-Acculturation 8-Re-entry stress

8. Occupational Stress-Foyle 99 The work itself -overload -technical problems -professional isolation Working environment -working conditions Working relationships -leadership (national and expat) -colleagues

9. Marital Stress Dual career families The role of spouses (often wives) Singleness Stress- loneliness Re-entry stress Temporary home leave Permanent re-entry Foyle-99

10. Foyle, M et al. Expatriate Mental Health. Acta Psychiatr Scand 97(4):278-283. Apr 1998 Confirmed that highest risk ofmajor depression among returning missionaries and depression associated morbidity is family history of depression or prior personal history of depression (1999) Missionaries without these risk factors often have adjustment disorder depression.

11. Primary Sources of Mental Health Challenges of Cross Cultural Medical Workers: Unique to medical workers? • Other references • PRISM

13. Main challenges to medical missions work • Not enough qualified workers • Poor cooperation with the local system, bureocracies, and ineffective systems • Not enough money or equipment • Lack of strategy to guide medical mission work • Lack of support from their organization • No plan for sustainability

14. Anxiety 50-60% of medical missionaries endorsed 4-5 on a 0-5 scale level of anxiety • Duration not identified • Direct consequences not stated • Could reasonably be expected to reduce quality of life and productivity at times

15. Depression 30% in all areas but Europe and North America endorsed 4-5 on a 0-5 scale of depression • Duration not specified • Consequences not specified • Could reasonably be expected to reduce quality of life and productivity at times

16. Other: Unique to cross cultural medical workers • Changing practice when resources limited • Medical language communication barriers • Different support systems- labs, imaging… • Different human support systems- nurses, medical assistance, pharmacy • Different role expectation- authoritarian vs collaborative model • Primary MD to other Ms • Primary MD to family • Etc. etc…….

17. Cognitive Strategy- Know the Consequences The cost of not caring for oneself The findings are clear: Physicians who are neither fatigued nor distressed provide safer patient care and are less likely to injure themselves. West C, Tan A, Shanafelt T. Association of resident fatigue and distress with occupational blood and body fluid exposures and motor vehicle incidents. Mayo Clin Proc. 2012; 87(12):1138-1144. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306(9):952-960.

18. Major Depression or Adjustment Depression, or Burnout:Consequences in every domain of life • Spiritual • Social • Psychological • Physical

19. Objective 2: Participants will be able to describe at least three cognitive-behavioral strategies that can be utilized to improve mental self care. Cognitive Strategy: Know some specific personal solutions Marjory Foyle MD- “Holidays” = know you are human and act like it. That is who God created you to be!

20. “A good doctor is a good person.” So asserted philosopher Jacob Needleman In The Way of the Physician, [1985]he elaborated that “the qualities of a good physician are inseparable from the qualities . . . of a real and authentic human being”(p 83) and “the meaning of being a physician can only be recovered through a rediscovery . . . of the meaning of human life itself, the meaning of being alive.”3(p xiii) Physicians’ Well-being and Safety: It’s Not All About SleepPaul H. Rockey, MD, MPH,Accreditation Council for Graduate Medical Education,515 N State St, Ste 2000, Chicago, IL 60654 (prockey@acgme.org). Mayo Clinic Proceedings Volume 87, Issue 12 , Pages 1135-1136, December 2012

21. Shanafeltet al categorized factors in several domains that can assist in our rediscovery: STRATEGIES 1.relationships: spending time with our family, friends, and significant others; 2. religious beliefs/spiritual practices: attending to and nurturing our spirituality; 3. self-care practices: actively cultivating our personal interests and self-awareness through, for example, reading, exercise, and self expression; adequate sleep, nutrition, and regular medical care are essential, although we often think these needs only apply to our patients; and 4. life philosophy: developing and maintaining a positive philosophic approach to life that engages our values, Including finding a balance between our personal and professional lives. Shanafelt T , Sloan J , Habermann T . The well-being of physicians . Am J Med . 2003;114(6):513–517

22. A Best Source- used freely with permission • Mental Health Resources for Cross Cultural Workers Ron and Bonnie Koteskey, 122 Lowry Lane, Wilmore, Kentucky  40390, USA   Phone: 859-858-3436 ron@crossculturalworkers.combonnie@crossculturalworkers.com • http://www.crossculturalworkers.com/sensitive areas • http://www.missionarycare.com/ open areas

23. Three proven strategies for mental and emotional health self-care • Challenge your assumptions • Schedule your priorities. • Accountably commit to action

24. Three proven strategies for mental health self care for cross-cultural medical workers • Challenge your assumptions • Schedule your priorities -Love God motivationally, emotionally, physically, and cognitively -Love your neighbor as yourself -Love yourself Loving ourselves means at least the following: A. Setting aside some time for yourself B. Thinking correctly about yourself (your self- talk, as a person made in God’s image) C. Generally taking care of God’s temple (our bodies) 3. Accountably commit to action

25. Cognitive strategy #1: Challenge assumptions • “A Christian doctor/dentist should be the best doctor/dentist in the group” • “I’m responsible for it all” vs. “He’s responsible for it all.” • “I’d rather burn out than rust out” • “I must sacrifice it all for Him” • “If I don’t do it no one will do it.” • “If I fail am I failing God? [or is God failing me?] The Insanity of God Nik Ripken • “What will they think…..?” • Etc. etc….. • Who is it that is admiredfor your work? Doc or Him? • Works witness or grace witness?

26. “What do you do when there are so many things to do, and not enough people to do them, and there’s no way to prioritize because everything’s a priority? This seems like a no-win situation and can lead to quick burnout. Because of such a high level of ministry responsibilities on the field, there’s no time for rest, renewal, or recreation, much less trying to be proactive and keep the body in shape, or to have quality time with the family.”

27. In this one paragraph the cross-cultural worker has touched on the most important factors relating to maintaining your mental and physical health. • Let us consider what we can do by considering our priorities.

28. Cognitive Strategy • Schedule your priorities. • The cross-cultural worker was right in talking about priorities. • Some people may tell you to “prioritize your schedule,” but it is much more important to “schedule your priorities.” • When you prioritize your schedule, you constantly feel under great stress, but you may accomplish little of lasting value. • You may become one who is constantly putting out fires, rather than preventing the fires in the first place. • Prevention is better than cure.

29. What is most important? Priority 1  1- Love God motivationally, emotionally, physically, and cognitively Jesus was asked this question in Mathew 22 when an expert in the law asked him which commandment was the greatest. Jesus told him to love God with all his heart, soul, and mind. Of course, Jesus was quoting Deuteronomy 5 where Moses had told the people to love God with all their soul, heart, and strength. The command to love God motivationally, emotionally, physically, and cognitively has been around for centuries, and it is still valid today.

30. You may say that this command is certainly relevant to your spiritual condition, but What does it have to do with your mental and emotional health?

31. Consider the following quotes from an article by Harold Koenig in the Journal of the American Medical Association in October, 2000. • “More than 850 studies have now examined the relationship between religious involvement and various aspects of mental health. • Between two thirds and three quarters of these have found that people experience better mental health and adapt more successfully to stress if they are religious.”

32. “An additional 350 studies have examined religious involvement and health. The majority of these have found that religious people are physically healthier, lead healthier lifestyles, and require fewer health services. • The magnitude of the possible impact on physical health—particularly survival—may approximate that of abstaining from cigarette smoking, or adding 7 to 14 years to life.” Harold Koenig in the Journal of the American Medical Association in October, 2000

33. #1 Action:Schedule your relationship with God The best thing you can do to maintain your mental and physical health is to place your relationship with God on your schedule first. This should be time for at least the following: -Spending time with him -Talking with him in prayer -Listening to him through meditating on his Word -Seeking forgiveness and reconciliation

34. Like today’s cross-cultural workers, Daniel lived and worked in a culture different from the one in which he was reared. • With his packed schedule of doing an outstanding job as one of the three top administrators in the nation, one might think that Daniel would not have much time for God. • However, his custom was to be on his knees thanking God for what he had done and asking for his help three times a day (Daniel 6). • Jesus- prioritized time with The Father

35. What is second most important? • 2- Love your neighbor as yourself. • When asked what was most important in Matthew 22, Jesus went on to say that the second most important was much like it, to love your neighbor as yourself. • Of course, this had also been around for centuries as Jesus was quoting from Leviticus 19. • This is especially relevant for cross-cultural workers as Jesus emphasized in John 13:34-35, that people will know we are his disciples by how we love each other.

36. Your social support system is one of the most important factors in maintaining your health, both physical and mental. This includes a variety of people. The specific persons depend on your situation in life, but probably include some of the following: -Your spouse -Your children and teenagers -Fellow cross-cultural workers -Host country co-workers -Pastor -Aging parents -Etc.

37. When faced with a crisis of life and death proportions, Daniel had a long-term relationship with three other expatriates to whom he could turn to ask for urgent prayers. Their prayers were answered (Daniel 2). Jesus prioritized relationships over work- even healing

38. # 2 Action: Scheduletime with important people To maintain your mental and physical health, place your relationship with fellow Christians as the second thing on your schedule. This should be time for at least the following: -Spending time with them -Talking to them -Listening to them -Seeking forgiveness and reconciliation

39. #3 Actiion: Schedule time for yourself Jesus said we should love our neighbor as we loved ourselves. Like loving God and loving our neighbor, loving ourselves means at least the following: -Setting aside some time for yourself -Thinking correctly about yourself (your self-talk, as a person made in God’s image) (Do you know who you really are? Precious child of God!) -Generally taking care of God’s temple (our bodies)

40. God dwelt in the Tabernacle, then in the Temple, and now dwells in us. • The apostle Paul pointed out that our bodies were the temple of the Holy Spirit so we should honor God with our body (1 Corinthians 6:19-20). • So the question becomes, how are we doing in taking care of God’s Temple? • That includes at least the following: • Eating right • Getting rest • Exercising regularly

41. Eating right. • At creation (Genesis 1) God gave us all the seed-bearing plants and fruit trees to eat—that is grains, vegetables and fruits. • That is very much like the recommendations of the US Department of Agriculture’s food pyramid. • After the Fall when we began eating meat, God put a number of restrictions on what kinds of meat and what parts of the animals we could eat. • As a college student in a culture very different from home, Daniel questioned the food in the cafeteria. • He proposed and conducted an experiment showing that vegetables and water are healthier than rich food and alcohol, an experiment repeated with the same results many times over the centuries (Daniel 1).

42. Getting rest. • God instituted a day of rest in each week in the Ten Commandments (Exodus 20). • This was a day in which no one in the household was to do any work, a day of restoration in each week. • Jesus later pointed out that the Sabbath was made for us, not us for the Sabbath (Mark 2). • New research points out that sleep (rest) is an essential component of a long and healthy life. • Although two kings had difficulty sleeping (Daniel 2 & 4), there is no indication that Daniel ever had that problem even though his circumstances were far more dangerous than those of either king. • Do you think Jesus voluntarily neglected sleep? Jesus wept. Jesus slept. [Remember sleeping on the boat in a storm]

43. Exercising regularly. • Although not mentioned as much as food and rest, Paul wrote that physical training is of some value (not as valuable as godliness, which is valuable for both this life and the next). • When he wrote that, there were not so many “labor saving” devices • so that people got sufficient exercise in the tasks of daily living. • we do not, so it is best for us to schedule exercise in our day. • We have to stretch things somewhat to find an example of exercise in the book of Daniel. • Although we do not recommend walking in fiery furnaces (Daniel 3), we do recommend walking, running, playing your favorite sport, etc. past the point of perspiration for at least a half hour several times a week. • Physical activity was part of Jesus’ life.

44. You may wonder what eating, rest, and exercise have to do with mental health. A. In general psychology research the three major categories that help cope with stress: • Social support (Priority 2) • Aerobic exercise (Priority 3) • Time for relaxation (Priority 3)

45. B. Six characteristics of happy people are that they tend to have the following: • A meaningful faith (Priority 1) • Close friendship or a satisfying marriage (Priority 2) • Good sleep and exercise (Priority 3) • Work and leisure that engage their skills (Priority 3) • High self-esteem (created in God’s image) (Priority 3) • Optimism (based on the reality of Easter) (Priority 1)

46. What is new about all this?Nothing. Just do it! BUT HOW? • For thousands of years people have known these things. • The problem is in doing them.

47. What is new about all this?Nothing. Just do it! BUT HOW? • When the expert in the law asked Jesus about important things in Luke 10, Jesus asked him what the law said, and he replied that one should love God and love your neighbor as yourself. Jesus told him he was right—that he should just go do it. Then, to justify himself the expert asked who his neighbor was. Jesus told the parable of the Good Samaritan, and then he asked the expert who was the neighbor. • Again the expert answered correctly, and again Jesus told him to go and do it. • Like the expert in the law, we know what we should do, we often just do not do it and try to justify our not doing it.

48. Strategy #3 Accountably commit to act Choose to act on your problems, with the God’s help. How to change? Pre contemplative> contemplative> commitment> begin>sustain • Intentionally make conscious decisions to do something about your struggles and problems. • A public commitment [or collaborative private commitment] to work on them along with regular reminders to yourself will make it more likely that you will actually do something about them = a coach a buddy? Even a “virtual” buddy.

49. Find ways to remind yourself [invite others to remind you] about your commitment to work on that problem • Find a symbol e.g a ring, wrist tie, Action Figure etc • Journal: Writing moves from abstract to “real”. • The best way to begin is to find out exactly how you are doing is by recording in a journal each day specifically how you are doing. Some apps can help with this but take time to engage • A brief calendar note is most likely to really get done.

50. Conclusion: strategies for mental and emotional health self care for cross-cultural medical workers • Specifically know the sources of challenge • Know the consequences • Know some specific solutions • Challenge your assumptions • Schedule your priorities • Accountably commit to action