Mental and Emotional Self-Care for the Cross-Cultural

Medical WorkerJWRichardson MD

GMHC 2014Nothing to Disclose

Abstract and ObjectivesCross-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.

Objectives:1- Participants will be able to describe the main sources of challenge to mental health of cross-cultural medical workers2- Participants will be able to describe at least three cognitive-behavioral strategies that can be utilized to improve mental self care

Objective 1: Participants will be able to describe the main sources of challenge to mental health of cross-

cultural medical workersCognitive Strategy.

-Specifically know the sources of challenge

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

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”

Most recent study:Stresses now are much the same as per Gish but different ranking-Foyle 991-Occupational stress was #1 in the 1990s2-Marital3-Singleness4-Parental5-Home country6-Child-education related7-Acculturation8-Re-entry stress

Occupational Stress-Foyle 99The work itself-overload-technical problems-professional isolationWorking environment-working conditionsWorking relationships-leadership (national and expat)-colleagues

Marital Stress Dual career familiesThe role of spouses (often wives)

Singleness Stress- loneliness

Re-entry stressTemporary home leavePermanent re-entry Foyle-99

Foyle, M et al. Expatriate Mental Health. Acta Psychiatr Scand 97(4):278-283. Apr 1998

Confirmed that highest risk of major 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.

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

Main challenges to medical missions work1. Not enough qualified workers2. Poor cooperation with the local system, bureocracies, and

ineffective systems3. Not enough money or equipment4. Lack of strategy to guide medical mission work5. Lack of support from their organization6. No plan for sustainability

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

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

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…….

Cognitive Strategy- Know the Consequences

The cost of not caring for oneselfThe 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.

Major Depression or Adjustment Depression, or Burnout:Consequences in every domain of life

•Spiritual•Social•Psychological•Physical

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 solutionsMarjory Foyle MD- “Holidays”

= know you are human and act like it.That is who God created you to be!

“A good doctor is a good person.” So asserted philosopher Jacob Needleman In The Way of thePhysician, [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

Shanafelt et al categorized factors in several domains that can assist in our rediscovery:

STRATEGIES1.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

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.com bonnie@crossculturalworkers.com • http://www.crossculturalworkers.com/ sensitive areas• http://www.missionarycare.com/ open areas

Three proven strategies for mental and emotional health self-care

1.Challenge your assumptions2.Schedule your priorities.3.Accountably commit to action

Three proven strategies for mental health self care for cross-cultural medical workers

1. Challenge your assumptions

2. Schedule your priorities -Love God motivationally, emotionally, physically, and cognitively -Love your neighbor as yourself -Love yourselfLoving 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

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 admired for your work? Doc or Him?• Works witness or grace witness?

“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.”

• 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.

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.

Cognitive Strategy

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.

What is most important? Priority 1

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?

•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.”

• “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

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

#1 Action: Schedule your relationship with God

• 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

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.

What is second most important?

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.

Your social support system is one of the most important factors in maintaining your health, both

physical and mental.

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

# 2 Action: Schedule time 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

#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)

•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

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).

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]

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.

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)

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)

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.

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.

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.

• 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.

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

Discussion

Inspiration or Deflation?

Evaluation of your thoughtful care for yourself Use the following scale to rate some of the things we have talked about:

4 = Excellent (Always) 3 = Good (Frequently) 2 = Fair (Sometimes) 1 = Poor (Seldom) 0 = Absent (Never)

1. Do I keep an effective rest for myself each week (a day I devote to doing something that refreshes me)? 4 3 2 1 0

2. Do I get enough sleep so that I am not sleepy the next day?4 3 2 1 0

3. Do I exercise to the point of perspiration 20-30 minutes 3-5 times a week?

4 3 2 1 0

4. Do I eat moderate portions of healthy foods 3-5 times a day?4 3 2 1 0

5. Do I monitor my health and seek appropriate medical help promptly?

4 3 2 1 0 6. Do I have enough consistent nurturing relationships with other people?

4 3 2 1 0

• If you rated yourself at two or lower on any of the above, you would do well to seriously consider improving your stewardship. • Even ones rated at three can be improved.

Accountably commit to act.

Resources • Foyle, M et al. Expatriate Mental Health. Acta Psychiatr Scand 97(4):278-

283. Apr 1998• PRISM – CMDA CMDE• Physicians’ Well-being and Safety: It’s Not All About Sleep

Paul 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

• The well-being of physicians . Shanafelt T , Sloan J , Habermann T .. Am J Med . 2003;114(6):513–517

• Religion, Spirituality, and Medicine: Application to Clinical Practice Harold G. Koenig, MD JAMA. 2000;284(13):1708. doi:10.1001/jama.284.13.1708-JMS1004-5-

• Mental Health Resources for Cross Cultural Workers Ron and Bonnie Koteskey, 122 Lowry Lane, Wilmore, Kentucky 40390, USA Phone: 859-858-3436 http://www.crossculturalworkers.com/

Resources • Mental Health Resources for Cross Cultural Workers

Ron and Bonnie Koteskey, 122 Lowry Lane, Wilmore, Kentucky 40390, USA Phone: 859-858-3436 ron@crossculturalworkers.com bonnie@crossculturalworkers.com • http://www.crossculturalworkers.com/ sensitive areas• http://www.missionarycare.com/ open areas• http://www.crossculturalworkers.com/index_stewardship.htm• http://www.crossculturalworkers.com/index_ought_to_know.htm

Stewardship of Self for Cross-Cultural Workers:General Principles• Study the Bible and the World • The Internet has much information available free of charge• Good books are available• Study yourself and others

• the capacity to learn about yourself and solve many of your problems by observing yourself and others

• Train up the child within• Self-control is aided by monitoring our own behavior and by rewarding

ourselves immediately and effectively for healthy behaviors. • Similarly, we can cope with unhealthy behaviors by substituting healthy

behaviors and reinforcing those.

• Tell the truth in love • Confessing and confronting, being both humble and assertive, expressing

both the negative and positive• On the one hand, cross cultural workers need to be humble and vulnerable,

admitting our mistakes, faults• On the other hand, cross cultural workers need to be able to set boundaries

with others

• Choose to act on your problems• Intentionally make conscious decisions to do something about your struggles

and problems. • A public commitment to work on them along with regular reminders to

yourself will make it more likely that you will actually do something about them.• Find ways to remind yourself about your commitment to work on that

problem

• A time for everything• Moderation can merge optimism and pessimism into a healthier realism. • Of course love is appropriate, but so is anger when appropriately expressed.

Likewise joy and elation are appropriate, but so are sadness and grief in some circumstances. • Denied emotions lead to problems• Moderation does not mean you are emotionless, just that your sadness is

moderated by joy, and so forth. • We are to be moderate not only in the experience and expression of emotion

but also in our thoughts and lifestyles.

• Health to the whole body• A balanced diet is essential for good physical and mental health• Having adequate sleep is important to our physical and mental health

• Fellowship• Research has repeatedly shown that the single most important factor in

dealing with stress is social support• Some cultures, such as the one in the United States, emphasize individuality

at the expense of the group• Within our larger group of acquaintances we need a smaller circle of close

friends with whom we can share much more deeply

• Bear your own burdens: Remember• We also need to encourage ourselves when we do the right things. • If other people are not around to provide that support, we need to “coach”

and “reward” ourselves for healthy behaviors. • We also need to confront ourselves when we do wrong. • Perhaps this is part of being responsible, to the degree we can be

• Use resources at hand• Use your natural gifts and experiences so that you can make use of the

materials around you.• Use things with which you are familiar

• Keep the vision• As we often say today, “One picture is worth a thousand words.” • Therefore, selecting a metaphor or analogy that fits your struggle, one that

provides hope and guidance, is often helpful

Conclusion: Three strategies for mental health self care for cross-cultural medical workers

1. Challenge your assumptions

2. Schedule your priorities• love God motivationally, emotionally, physically, and cognitively • love your neighbor as yourself• Love yourselfLoving 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