Missionary Outreach Support Services MOSS: A Model for Online Mental Health Consultation

1. Missionary Outreach Support Services (MOSS): A Model for Online Mental Health Consultation  Glen Moriarty, Psy.D. Joanne R. Schwandt December 6, 2005

2. Missionary Outreach Support Services Goal: To provide support and resources to Christian families throughout the world engaged in ministry through online, private, secure, mental health consultation.

3. Benefits and Challenges Benefits: Cost Effective Efficacious Disinhibition effect � freedom to express thoughts openly due to anonymity, invisibility Transcends geographical distance Challenges: Difference in cultures and customs for text-based relationships Technological difficulties Crossing National Boundaries Suler, 2003

4. Ethical Considerations Suitability: client poses a danger to himself history of suicidal, violent, or abusive behavior clients experiencing delusions, hallucinations, life-threatening situations or is abusing alcohol or drugs (Kraus, 2003) Informed consent (APA Ethics code) Limits of confidentiality (APA Ethics code) Liability of Technology (Rosik and Brown, 2001) Transmission, Therapist end, Client end, Legal Subpoena (Manhal-Baugus, 2001) Competency Training in Text-Based Communication (Manhal-Baugus, 2001).

5. Outcome Research Therapeutic alliance can be established through text communication (Cook and Doyle, 2002) Other studies show that it is comparable to f2f treatment: Magaletta, Fagan, and Ax, 1998; Cohen and Kerr, 1998; Barak, 2001 � compiles list of case studies that use text based therapy to treat anxiety, eating disorders, PTSD, panic, recurrent headaches, weight loss Studies also show internet use can both increase and decrease depression (LaRose, Eastin and Gregg, 2001)

6. Missionary Mental Health Missionary: � Any person who works full-time for a religious organization outside the borders of the home country and whose primary purpose is to communicate the gospel as revealed in the Bible (Jones and Jones, 2000) Many articles are theoretical and descriptive Characteristics: - Missionary population tends to worry more than norm population (Dillon, 1983) - High mobility and a variety of intercultural influences (Pollock, 1997) - Lack of Self-disclosure and a Denial of the existence of Stress (Chester, 1983)

7. Missionary Mental Health Missionary Women: Difficulty in balancing familial responsibilities and their ministerial roles (Skelton, 1986) Failure to recognize these roles may lead to low self-image and depression (Bowers, 1985) Increase in women applicants experiencing homosexual encounters (Gardner, Barer, and Kellogg, 1993) Missionary Children: Educational Needs Delayed psychosocial development (Wrobbel,1990) Importance of Family Relationship (Wrobbel and Ludeddemann,1990) Reentry Issues

8. Missionary Mental Health Dorothy Plackett - William Carey�s first wife who suffered from jealous delusions (Beck, 1993) Well-being of missionaries: Interpersonal Relationships Forgetting effects of physical illness Fatigue Professional inferiority Inadequate job descriptions Conflict between professional and spiritual obligations (Foyle, 1985) Spirituality � Related to Family Life Satisfaction (Andrews, 1999) Assessment of spirituality amongst missionaries shows significant problems such as identity, depression, and sexual orientation (Parshall, 1987) Occupational Satisfaction Attrition: - political crises, death in service, retirement, marital or familial difficulties, personal difficulties or in the sending body, adaptation to culture or occupation, lack of support, inappropriate training, lack of calling, commitment or immaturity (Limpic, 1997; Adiwardana, 1997)

9. Missionary Mental Health Stress: The average cross-cultural worker has approximately 600 points of stress per year (Carter, 1999) Five major sources of stress: Confrontation, cross-cultural communication, support maintenance, work overload, work priorities (Gish, 1983) Additional sources of stress: Culture shock, loneliness, depression, familial difficulties (education of children), lack of privacy Indirect hostility as expression of anger incited by stress (Taylor and Malony, 1983) Overall hostility scores lower than the norm population indicating a lack of self-disclosure or the lack of acceptance to express negative emotions (Taylor and Malony, 1983)

10. Missionary Mental Health Culture Shock: �Accumulated stresses and strains which stem from being forced to meet one�s everyday needs . . . In unfamiliar ways� (Whitecotton, 1996) Culture fatigue � eventually become worn down by constant adjustments (Allen, 1986) Precursor to anxiety and depression Specific Mental Health Disorders: Separation anxiety (Bullock, 1973) Post-traumatic Stress Crises that incite trauma (Carr, 1994; Carr, 1997) Elective Mutism (Beck and Hubbard, 1987) Child Molestation and Sexual Abuse (Kellogg and Hunter, 1993) Dissociative Identity Disorder (Rosick and Kilbourne-Young, 1999) Personality Disorders (Schubert, 1993) Traumatic Experiences: Missionaries are often in parts of the world where socioeconomic conditions expose the missionary to poverty, crime and disease (Carr, 1984)

11. Member Care Services Ongoing investment of resources by mission agencies, churches, and other mission organizations for the nurture and development of missionary personnel� (O�Donnell, 1997) Current Services: Candidate Selection Crisis intervention Treatment consultations Counseling on furlough and on location (Hall and Barber, 1996) Missionaries serving in East Africa reported a desire for member care services and a dissatisfaction of the services currently offered (Rosik, Richards, and Fannon, 2005) While member care services are growing, dual role conflicts and difficulty offering timely services to missionaries continue to be a problem.

12. Missionary Outreach Support Services Missionary Outreach Support Services: An Educational consultation website for mental health services Uses Asynchronous communications Utilizes Email as form of online service provision

13. Four Email Exchange Based on principles of motivational interviewing, brief solution-focused therapy and narrative approaches. Four Emails: Build rapport and normalize the problem - Connect, Convey safety, reframe problem as something to be overcome Address the consultation question: - Client has choices, provide self-help techniques - Revisit maintaining factors and circumstances Planning Validate positive changes Formulate plan for after treatment Summarizing Summarize and validate client�s progress - Zelvin and Speyer, 2003

14. Four Email Exchange

15. Four Email Exchange Subject Heading Gains attention Engages client Build Rapport Introduction Introduces Topic Summarizes central issue Focused and Directive Addresses client�s interpretation of problem Body Confrontation and Rapport Summarizing paragraph Encourage and Challenge Condense and Help Client Remember Main Principles

16. Consultation Process 1 . Missionary visits www.missionaryoutreach.net 2. Uses own email or hushmail to express interest in receiving consultation. Consultant receives email and sends missionary demographic form, research link, and informed consent. Missionary fills in relevant information and digitally signs the informed consent. Consultant constructs initial response and discusses response and consultant question with licensed psychologist. Consultant, under the supervision of a licensed psychologist, works with the missionary until the 4-step model is completed or the issue is resolved.

17. Website Overview of Website Questions, Comments, Suggestions? Thank you very much for your time. Please contact me if you are interested in working or collaborating with us. God Bless. glenmor@regent.edu or (757) 226-4341

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