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Psychological and Readjustment Problems Associated with Emergency Evacuation of Peace Corps Volunteers - Hirshon et al.,'Journal of Travel Medicine,'Volume 4,Number 3

Psychological and Readjustment Problems Associated with Emergency Evacuation of Peace Corps Volunteers - Hirshon et al.,'Journal of Travel Medicine,'Volume 4,Number 3

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Psychological and Readjustment Problems Associated with Emergency Evacuation of Peace Corps Volunteers - John Mark Hirshon,Thomas R. Eng,Katherine A.Burkow,and Nedra Hartzell.'Journal of Travel Medicine,'Volume 4,Number 3
Psychological and Readjustment Problems Associated with Emergency Evacuation of Peace Corps Volunteers - John Mark Hirshon,Thomas R. Eng,Katherine A.Burkow,and Nedra Hartzell.'Journal of Travel Medicine,'Volume 4,Number 3

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Psychological and Readjustment Problems Associated withEmergency Evacuation
of
Peace Corps Volunteers
Jon Mark Hirshon, Thomas
R.
Eng, Katherine
A.
Brunkow, and
Nedra
Hartxell
f3ackground:To assess the psychological impact of emergency evacuation on individuals temporarily residing
in
foreigncountries, we surveyed two groups of recently returned Peace Corps Volunteers.
Methods:
Cases were individuals (n
=
265) who had been evacuated under emergency circumstances from their coun-tries of service: Liberia, the Philippines, and Yemen. The control group (n
=
90) consisted of the immediate predecessors
of
cases from the same countries who had completed their service under regular circumstances.
Results:
There were no significant age or gender differences between cases and controls. The median length of servicein the foreign country was 14 months for evacuees and 24 months for regular returnees. Feelings of depression wereself-reported by
60%
of evacuees while 29% of controls reported this. For feelings of disorientation,
55%
of cases versus
33%
of
regular returnees reported such symptoms. Other symptoms identified by more than
40%
of evacuees included:difficulty making decisions (49% versus 26% of controls); anxiety
(46%
versus 27% of controls); numbness of feelings
(43%
versus 14%
of
controls); and periods of crying (43% versus 12% of controls).Conclusion: Temporary residence in a foreign culture may be associated with significant psychological symptoms uponreturn to one‘s home country. When forced to depart from one’s host country under emergency conditions, the likelihood
of
individuals reporting these symptoms markedly increases.
Residing in a foreign country can be psychologi-cally demanding.’.’ One may be required to learn a dif-ferent language and adapt to a new culture. Collectively,the process of adjusting to a new sociocultural milieu hasbeen termed “culture
hock."^
Each year, many thousands
of
individuals relocate temporarily
to
developing coun-tries for stays ranging from weeks to years. Upon return-ing to one’s country of origin, readjustment to one’s homeculture, which involves many of the same psychologicalissues faced by departing individuals, is often neededand may be termed “reverse culture ~h0ck.l’~ndernormal circumstances this can be difficult; however,emergency evacuation under adverse conditions couldpotentially cause additional stress to an already vulner-able individual.The word‘reentry’became part of the American lex-icon through the space program. People learned that reen-try to the earth was “as stressful and dangerous as leaving
Jon
Mark Hirshon, MD, MPH: Johns Hopkins School ofHygiene and Public Health, Baltimore, Maryland; Thomas
R.
fng,
VMD,
MPH:
Office of Medical Services, Peace Corps,Washington, D.C., also International Health Program Office,Centers for Disease Control and Prevention, Atlanta,Georgia; Katherine
A.
Brunkow, MSW: Private Practice andWashington Psychoanalytic Institute, Washington, D.C.;Nedra Hartzell, PhD.: Office
of
Return Volunteer Services,Peace Corps, Washington, D.C.Reprint requests:
Jon
Mark Hirshon,
MD,
MPH,
Department
of
Emergency Medicine, The Johns Hopkins BayviewMedical Center,
4940
Eastern Avenue, Baltimore, MD 21224.
J
Travel Med
1997;4:128-131.
Cross-cultural reentry-the “experience of fac-ing previously familiar surroundings after living in
a
dif-ferent environment”-also can be stressful.h Thisexperience has been hypothesized to be more difficultthan the initial move to
a
foreign ~ulture.~.’he unex-pected dificulty with reentry has the power
to
renderineffective those involved in the process.6,8 lanning forthe return
to
one’s home country after living abroad canreduce the level of surprise of a di5cult reentry.The Cana-dian International Development Agency reported that“unexpected changes are much harder
to
cope withthan expected changes.”‘This study examines some
of
the psychologicalproblems faced by Peace Corps Volunteers who wereabruptly evacuated from their host countries. Outcomemeasures are compared
to
Peace CorpsVolunteers whohad completed their service under regular circumstances.
Background
The Peace Corps
of
the United States
is
a federallyfunded international development agency that sponsorsadult American volunteers in developing countries. PeaceCorpsVolunteers live and work under conditions similar
to
those of the host country people whom they serve. Ser-vice
is
approximately
2
years. Successful involvementrequires the ability to adapt
to
a
new culture which is likelyto include different languages, gender roles, food, hous-ing, sanitation, health risks, and expectations concerningindividual rights, privacy, work, and the possibility forchange.’ After
2
years, the Volunteers are either reas-signed to
a
new post or repatriated to the United States.
128
 
Hirshon
et
al., Adjustment Problems Associated with Evacuation
of
Peace Corps Volunteers
129
In the process of adapting,Volunteers often form deepattachments to the people with whom they live andwork.At the same time
as
they form these relationships,Peace Corpsvolunteers are restricted &om fully integratinginto their new environment. For example, they cannotuse local medical facilities or participate in politicalactivities.Adjustment to these multiple realities involvesthe complex task of maintaining one’s own identitywhile being open to very different views.An early study of psychological adjustment pat-terns of over 1000 former Peace CorpsVolunteers iden-tified what the authors called the “crisis
of
reentry.”” Twolater studies supported the difficulty of reentry: fifty-onepercent (51%) of formerVolunteers described their re-adjustment
to
the United States
as
somewhat difficult orvery difficult,“’ nd in
a
1977 survey, 62% percent reporteddifficulties with reentry.”In
1990,
approximately 6000 volunteers served inmore than
70
developing countries. During that year, threeincidents occurred which necessitated the mass evacu-ation of individuals serving in three countries. In March1990,112Volunteers were evacuated fiom Liberia because
of
the ongoing civil war.
In
July 1990,226Volunteers wereevacuated from the Philippines because of security issuesarising from the kidnapping of
a
Peace CorpsVolunteer.In August 1990, 44 Volunteers were evacuated fromYemen due to threats against the American communityduring the period prior to the Persian
Gulf
War. Mostevacuees had less than
3
days’notice prior to evacuation.We hypothesized that the disruption of an emergencyevacuation produced more stress than
a
planned depar-ture. A survey was developed
to
assess the evacuees’ per-ceptions of their experience, the psychological effects ofthe evacuations on thevolunteers, and their current level
of
functioning at the time of the survey.
Methods
Volunteers who had been evacuated from Liberia,Yemen, and the Philippines in 1990 constituted the casesin this study. Controls were individuals who had workedin these same countries immediately prior
to
the evac-uated Volunteers and had departed under regular con-ditions via the normal end-of-service orientation process.
All
evacuees and regular returnees were provided with
a
debriefing conference except evacuees from Liberia.A self-administered questionnaire was developedwith the assistance of
a
clinical social worker to collectdata on Volunteers’ perceptions
of
psychological andsupport issues.This questionnaire was based on the diag-nostic criteria of post-traumatic stress disorder and adjust-ment disorders from the Diagnostic and Statistical Manualof Mental Disorders.’2
It
queried the existence and dura-tion of
a
number
of
psychological symptoms, includingfeelings of disorientation; numbing of feelings; feelingimmobilized; disturbing dreams; avoidance
of
thinkingor talking about country experience; periods of crying;depression; anxiety; difficulty with sleep; change inappetite; irritability or outbursts of anger; and difficultymaking decisions. Questions relating to circumstances sur-rounding the evacuation (e.g., ability
to
say good-bye
to
friends), personal safety, and current activities were alsoincluded. The surveys for evacuees and nonevacueeswere the same except for questions relating
to
the cir-cumstances of evacuation. Confidentiality
of
responses
was
assured.The survey was conducted in January 1991, approx-imately 5 months after the
last
country evacuation. Oddsratios
(OR)
and 95% confidence intervals
(CI)
werecalculated using an exact method.13
Results
Of 356 questionnaires sent
to
evacuees, 265 (74%)were completed, and of 189 sent toVolunteers who haddeparted under regular circunistances (“regularreturnees”),
90
(48%) were returned (Table l).There wasno significant difference in the age or gender distribu-tion amongvolunteers in the three countries.The medianlength of stay for cases was 14 months (range: 1-64) andfor controls was 24 months (range: 4-39). Only 27% ofevacuated volunteers had an opportunity to say good-bye
to
friends,
as
opposed
to
97%
of regular returnees
A
higher proportion of evacuees reported psycho-logical symptoms compared
to
regular returnees. Sixtypercent of evacuees reported depression compared to 29%ofregular returnees
(OR
[95%
CI]
=
3.69
[2.14-6.461)(Table 2). Fifty-five percent of evacuees reported feelingsof disorientation compared to 33% of regular returnees
(OR
[95%CI]
=
2.45 [1.45-4.201). Forty-two percentof evacuees and 12% of regular returnees reported peri-ods of crying
(OR
[95% CI]
=
5.34 [2.66-11.611).
In
fact,
all
psychological symptoms except change in appetitewere significantly more likely in evacuees than in regu-lar returnees. However, the median duration of symptomswas either the same or shorter for
all
symptoms amongthe evacuees compared to the regular returnees.
To
evaluate other potential contributing factors
to
psychological stress, questions were asked relating
to
personal safety and whether the Volunteer had beenthreatened or harmed during their stay. On
a
four-pointsubjective scale (no, little, some, or great degree of threat),few evacuees (496, 11/262) or regular returnees
(3%,
3/89) felt
a
great degree
of
threat
to
their personal safety.However, 46%) (121/262)
of
evacuees reported little orsome degree of threat versus 65% (58/89) of regularreturnees, while
50%
(130/262) of evacuees felt no threat
(OR
[95% CI]
=
78.63 [24.43-396.131).
 
130
Journal
of
Travel Medicine, Volume
4,
Number
3
Table
1
Characteristics of Evacuated Volunteers and Those Who Departed under Regular Circumstances
~~ ~ ~ ~~~~~~~~~~~ ~~~~~~~ ~~~~~~~~~~~~~~~
Liberia Philippines Yemen TotalRegular Regular Regular RegularEvacuees Returnees Evacuees Returnees Evacuees Returnees Evacuees Returnees
Percent
85.7 51.2 68.8 43.0 76.7 70.0 74.4 47.6
responding
(84/98) (21/41) (1481215) (551128) (33/43) (14/20) (265/356) (90/189)
to
surveyfemale
in
years
(22-68) (23-69) (22-72) (23-69) (23-77) (24-77) (22-77) (23-77)
Percent
63.060.050.045.3 69.7 28.6 56.5 46.0
Median age
2527 262728 25.5 2627
(range)
in
months
(3-64) (24-31) (4-35) (4-38) (1 27) (15-39) (1-64) (4-39)
(range)Median
stay
I6 24 12 27 14 24 14 26
Percent
able
35.7
100.0
13.7 96.4 62.5 92.9 26.7 96.6to
say
(30184) (20/20) (201146) (53/55) (20132) (13114) (70/262) (86189)
goodbyeversus only 31% (28/89) of regular returnees. In addi-tion, only 18% (47/263) of evacuees were threatened orharmed versus 35% (31/89) of regular returnees.When asked about the return
to
the United States,many evacuees found the transition difficult. On a four-point scale (very easy, somewhat easy, somewhat hard, veryhard), 57% (146/254) of evacuees and 39% (34/88) ofregular returnees found the transition
at
least “somewhathard.” Only 13% (34/254) of evacuees found the tran-sition very easy versus
20%
(18/88) of regular returnees.
Discussion
Transcultural stays may be associated with significantpsychological symptoms upon return
to
one’s homecountry. In this study, approximately 25% of Volunteerswho returned under regular circumstances experiencedfeelings of depressi0n.A significant minority of theseVol-unteers self-reported various other symptoms consis-tent with the diagnostic criteria for post-traumatic stressdisorder or adjustment disorder.When individuals were forced to depart from theirhost country under emergency conditions, however, thepercent of individuals reporting these symptoms markedlyincreased. For example, over half of the evacuees reportedfeelings of depression or feelings of disorientation, andover 40% reported other concerning symptoms related
to
psychological stress.There are limitations to this study. Since symptomsare self-reported and are open
to
interpretation by theresponders, self-reporting is open
to
distortions of mem-ory and self-perception. Terms such as “depression” and“anxiety” assume some shared understanding, ince no def-initions were included with the questionnaire, and there-fore were not based on the definitions and distinctionspotentially made by a clinician. During the 2-year tourof duty, it
is
common for someVolunteers
to
return pre-maturely because
of
psychological or physical difficulties.In this study, regular returnees may potentially representa more stable cohort of Volunteers since most had com-pleted their 2-year commitment. Only
48%
of Volun-teers who had completed their service under regularcircumstances esponded to the questionnaire.The responserate in this group was partially due
to
the fact thatreturnedvolunteers are
a
highly mobile group and somequestionnaires never reached the intended person. Evac-uees may
also
have felt
a
greater need to respond because
of
the psychological effects of their recent experiences.Reported duration of symptoms for both cases andcontrols was similar. However, since the survey was con-ducted in January 1991, many of the evacuees had beenin the United States for less than 6 months and thiscould have affected the duration of their symptoms. Ofadditional note, a higher proportion of regular returneesreported being threatened or harmed. This may reflectthat regular returnees were on average longer in coun-try than evacuees.The Peace Corps originally initiated this study
to
learn more about the psychological impact of emer-gency evacuation. Because the findings documented theextent of stress, several important changes have occurred.Administrative officers now receive training in emergencyevacuation p1anning.A new manual offers
a
crisis inter-vention model for managing logistics, improving com-munications, and anticipating reactions of Volunteers,such as resistance
to
the evacuation and intense or con-tradictory feelings. Immediately aher emergency evac-uation, evacuees attend a debriefing workshop. Mentalhealth professionals conduct these meetings in order
to
facilitate group discussions
of
experiences, individualconsultation, and education about typical stress reac-tions. This offers opportunities
to
say good-bye
to
in-country fkiends and othervolunteers
as
well as to preparefor the return to the United States or for possible con-tinuation of Peace Corps service in another country.

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