The Mobile Member Care Team as a Means
of Responding to Crises: West Africa by Karen F. Carr, Ph.D.
Chapter in Psychological Interventions in Times of Crisis. 2005. Bob Sternberg and Laura Barbanel, Eds. Springer Publishing Company.
Introduction
Karen Carr is the Clinical Director of the Mobile Member Care Team – West Africa (MMCT) which is a non-profit organization focusing on training and crisis response for missionaries and cross cultural workers in West Africa. Karen received her Ph.D. in Clinical Psychology from Virginia Commonwealth University in 1989. She did a post-doctoral fellowship in forensic psychology at the University of Virginia from 1989-1990. She then spent the next eight years working at a community mental health center in Henrico County, Virginia, first as a Clinical Supervisor and then as the Program Manager of the Emergency Services Unit. In 1998, she left this job to help develop and launch a crisis team, which became known as the Mobile Member Care Team. She and her two teammates, Darlene Jerome and Marion Dicke currently live and work in Ghana, West Africa.
Karen’s interest in cross-cultural work actually began in 1983 when she went to Guatemala to do short-term work with a group of linguists. At that time she witnessed many workers who had experienced the trauma of war, evacuation, kidnappings, and robberies and were suffering post-traumatic symptoms. She was burdened by the fact that many of these symptoms and difficulties might have been prevented if the workers had received early intervention or if other preventative programs had been in place. It was this experience followed by other short-term trips to Latin America, Africa, and Asia that planted the seed of the MMCT vision in Karen’s heart, which finally came to fruition in 1998.
An American psychologist working in West Africa
I woke up at about 4 am that morning of September 19, 2002 in Bouaké, Côte d’Ivoire to the sound of machine guns. Our multidisciplinary team of three, known as the Mobile Member Care Team, had just begun leading a workshop for 14 cross-cultural workers, teaching them how to facilitate Sharpening Your Interpersonal Skills workshops (Williams, 2002) across West Africa. My first thought as I lay in bed and listened to the exchange of gunfire in the distance was that the gang of robbers who had been terrorizing the city for almost a year had finally been trapped and that they were having a shoot out with the police. But, as the gunfire became more intense and went on and on, I began to suspect that we might be having another attempted coup in the country. The radio news at 6 am confirmed that rebels were attacking government troops in three strategic locations in the country, including Bouaké, the city where we were training. This was the beginning of an eight-day siege that kept us trapped in a building, caught in the crossfire between government and rebel troops until we were finally evacuated out of Bouaké by French soldiers. When we got out, we were exhausted and in need of care. This time, instead of us being the ones to provide the debriefing and care, we were on the receiving end of it. And we were ready for it.
Two months before, I was in this same city, responding to a large-scale crisis. Eight armed robbers had entered a boarding school campus and spent the next couple hours holding people hostage trying to get money. As they left, they shot and killed one of the security guards and took one of the missionaries hostage, telling him that they were going to kill him and beating him around the face and head continuously. When they pulled over the car and got out to shoot him, he managed to escape, running a zig-zag route as bullets flew around him.
Our crisis team was called within hours of the robbery. I went up along with a visiting colleague, two psychology doctoral students who were there for a student practicum, and two missionaries we had trained to be peer crisis responders. We spent the next two days talking with adults and children, helping them restore some sense of calm, safety, and peace of mind. I remember sitting across from the man who had been taken hostage and looking at his bruised, swollen, and severely lacerated face as he talked about his ordeal. It struck me in that moment how personal this crisis felt to me—every person that I talked with that day was someone I had previously met, either in a workshop or in some social context. These people weren’t just clients to me, they were my friends and their crises had an emotional impact on me.
One couple I met with after that crisis were dorm parents for junior high boys. I had done a psychological assessment as part of their screening process and had recommended that they be accepted into that position. The man was particularly impacted by the robbery of the school. He saw the robbers drive off with his friend and felt a certain level of responsibility in not being able to prevent this from happening. Some weeks before, he and some of his friends had rushed over to a mission guesthouse nearby where a single missionary woman was locked inside while robbers were trying to break in. They managed to scare them off. This man talked with me about the stress he was feeling and how he was having some difficulty sleeping at night. We talked about various ways that he could lower his anxiety level. Some weeks later I heard that he had gone for some medical care because he was having chest pains. He was cleared of any medical problems. The day before the war started, this man was jogging around the campus track, and he fell over and died suddenly.
Understandably, the entire campus, and especially his family, friends, and the junior high boys under his care, were already in an acute state of grief and shock when the war began. I had left the workshop to spend the day with the grieving family and as I looked in the face of his widow and his children, I thought about our conversation from several weeks before. I remembered his wife saying how relieved she was that she had not been made a widow when he had attempted to rescue his friend who was being kidnapped. “I’m just glad that I’m not a widow today.” Those words haunted me as I looked at her grieving face. This woman and her children were not just clients to me. They were part of my personal life, part of the fabric of my social support system. I was in their world, they were in mine, and our worlds had been permanently changed.
The Mobile Member Care Team first came to Abidjan, Côte d’Ivoire, in 2000 to set up base and begin providing training and crisis response to missionaries across West Africa, a region about two-thirds the size of the U.S. We came with vision and passion; a vision to see missionaries and cross cultural workers thriving in their work, not just surviving it. We came with a love for Africa and Africans and a desire to learn more about the diverse and rich cultures on the continent. We knew that by living in West Africa, we too would be exposed to crisis and trauma and an ongoing challenge would be to maintain our own mental health while also trying to help the people around us. But, it is one thing to know the risks intellectually and another thing to live it day in and day out. That is why we were glad to receive care ourselves from mental health professionals who came from the States shortly after we were evacuated from Bouaké. They met us in Abidjan, Côte d’Ivoire, our home base, and spent hours with us individually and as a team.
During that time, I was able to talk about the series of stressful events I had experienced over the past year and to begin to work through some of the emotional implications and personal lessons. I talked about the fears I had when we harbored 40 Liberian refugees during that eight-day siege—fear that mobs would come to kill them before our eyes. I talked about the pain of seeing people from Burkina Faso who had been burned out of their homes by Ivoirian militia, carrying all their possessions on their backs as they walked through our parking lot. I talked about the grief of seeing a country as beautiful and promising as Côte d’Ivoire begin to crumble and decay before our eyes because a few people wanted war while the majority longed for peace. I cried, I asked questions that didn’t have answers, and I went back to the roots of why I was there. I found that those roots were deep and enduring and that I could finally answer the question of whether or not I was cut out to do this work. It wasn’t about my strength or energy or will, really. It was about knowing that this was exactly what I was supposed to be doing and what I was made to do. As long as I could do the work with a motivation of love for the people I was helping and joy in doing that work, then I could keep going. After a period of rest and vacation, which helped to restore us to a place of renewed energy and vision, we entered into a new season of our work.
Because the war continued, we were forced to relocate to a new country. So, as a team, we moved to Ghana, next door to Côte d’Ivoire. It was still centrally located in our 14-country service area and we were able to continue our efforts. This move also opened up new doors of opportunity for us to be more deeply involved with Africans.
What is the Mobile Member Care Team?
The Mobile Member Care Team is a non-profit organization designed to provide training and crisis response to missionaries and cross-cultural workers living in West Africa. We work with the more than 10,000 missionaries and cross-cultural workers living in the 14 countries of West Africa, from Senegal to Nigeria. These workers come from many areas of the world (including the US, Canada, Europe, Brazil, Korea, Nigeria, and Ghana) and are members of a variety of organizations that focus on different services including medical care, community development, relief work, education, literacy, Bible translation, and church planting. Our goal is to help these workers cope and function effectively and with integrity in the midst of crises and constant exposure to violence.
We do this using a Community Psychology model, aiming to improve community life by promoting psychological well-being and preventing disorder. Using a primary prevention approach, we provide psycho-education that teaches practical skills such as how to manage conflicts, how to grieve, how to handle stress, and how to help others during crisis and trauma. These workshops serve the purpose of building awareness of needed skills, increasing existing skills, building and strengthening relationships within the communities, increasing knowledge, and creating networks. The training is very interactive, utilizing various methods of adult learning including small group tasks, whole group interaction, case studies, demonstration of skills, practicing skills, and personal reflection. Believing that there are strengths and skills within the community already that can be enhanced and accessed, we provide specialized crisis response training as a way of expanding helping resources within the community (Reissman, F., 1990).
Secondly, we provide direct care to cross cultural workers with psychological assessments, brief therapy, crisis intervention, and the mentoring of individuals who can provide psychological first aid to their peers (whom we call peer responders). To date, over 1000 cross-cultural workers have directly accessed these MMCT services in West Africa.
Each team member of MMCT is supported by donations from churches and individuals. There are no salaries paid to staff. Organizational costs are covered by workshop registrations and donations given by individuals and organizations who believe in the need for a service such as this.
What kinds of crises do Westerners living in West Africa experience?
Initially when we came to West Africa, our primary clientele consisted of Westerners involved in mission work or humanitarian aid. These were people who came from fairly wealthy nations (US, Canada, England, Holland, France, Germany, etc.) who were making large personal sacrifices to work in a developing country. There are stresses and crises that are unique to someone in this situation and they can perhaps be put into several categories:
Violent crime – This is often something that missionaries directly experience, as opposed to being something they witness. The most common incidents are armed robberies, carjackings, and assaults in the course of a robbery. Typically there is not a well-developed or adequate police force to respond to these crimes. Because of corruption in some countries, the police may also be involved in, or overlook the crimes.
Violence related to war – This is typically not directed against missionaries, but they are observers to it and it may involve civil unrest, mobs, riots, and evacuation. Occasionally, missionaries may be caught in the crossfire or other war associated events.
Cultural adjustment issues – Things that are most difficult to deal with in West Africa are heat, language difficulties, dealing with poverty, not understanding or accepting cultural norms or cues, difficult traveling conditions, corruption in government officials, and infrastructure breakdown (i.e., intermittent or lack of electricity, water, trash removal, phone, and internet).
Health and sanitation – There is the constant threat of malaria, typhoid, dysentery, parasites, meningitis, AIDS, and injury or death from traffic accidents.
Job stress – There are constant demands and pressure, not enough time off, not enough staff, etc. A person may not be in a job that suits his/her skills.
Interpersonal crises – Most commonly these stem from the unresolved conflicts and tensions that come from being on a multi-cultural team that one did not choose. Many team members are living and working with each other under very high-pressure situations.
Grief and loss – There are many losses including separation from family (parents, adult children, or younger children placed in boarding schools), premature death of friends and colleagues, loss of security, safety, familiarity, possessions, hopes, dreams, and constant changes of friends and living situation.
The psychological consequences of living with these types of stresses on a daily basis without adequate resources to respond to them most typically include depression, anxiety, acute stress disorder, post-traumatic stress disorder, and the exacerbation of pre-existing psychological conditions (i.e., personality disorders). When people or their organizations request counseling, the most typical presenting problems are burnout (fatigue, apathy, irritability, etc), depression, anxiety, interpersonal conflicts, or behavioral problems with children. Upon assessment, many of these symptoms are related to unresolved grief or an accumulated response to ongoing stress or trauma. It’s not uncommon to hear a missionary describe multiple traumas that he/she has experienced over the years and to discover that this is the first time he/she is talking about them.
Interestingly, many missionaries have lived with these kinds of stresses and have endured numerous crises, and yet have demonstrated a level of resilience and strength that is remarkable. Few studies have been done to examine the factors that contribute most significantly to this resilience but in conversations with many of these individuals, several core themes emerged. One is a sense of call or purpose. Those who feel that they are fulfilling their life’s purpose by being in that place are more able to endure loss, hardship and disappointments than those who came for other motivations such as attraction to the job, a sense of adventure, or pressure from a spouse or family. The problem with these motivations is that one may not end up in the job one came for, the setting may not be adventurous or romantic at all, and coming because of pressure from a family member will lead to a sense of resentment later on.
A second theme that emerges as significant is having a sense of strong social/emotional support. The literature has identified two key areas of support contributing to resilience, which are team cohesion and consultative leadership style (Fawcett, J., 2002; Fawcett, J., 2003). We view team cohesion as a means of promoting resilience and lowering stress level overall and therefore much of our programming is designed to promote better communication and to develop skills related to conflict management. Secondly, many cross-cultural workers reference the presence and attitude of their leaders as being a critical factor in how they coped with various traumas and stressors. In fact, there seems to be a distinct negative correlation between expressions of bitterness or disappointment in leadership during times of crisis and ability to adapt successfully to the losses of the trauma. This may be related to the actual support given by the leadership as well as the person’s perception of and trust in their leadership in general. (Fawcett, G., 2003).
These observations of what contributes to resilience and successful adaptation to crisis have helped to shape our programming, which aims to promote coping and prevent those things which may lead to premature attrition or unhealthy coping responses. Those programs are described in more detail in the section entitled “The workshops of MMCT—The Training Strategy.”
Psychological Issues to deal with after being in a war zone and evacuating
A unique type of stress that many expatriates living in West Africa have had to cope with is that of evacuating from the country they are living in during times of war and immediate danger (Carr, 2004). The experience of being evacuated from Bouaké and then subsequently from Abidjan, taught me several important lessons about the psychological impact of this kind of event which has implications for the kinds of themes that are important to address in any counseling offered post-evacuation. The key psychological issues are as follows:
Guilt – One thing in the evacuee’s mind is who is being left behind. As we drove out of Bouaké, the streets were lined with Africans who were unable to leave. The silence was damning, the expressions hopeless, our guilt acute. The evacuee wonders what will happen to the ones left behind. There is a sense of abandoning others. This feeling may be more intense after one leaves and then realizes that he or she did not leave adequate resources behind (i.e., advance pay for any employees who had to stay). Guilt may be enhanced or diminished according to what African colleagues have said to their expatriate friends before they left—whether it was a message encouraging them to leave or a plea to stay. Leaders may be particularly prone to guilt depending on how they made the decision for themselves and others to leave and how their followers or national colleagues have responded to them (i.e., with compliance or with resentment, criticism, and anger).
Anxiety – While we were under siege in Bouaké, we received frequent calls from the American embassy assuring us that they were working on getting us out of this dangerous situation. They repeatedly asked us for information about who was there and wanted to know the nationalities of each of us. We were a diverse group of 12 Americans, four Nigerians, and two Canadians. When the embassy personnel said, “Don’t worry, we’ll take care of our people, “I reminded them that our group was not all Americans and was told that there would be no guarantee of the non-Americans being evacuated out. Our leadership team of four discussed among ourselves who would stay behind with the Nigerians if they were not allowed to come. We knew we would not leave them alone, but we did not know what the implications of that would be. There was constant uncertainty about this until the day and hour that we actually all got out. Another source of anxiety for us was related to the physical danger we faced. When the fighting was the most intense, there were bullets striking the building we were in and we all lay on the floor in a hallway corridor with mattresses against the windows to prevent being injured by shattered glass. We wondered what we would do if any of us were injured or had a medical crisis. There would be no way to get anyone safely to a medical facility. In fact, one of our participants did get malaria during these eight days but we had medication for it with us. One of our team leaders fainted from the heat and dehydration, which gave us all a scare since our colleague from the school had died of an apparent heart attack just days before.
Another anxiety is knowing that friends and relatives who are far away are hearing the news of the war and that we may not be able to communicate with them concerning how things really are. Sometimes things are not as bad as the media is portraying it and sometimes they are worse. When we were under siege at Bouaké our phones worked the entire time we were there. I can remember at one point, when the shelling was particularly close, praying that my mother would not choose to call at that moment to find out how we were. Fortunately, she did not.
Additionally, there are anxieties and fears that come post-evacuation with the uncertainties of where one will live, what will happen to one’s possessions, what will happen to those left behind, and what the future will hold in general. One’s goals and expectations all go through a process of re-evaluation and it is very helpful to have compassionate, patient leadership present during this time of questioning and uncertainty (Fawcett, J., 2002).
Grief – The evacuee feels a tremendous amount of sadness and grief during and after the evacuation. There are multiple losses. For our team, there was the loss of friends. Some of our expatriate friends and our governing board scattered to many different countries after the evacuation while others stayed behind. When we left for Ghana and said goodbye to our national friends and employees we didn’t know if we would ever see them again. There was also the loss of our home and possessions. As we left, we had to make the difficult choice of what was most important to put into a suitcase. Irreplaceable mementos such as photos and letters were the first to be packed. We were later able to have some of our things shipped over to Ghana but others left everything behind and did not recover those things. The grief of evacuation continues after one leaves the country because many times the war is ongoing and from a distance one hears the news of atrocities such as rape, looting, mass graves, etc. This is currently the case in Côte d’Ivoire.
Anger – It’s very common to feel a strong sense of anger and outrage at the injustices and senselessness of the war. This anger may be directed towards the organizational administration particularly when evacuation decisions are made unilaterally or if the person did not agree with a team decision to evacuate. Individuals can be helped by guiding them to evaluate the intensity of their anger in relation to actual events and to find appropriate ways to express and release these feelings. One missionary child I worked with expressed strong feelings of anger towards the rebels who had started the war and said that he wanted to go fight them himself. He also manifested his anger at school and at home, getting into fights and losing his temper frequently. It helped him to be able to identify his anger as part of his grief related to the losses he had experienced because of the war. With counseling and the help of his parents, he was able to develop more adaptive ways of coping with those feelings.
Existential Questions – Events such as evacuation raise questions such as, “Why did this happen?”; “Why did God allow this to happen?”; “What is my purpose here?”; “Where is justice?” Many of these questions can’t be answered, but just having the opportunity to ask them in the presence of a non-judging person who can sit with the ambivalence and uncertainty can be very helpful. Over time this person can gently guide the evacuee to look at what they are learning from this and how they can grow as a result.
Africans in Crisis
Shortly after we arrived in West Africa, we began to realize that even though our team consisted of all North Americans, our clientele would not just be other Westerners. There was a need and request for our services from Africans as well. At first we hesitated, feeling that what we had to offer had been developed by Westerners and might not apply to African culture. There was also the language difficulty. All of our materials were in English and many of the African countries we work in are Francophone. However, Nigeria, Ghana, Sierra Leone, and Liberia, are in our service area and are English speaking. We responded to a request to come to a gathering of Nigerian missionaries in 2002. This was our first test of using our workshop materials with Africans and we looked to them for input and feedback.
We spent several days speaking at the Nigerian Evangelical Missions Association (NEMA) conference. This was a spiritual renewal conference for Nigerian missionaries. The conference planners were expecting about 1000 missionaries to come, but the overflowing main assembly hall was filled with 1400 registered participants. We spoke twice to the whole group about managing stress, asking each of them to go through the process of identifying their stressors and their physical and emotional reactions to their stress, and then problem-solving ways that they could better manage this stress. This was done in 700 pairs! In the afternoon of each day when the heat rose to about 102 degrees, we did workshops for 300-400 at a time on managing conflicts. The four of us with the Mobile Member Care Team stood in the middle of a group of about 400 people who surrounded us in chairs, sitting as close together as they could. We were all outside, under a large tent covering, but the sun came through where we stood in the middle, dripping with sweat. We shouted at the top of our lungs because there was no microphone. In the back a man stood in front of a group of about 30 people translating everything we said into Hausa, the local language (for a small group there who did not speak any English).
After a short time of going over the handouts, we got them into pairs to talk about the areas of conflict management that they needed to work on and the sound was thunderous. I looked at the pairs and they were waving their arms, pointing to their handouts, sharing their hearts. Next we used role-play—asking two of the participants to demonstrate a scenario of handling a conflict poorly and then handling it well. Then we had them practice with made up scenarios, handling a conflict using some general principles of healthy conflict resolution. The session addressed attitudes about conflict (i.e., a tendency to avoid it or a tendency to win at any cost to the relationship), but also addressed practical ways to resolve differences. We wondered how this seminar would translate cross-culturally. After all, in many non-western cultures, conflicts are not resolved by face-to-face discussion but rather through a third party or other indirect means such as storytelling. However, in many Nigerian cultures, there can be heated debate that occurs face to face and many organizations had already experienced divisions and staff attrition because of unresolved conflict. We didn’t in any way discount cultural traditions of managing conflicts, but offered some alternatives which were new ideas, and these did not seem to present a problem for those present.
Later we met with over 100 organizational leaders who wanted to talk with us about how to improve member care in their organizations. We asked them about the kinds of stresses and challenges that their full-time volunteer staff were facing as they worked in cross-cultural settings. Many of the issues that they described overlapped with the kinds of crises experienced by Westerners living in West Africa. But there are perhaps some variations in the themes and patterns. Categories of crises for Africans working in human service careers might look like this:
Violence related to war – Rather than being mere observers, many African workers are in the midst of the war. They are direct targets because of the ethnic group or religious group to which they belong. Because of this they have experienced things such as family members being killed before their eyes, family members being raped in front of them, torture, homes being burned down or destroyed, entire villages destroyed, disappearance of family members, separation from family members while fleeing the war (some of whom have never been reunited), and injuries caused by bombs, guns, machetes, and mines.
Economic stress/crisis - Many of the workers rely on the donations of family members, friends, or churches for their income and are under-supported which means they are living at or below the poverty level. For many of them, this is a voluntary status – they have been educated as doctors, engineers, or teachers but choose to volunteer their services for a parachurch organization and sacrifice the security of a set income.
Children’s education – While Westerners tend to have schooling options for their kids such as boarding school, international schools, or homeschooling, Africans do not have as many options and face serious challenges with getting a proper education for their children.
Job expectations and lack of margin – Many African pastors and church workers are expected to be available to those in need 24 hours a day and do not feel that they have the right or permission to turn people away or to set office hours that would allow them to have rest and margin. This leads to neglect of families and self-care.
Although the types of crises or sources of stress may differ between Africans and Westerners, many of the internal stresses are the same. Cultural norms may affect patterns of response such as unwritten rules about how grief or anger is expressed, but often the cognitive, behavioral, and emotional responses to trauma, grief, and loss are remarkably similar. It is the human reaction to loss to deny, be angry, be fearful, be sad, withdraw, and gradually to re-enter and rebuild with new strengths, new hopes, and the ability to help others (Greeson et. al., 1990). This pattern is commonly manifested regardless of culture, age, religion, or gender.
In Rwanda there is a proverb that says a man should swallow his tears. Many African men that I have talked to have told me that in fact it is very unusual for an African man to cry (although it really does depend on the ethnic group he comes from). Of course, we often hear this from North American men as well. Recently, we conducted a workshop with 24 participants, half of whom were men from Nigeria and Ghana. One of the facilitators was a man and as he shared one story, he became tearful. Rather than being ashamed of this behavior or rejecting it, several of the Africans stood up at the end of the workshop and thanked this man for being a role model and for communicating that it was OK to cry.
In general, we seek to understand and respect cultural differences and norms as we work with people who are not from our own culture. But, we have learned that certain aspects of any culture (including and maybe especially North American culture) are not necessarily right or healthy just because they are the norm. We feel that we have gained the credibility and permission, by staying in a position of learners, sometimes to challenge cultural norms to the extent that they do not contribute to effective interpersonal relationships or adaptive responses to trauma. A specific example would be a cultural norm that says that a woman who is raped should be ashamed of herself and should never talk about what happened. We are not value free in our profession. We are not neutral. We have a mission and it is about promotion of mental health and the prevention of mental illness. Sometimes that means challenging cultural values and norms.
