Missionaries Ought to Know About ...
What Missionaries Ought to know about Trauma, PTSD, and CISD
Ronald L. Koteskey
You may look
at this title and say, "I've experienced some traumatic things as a
missionary, but what in the world are PTSD and CISD? Does trauma affect
children like it does adults? What happens to those who help the
traumatized? Is there anything we can do to help prevent serious
problems following trauma?
What is trauma?
People who respond with intense fear, helplessness or horror when
they are confronted with something that involves the threat of death or
serious injury to themselves or others experience trauma. This may be
something people actually experienced themselves or something they
Although this can happen to anyone anywhere in the world in the form
of accident, assault, rape, etc., missionaries in some cultures are more
likely to have such experiences, and less likely to have someone who
knows how to help them at the most crucial time. Missionaries are often
more likely to experience conflicts, such as guerilla warfare, coups,
and evacuations. They may also be more likely to live where natural
disasters, such as typhoons, earthquakes, and volcanic eruptions, occur
frequently. They may also live through epidemics, such as cholera,
typhoid, or malaria. Terrorism, kidnapping, and being held hostage are
more common in mission settings. If missionaries do not experience the
trauma firsthand, they often witness it in national friends.
What is PTSD?
Although nearly everyone living through such events has some symptoms
for a week or two, some have much longer-lasting minor symptoms that do
not interfere with their lives. However, some experiencing severe trauma
develop Posttraumatic Stress Disorder (PTSD), and their symptoms are.
- Re-experiencing the traumatic event in the form of having
recurring images or thoughts, or distressing dreams, feeling as if
the event is happening again, and reacting physiologically to
stimuli associated with the event or similar to the event
- Avoiding things associated with the trauma, such as conversations,
activities, places, people or feeling detached from others, unable
to experience emotions, and unable to remember significant parts of
- Experiencing symptoms of increased arousal, such as being easily
startled, unable to sleep, irritable or angry, and having difficulty
These symptoms may occur immediately or be delayed for months or
years. They may last for a few months or for many years. PTSD has been
called combat fatigue and shell shock when found among the military in
What is CISD?
Critical Incident Stress Debriefing (CISD) is a method of helping
prevent PTSD from developing in someone who has experienced trauma. CISD
is a structured group meeting ideally conducted by a trained
professional between 24 and 72 hours after the crisis. A day is needed
for the shock and numbness to wear off and for the people to rest and
attend to immediate needs. After three days people begin to "seal
off" emotionally and distance themselves from the trauma.
Unfortunately, with airline scheduling problems, needed visas, lack of
funds, etc., trained professionals may not be available within 72 hours,
so those present but not directly involved in the crisis may want to
deal with trying to prevent PTSD. Here are the outlines of a CISD which
usually takes two or three hours.
- Introduction. Explain the purpose of CISD, discuss what will and
will not be held confidential, make sure that only those directly
involved in the crisis are present and that all directly involved
are present, give opportunity for questions, and have prayer
together. (If some do not want to participate, point out to them
that they may not need help, but they may be helpful to others in
- History. If the people involved know each other well, this step
may be omitted. However, if they are not part of an already
established group, having each one briefly give a personal
testimony, family history, personal background (education, work,
marriage, children, happiest times, most stressful times, strengths,
and weaknesses) may be helpful.
- Facts. Ask each member of the group to tell about what happened
and what his or her role was. This may include anything from
watching helplessly as someone died to pulling people from the
wreckage and saving their lives.
- Thoughts. Ask members of the group to give the first thought they
remember after they stopped behaving automatically. It may be
something as simple as worrying about a pet or as complex as
wondering what would happen to their child if they died.
- Reactions. Ask each person to talk at a more emotional level about
his or her experience, perhaps by asking, "What was the worst
part of it for you?"
- Symptoms. Ask members to describe any symptoms they experienced
during and after the event, such as disturbed sleep, lack of
appetite, or poor concentration.
- Spiritual struggles. Experiencing trauma may impact members' faith
in God or concept of God. Indicate that it is safe to report
questions about God. You may want to pray with them, even repeat
some of the Psalms of David as he questioned God.
- Education. Summarize the meeting and note that their symptoms are
normal for anyone who has experienced severe stress; then give them
some techniques to help reduce stress. Tell briefly about PTSD and
note that common reactions to trauma are feelings of anger, anxiety,
denial, depression, guilt, grief, tension, and gastrointestinal
- Referral. Finally, encourage participants who experience
continuing problems to see a mental health professional for CISM
(Critical Incident Stress Management), because you have just given
first aid, not full treatment.
What about children and trauma?
Children are also affected by trauma and need care much like adults.
Parents, teachers, pastors, and friends of the family may be most
helpful to children.
- The presence of supportive loving adults is the greatest need of
traumatized children. Children find the greatest comfort in knowing
that they will not be left alone, that someone will be there for
them whenever needed.
- Children need to be given enough information to comfort them, but
not so many details that it increases the trauma. Always tell
children the truth; covering up the facts leads to distrust later
- Like adults, children need to be able to process what has happened
to them with other children their own age. Also like adults, they
need a facilitator present-a supportive, loving adult.
The general health of the family influences how severely the trauma
will affect the child. Children from dysfunctional families are much
more vulnerable to the effects of traumatic situations.
Does debriefing affect the helpers?
Yes. The debriefers must be debriefed. Leading a debriefing is an
emotionally draining experience, and anyone doing it is very likely to
experience the very symptoms they have heard others describe. They need
some way to process what they have been through themselves, again within
24-72 hours. If not, the debriefers may well experience compassion
fatigue and become cynical themselves.
This does not need to be another full CISD but may be an informal way
to talk through what has happened to them. They should have people
praying for them. They should not schedule other emotionally demanding
events after the debriefing so that they will have time themselves to
debrief. If possible, the debriefers should work in pairs so that they
can get together later and debrief each other.
What can we do to prevent trauma?
Your agency should have contingency plans for potentially
traumatizing situations. Decisions should already be made on such
questions as to whether or not ransom will be paid, who will go to help
people in traumatic situations, who will speak for the mission during
crisis times, and so forth.
You should know how to act to minimize danger. For example, you
should know where flash floods are likely to occur, and avoid those
roads when you see clouds in the mountains. Or how do you tag your
luggage? "Dr. Jonathan Q. Smith, PhD, Executive Director, Important
Mission International" is a much more inviting target for hostage
takers than is "John Smith, 123 The Lane."
You should know what to do if a potentially dangerous situation
occurs. For example, what do you do if an earthquake occurs? Running
from a brick building is not wise. What do you do if you are taken
hostage? Those early minutes of captivity are some of the most
dangerous, and resistance in the face of overwhelming odds may result in
your becoming a corpse.
We live in a fallen world, and trauma cannot always be avoided.
However, by using the best resources that we have available and the
spiritual resources that God supplies, we can emerge from the situation
only scarred to some extent, but not total casualties.
Member Care Consultant