Mental illness remains widely misunderstood, and yet represents a significant issue for missions in the twenty-first century. This is because of the prevalence and effects of poor mental health amongst the people whom we serve and amongst those who serve cross-culturally. It is arguable that mental health represents the single biggest threat to prolonged and effective service of mission workers today. The paper provides a brief history of concepts of mental health and illness, discusses mental illness globally (where we live and work) and missionally, and mental illness in relation to mission workers.
Lightyear is a social researcher working in Southeast Asia, training governments in good practice and churches in cross-cultural mission.
Mental Health and Mission
Mission Round Table Vol. 12 No. 3 (Sep-Dec 2017): 25-28
Mental illness remains widely misunderstood, and yet represents a significant issue for missions in the twenty-first century. There are two reasons for this. Firstly, because of the prevalence and effects of poor mental health amongst the people whom we serve; and secondly, because of the prevalence and effects of poor mental health amongst those who serve cross-culturally. I will argue here that mental illness represents to mission work, in some ways, the twenty-first century equivalent of communicable diseases of the nineteenth and twentieth centuries such as leprosy and tuberculosis, as it is poorly understood, highly disabling, socially stigmatizing, and often a chronic condition which has profound impacts on sufferers and their families. Moreover, where communicable diseases represented a major threat to the lives and well-being of cross-cultural (and local) workers in previous centuries, it is arguable that mental health represents the single biggest threat to prolonged and effective service of mission workers today.
1. Mental health and illness: a brief history (of what we mean)
Michael Foucault and others describe the conceptualization of mental illness through time, showing how the forms and behaviour, and subsequent “categorizing and policing” of mental illness have changed through history. Industrialization plays a key role, in that increasing universalization of rights, roles, and expectations also defines the boundaries of normality, in terms of behaviour, which previously were defined and managed more locally in rural, agrarian societies. This is significant in an era of both increasing and changing industrialization (sometimes termed Industry 4.0) where job and income insecurity, migration, cyber-threats, and rapidly changing identity politics represent emerging threats to mental and social well-being.
The role of culture in mental illness is significant, both in terms of how mental illness is defined and managed. However, increasingly, the construction of culture is undergoing change, again largely due to technological advances enabling globalized communication. Thus, whilst understandings of culture based on widely understood norms may have validity, people from different cultures interact, consume, and produce “culture” which represents fusions of different strands. As cultural constructs change, so the understanding and classification of mental illness also change.
Religious beliefs inform understandings of mental health, from mental well-being approaches found in Buddhist meditation, to more behavioural perspectives found in Islamic teaching. In most traditions, definitions are highly varied and frequently include the involvement of evil spirits and other supernaturally attributed phenomena.
Within the Christian worldview, too, a diversity of perspectives exist on mental health, with some perspectives more rooted in Enlightenment-based biomedical models, and others functioning almost exclusively in the spiritual domain. Whilst much is often made of the dichotomy between “Western” and “Eastern” perspectives on mental illness, careful analysis of popular beliefs reveals that the differences are less stark than sometimes presumed. Even within the evangelical tradition, perspectives of and approaches to mental health vary, from seeking medical help to applying spiritual disciplines, dealing with hidden sins, and exorcisms. Evangelicals remain divided on the validity of some approaches, such as psychotherapy, drug treatment, or casting out demons.
The first point, then, is an appreciation of the historical and cultural rootedness of concepts of mental illness. But at the same time, this should not discourage us from engaging—“Well, depression means something different ‘over there’ so there’s not much we can do”—but rather encourage us to respond. An approach to mental well-being which has its rooting in identity in Christ and in the createdness of human beings provides a starting point which can enable engagement with different perspectives on mental health and illness without descending into meaningless relativity. An understanding of worldview is a critical element to our understanding of mental health. In other words, cross-cultural workers who engage deeply with worldview issues are well positioned to engage with the complexity of mental illness.
2. Mental illness globally (and where you live and work) and missionally
The World Health Organization describes mental illness as the leading cause of ill health and disability worldwide. Promoting mental health and well-being, and the prevention and treatment of substance abuse, are integral parts of the Sustainable Development Agenda adopted by the United Nations General Assembly on 25 September 2015 to transform our world by 2030. In much of East Asia, signs of declining mental health are expressed in a variety of ways: increasing suicide rates and drug and alcohol abuse. Moreover, social trends—including changes in technology—paradoxically may contribute to new forms of mental illness, such as gaming addiction.
When described using standard medical definitions, the forms or categories of mental illness differ based on the approach, but broadly speaking encompass conditions such as depression, anxiety, schizophrenia, manic-depressive disorders, personality disorders, addiction, and mental illness associated with other medical conditions. Again, however, how these are defined and managed is often contingent upon the particular context—cultural, religious, and economic. What we can say, however, is that mental health issues, however they are defined and managed, represent an increasing problem in East Asian and other countries that is not matched by a corresponding increase in resources available to address the issue.
The historical example of leprosy demonstrates that a concern for people affected by leprosy drew upon the biblical examples of Jesus healing lepers and gave rise to a significant mission movement which embraced a multi-dimensional approach, with medical, social, and spiritual care. The early responses to what was a poorly understood and much feared condition left a legacy whereby mission groups contributed to the global elimination of the disease and, in many places, brought lasting change to the way affected persons are treated. In the context of the twenty-first century, mental illness, in its various forms, in many ways reflects the challenge to missions that leprosy was in the nineteenth and twentieth centuries: poorly understood, highly stigmatizing, often chronic, widespread but equally largely ignored, and needing a very holistic approach. In those days, it was people with leprosy who were frequently characterized as the “least, the last, and the left behind.” In our day, and perhaps as has always been, the least, last, and left behind are increasingly likely to include people with mental illness or learning disabilities—and where women are often disproportionately stigmatized and excluded.
Thus, the second point: how should we respond to the issue of our day, an issue which potentially represents a far more serious and widespread missional challenge than even leprosy did in previous centuries? How does our mission outreach acknowledge and respond to the rapidly emerging yet unmet needs of people with mental illness, where a holistic approach—much like that towards leprosy—is not only possible, but required?
3. Mental illness and mission workers
Recent surveys indicate that mental-health related issues are amongst the top seven reasons for what is known as “missionary attrition”. Analysis of medical records of early-returned LDS (Latter-day Saints) missionaries by Drake and Drake indicated that mental illness alone was responsible for premature return in 38 percent of early returnees. Mental illness “is overrepresented in early returned missionaries (ERMs) compared to their peers who complete their full term of expected missionary service… the challenges and hardships missionaries face may overwhelm their coping resources and exacerbate the turmoil, anxiety, and crises of emerging adulthood.
Thomas and Thomas draw parallels to post-traumatic stress disorder (PTSD) and suggest a “mission-related stress disorder” (MRSD) as a “framework for understanding and assisting missionaries with the effects of stress during and after their missions”. However, lack of specific inquiry into mental-health-related issues in surveys such as ReMAP—possibly reflecting the paucity of awareness or acknowledgement of specific mental health issues—means that the issue of mental health is often approached either through more well-known and well-accepted forms (such as post-traumatic stress disorder) or using non-specific euphemisms of processes (such as “Burnout”. This illustrates the first of three problems: the lack of a reasonable common understanding of mental health, fueled by the social unacceptability of mental health in Christian society, which leads to imprecise terminology which paradoxically makes it more difficult to recognize and render assistance. The inability to properly “name” what is happening may hinder attempts to help.
Secondly, the lack of a common framework for understanding potentially limits the kind of help that can be received. Those defining mental illness from a purely biomedical perspective may shy away from interventions drawn from a more spiritual/supernatural epistemology; yet evidence would suggest the need to consider multiple perspectives in the approach to mental illness. A substantial body of research gives insights into specific considerations for longer and short term workers, female workers, third-culture kids, and those in more traumatic circumstances, as well as practical ways to help early returnees. The concept of resilience building forms part of a three-fold area of focus: preparation, prevention—largely through awareness and understanding of stressors and the development of systems which promote good mental health—and early identification and management, with an emphasis on building awareness, coping and communication skills, identity issues, and resilience.
Thirdly, and linked to the first two points, is the shift in approach away from locating mental illness or mental health primarily in the person (who is labeled “weak,” or “mentally unsuited”) or an event (which is said to be “stressful” or “traumatic”) to viewing mental health as an outcome of more complex interplays between people, circumstances, beliefs, and expectations. This has the potential to lead us to articulate better questions on how to reduce the degree to which mental health issues impair the work of missionaries. Here, we come back to the point made in the introduction, where we appealed to a parallel understanding between the threat posed by tuberculosis in the nineteenth and twentieth centuries to missionaries, and the threat posed by mental illness in the twenty-first century. It is not just the size of the threat, nor the degree of ubiquity: ultimately, where the incidence of tuberculosis has been reduced it has been achieved by addressing the illness from multiple angles—better nutrition and housing (the basic circumstances of living), vaccination, identification of people at higher risk, early and effective treatment, and public campaigns of awareness. Arguably, a similar approach is needed with mental health—careful attention to the circumstances of living, preparation (including identifying people and situations of higher risk), and early intervention—all done against a backdrop of increased public awareness. What could that look like for a mission organization? Here are five suggestions:
- Develop an organizational culture which allows proper naming and discussion of mental health issues. This should not be satisfied with using convenient euphemisms, but acknowledge the wide range of forms which mental illness takes.
- Analyze the “conditions of living” and working for workers. This should include not only the obvious stressors—war, poverty, culture stress—but organizational issues such as conflict, poor communication, unrealistic expectations, and isolation. The question is then asked “How can we develop more healthy working conditions in these circumstances?”
- Address issues of resilience from the beginning. Again, this should not only try to locate resilience in the individual, but in groups and structures. This should include paying attention to maintaining healthy spiritual and emotional well-being and providing resources to facilitate that.
- Increase awareness of administrators to identify situations of high-risk or early signs of mental illness. This links to point (1) where a culture of openness is needed, as well as increased understanding of what mental illness is.
- Integrate approaches to address issues of mental health which take into account differing belief systems and needs. This argues neither for the primacy of a biomedical or a supernatural epistemology, but rather that people are likely to benefit from more than one approach. Integration includes specific attention to development of awareness and skills, such as how to communicate with others (concerning mental illness), coping mechanisms, and dealing with issues of shame and guilt.
Conclusion: Wounded healers
The concept of the “Wounded Healer” may be apt, and leads us to two conclusions. Firstly, when looking back into how the challenge of leprosy-affected persons inspired a particular mission movement in the previous two centuries, accepting the conceptual relevance of mental health in our context can potentially give rise to new forms of integral mission to socially excluded people across the world—of which there are already numerous examples.
Secondly, when looking at addressing the issue of mental health amongst workers, we may well find it harder to separate this from outreach; and perhaps the outreach is best done by organizations which have a deep self-understanding of the issues of mental health and experience in enabling rehabilitation of people with mental health issues. In other words, our outreach is linked to our internal understanding of mental health, so that the issues need to be considered simultaneously.
 Michael Foucault, History of Madness (New York: Routledge, 2013).
 Mary De Young, Madness: An American History of Mental Illness and Its Treatment (Jefferson, N.C.: McFarland, 2010).
 J. Cooper and N. Sartorius, “Cultural and Temporal Variations in Schizophrenia: A Speculation on the Importance of Industrialization,” The British Journal of Psychiatry, 130 (1977): 50–55; N. E. Waxler, “Is Mental Illness Cured in Traditional Societies? A Theoretical Analysis,” Culture, Medicine and Psychiatry, 1, no. 3 (1977): 233–253.
 Jeremy Greenwood, The Third Industrial Revolution: Technology, Productivity, and Income Inequality (Washington D.C.: American Enterprise Institute for Public Policy Research, 1997); N. Jazdi, Cyber Physical Systems in the Context of Industry 4.0. Paper presented at the 2014 IEEE International Conference, “Automation, Quality and Testing, Robotics,” Cluj-Napoca, Romania, 22–24 May 2014; Herner Lasi, Peter Fettke, Thomas Feld, and Michael Hoffmann, “Industry 4.0,” Business & Information Systems Engineering, 6, no. 4 (2014): 239–242.
 Richard J. Castillo, Culture and Mental Illness: A Client-centered Approach (Pacific Grove: Brooks/Cole, 1997); Suman Fernando, Mental Health, Race and Culture, 3rd ed. (Basingstoke, Hampshire: Palgrave Macmillan, 2010); Harriet P. Lefley, “Culture and Chronic Mental Illness,” Hospital and Community Psychiatry, 41, no. 3 (1990): 277–286; W. S. Tseng and J. Hsu, “Chinese Culture, Personality Formation and Mental Illness”, International Journal of Social Psychiatry, 16 (1970): 5–14.
 Michael de Certeau, The Practice of Everyday Life. Translated by Steven Rendall. (Berkeley: University of California Press, 1988). Originally published as L’invention du Quotidien. Vol. 1, Arts de faire (Paris: Gallimard, 1980); Ananya Roy, “The 21st-Century Metropolis: New Geographies of Theory,” Regional Studies, 43, no. 6 (2009): 819–830; Paul Willis, “Foot Soldiers of Modernity: The Dialectics of Cultural Consumption and the 21st-Century School,” Harvard Educational Review, 73, no. 3 (2003): 390–415.
 Weshan Jia, The Remaking of the Chinese Character and Identity in the 21st Century: The Chinese Face Practices (Westport, C.T.: Greenwood, 2001); Sing Lee, “From Diversity to Unity: The Classification of Mental Disorders in 21st-Century China,” Psychiatric Clinics of North America, 24, no. 3 (2001): 421–431.
 Harold G. Koenig, ed., Handbook of Religion and Mental Health (San Diego: Elsevier, 1998).
 M. R. Walley, “Applications of Buddhism in Mental Health Care,” In Beyond Therapy: The Impact of Eastern Religions on Psychological Theory and Practice, Guy Claxton, ed., (Somerville, MA: Wisdom, 1986), 11–70.
 T. Baasher, Islam and Mental Health, Proceedings of the Third International Conference on Islamic Medicine, Jeddah, Saudi Arabia, 2001: 588–593.
 Y. Kahana, “The Zar Spirits, A Category of Magic in the System of Mental Health Care in Ethiopia,” International Journal of Social Psychiatry, 31, no. 2 (1985): 125–143; R. G. Malgady, L. H. Rogler, and G. Costantino, “Ethnocultural and Linguistic Bias in Mental Health Evaluation of Hispanics,” American Psychologist, 42, no.3 (1987), 228–234; S. Razali, U. Khan, and C. Hasanah, “Belief in Supernatural Causes of Mental Illness Among Malay Patients: Impact on Treatment,” Acta Psychiatrica Scandinavica, 94, no.4 (1996): 229–233.
 H. C. Covey, “Western Christianity’s Two Historical Treatments of People with Disabilities or Mental Illness,” The Social Science Journal, 42, no. 1, (2005): 107–114; J. L. Farrell, and D. A. Goebert, “Collaboration between Psychiatrists and Clergy in Recognizing and Treating Serious Mental Illness,” Psychiatric Services, 59, no. 4 (2008): 437–440; K. Hartog and K. M. Gow, “Religious Attributions Pertaining to the Causes and Cures of Mental Illness,” Mental Health, Religion and Culture, 8, no. 4 (2005): 263–276.
 M. Galanter, M and D. Larson, “Christian Psychiatry: The Impact of Evangelical Belief on Clinical Practice,” The American Journal of Psychiatry, 148, no. 1 (1991): 90–95; L. R. McLatchie and J. G. Draguns, “Mental Health Concepts of Evangelical Protestants,” The Journal of Psychology, 118, no. 2 (1984): 147–159.
 World Health Organization, World Report on Disability (n.p.: Malta, 2011), www.who.int/disabilities/world_report/2011/report.pdf (accessed 9 October 2017)
 World Health Organization, “Mental Health Included in the UN Sustainable Development Goals,” http://www.who.int/mental_health/SDGs/en/ (accessed 9 October 2017).
 Herbert Hendin, Lakshmi Vijayuakumar, José M. Bertolote, Hong Wang, Michael R. Phillips, and Jane Pirkis, “Epidemiology of Suicide in Asia,” in Suicide and Suicide Prevention in Asia, Herbert Hendin, Michael R. Phillips, Lakshmi Vijayakumar, Jane Pirkis, Hong Wang, Paul Yip, Danuta Wasserman, José M. Bertolote, and Alexandra Fleischmann, eds., (Geneva: World Health Organization, 2008), 7–18, http://www.who.int/mental_health/resources/suicide_prevention_asia.pdf (accessed 16 Oct 2017).
 N. M. Petry, F. Rehbein, D. A. Gentile, J. S. Lemmens, H. J. Rumpf, T. Mößle, G. Bischof et al., (2014). An International Consensus for Assessing Internet Gaming Disorder using the New DSM‐5 Approach,” Addiction, 109, no. 9 (2014): 1399–1406.
 T. A. Widiger and L. A. Clark, “Toward DSM-V and the Classification of Psychopathology,” Psychological Bulletin, 126, no. 6 (2000): 946–963.
 A. T. A. Cheng, A. T., and C.-S. Lee, “Suicide in Asia and the Far East,” in K. Hawton and C. Van Heeringen, eds., The International Handbook of Suicide and Attempted Suicide, (Chichester: John Wiley, 2000): 29–48; World Health Organization, World Report on Disability, (n.p.: Malta, 2011); R. Kohn, S. Saxena, I. Levav, and B. Saraceno, “The Treatment Gap in Mental Health Care,” Bulletin of the World Health Organization, 82, no. 11 (2004), 858–866.
 Z. Gussow and G. S. Tracy, “Stigma and the Leprosy Phenomenon: The Social History of a Disease in the Nineteenth and Twentieth Centuries,” Bulletin of the History of Medicine, 44, no. 5 (1970): 425–449; D. G. Joseph, “Essentially Christian, Eminently Philanthropic: The Mission to Lepers in British India,” História, Ciências, Saúde-Manguinhos, 10 (2003): 247–275; S. Kakar, “Leprosy in British India, 1860–1940: Colonial Politics and Missionary Medicine,” Medical History, 40, no. 2 (1996): 215–230; M. Worboys, “The Colonial World as Mission and Mandate: Leprosy and Empire, 1900–1940,” Osiris, 15, (2000): 207–218.
 Mike Griffiths, Disability in Myanmar: Findings from Contemporary Research (Yangon: Social Policy and Poverty Research Group, 2016).
 Ronald Koteskey, “What Missionaries Ought to Know about Attrition,” Missionary Care, http://www.missionarycare.com/attrition.html (accessed 9 October 2017).
 T.S. Drake and M. L. Drake, Emotional Factors Affecting the Physical Diagnosis in the Early Release of Young Missionaries (unpublished conference presentation). Proceedings from 2014 Association of Mormon Counselors and Psychotherapists (AMCAP) Convention, Salt Lake City, UT.
 Kristine J. Doty, S. Zachary Bullock, Harmony Packer, Russell T. Warner, James Westwood, Thomas Ash, and Heather Hirsch, “Return with Trauma: Understanding the Experiences of Early Returned Missionaries,” Issues in Religion and Psychotherapy, 37, no. 1 (2015): 35–36, http://scholarsarchive.byu.edu/cgi/viewcontent.cgi?article=1555&context=irp (accessed 9 October 2017).
 M. H. Thomas and M. P. Thomas, “The LDS Missionary Experience: Observations on Stress,” Issues in Religion and Psychotherapy, 15, no.2 (1990): 49–79.
 Doty et al., “Return with Trauma,” 37; Thomas & Thomas, “The LDS Missionary Experience,” 49–79.
 Detlef Bloecher, “Good Agency Practices: Lessons from ReMAP II,” Evangelical Missions Quarterly, 41, no. 2 (2005): 227–237, https://www.emqonline.com/node/1837 (accessed 9 October 2017); David Selvey, “The Truth of Missionary Attrition,” Faith Blogs (24 Oct 2015), https://blogs.faithlafayette.org/2015/10/24/the-cost-of-missionary-attrition/ (accessed 12 Oct 2017).
 Karen Carr, “Trauma and Post-Traumatic Stress Disorder among Missionaries,” Evangelical Missions Quarterly, 30, no. 3 (1994): 246–255.
 C. B. Eriksson, J. P. Bjorck, L. C. Larson, S. M. Walling, G. A. Trice, J. Fawcett, and D. W. Foy, “Social Support, Organisational Support, and Religious Support in Relation to Burnout in Expatriate Humanitarian Aid Workers,” Mental Health, Religion and Culture, 12, no. 7 (2009): 671–686.
 M. F. Foyle, M. Beer, and J. Watson, “Expatriate Mental Health,” Acta Psychiatrica Scandinavica, 97, no. 4 (1998): 278–283.
 Lynette H. Bikos, and M. Elizabeth Lewis Hall, “Psychological Functioning of International Missionaries: Introduction to the Special Issue,” Mental Health, Religion and Culture, 12, no. 7 (2009): 605–609.
 Lynette H. Bikos, Michael J. Klemens, Leigh A. Randa, Alyson Barry, Thomas Bore, Renee Gibbs, and Julia Kocheleva, “First-year Adaptation of Female, Expatriate Religious and Humanitarian Aid Workers: A Mixed Methods Analysis,” Mental Health, Religion and Culture, 12, no. 7 (2009), 639–661.
 Michael J. Klemens and Lynette H. Bikos, “Psychological Well-Being and Sociocultural Adaptation in College-Aged, Repatriated, Missionary Kids,” Mental Health, Religion and Culture, 12, no. 7 (2009): 721–733.
 Carr, “Trauma,” 246–255.
 Doty et al., “Return with Trauma,” 33–46.
 Marie Earvolino‐Ramirez, “Resilience: A Concept Analysis,” Nursing Forum, 42, no. 2 (2007): 73–82.
 Jeff P. Bjorck and Jean-Woo Kim, “Religious Coping, Religious Support, and Psychological Functioning Among Short-Term Missionaries,” Mental Health, Religion and Culture, 12, no. 7 (2009): 611–626.
 Eriksson et al., “Social Support,” 671–686; Foyle et al., “Expatriate Mental Health,” 278–283.
 Christopher H. Rosik, April Summerford, and Jennifer Tafoya, “Assessing the Effectiveness of Intensive Outpatient Care for Christian Missionaries and Clergy,” Mental Health, Religion and Culture, 12, no. 7 (2009): 687–700.
 Doty et al., “Return with Trauma,” 33–46.
 S. P. Selby, A. Braunack-Mayer, N. Moulding, A. Jones, S. Clark, and J. Beilby, “Resilience in Re-Entering Missionaries: Why Do Some Do Well?” Mental Health, Religion and Culture, 12, no. 7, (2009): 701–720.
 David Sedgwick, The Wounded Healer: Countertransference from a Jungian Perspective (London: Routledge, 2016).