Copyright © 2005 Royal Australian College of General Practitioners Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners.BACKGROUND: Re-entry adjustment affects Australian cross cultural workers returning home; and for many, loss and grief issues arise. General practitioners are often the first point of contact in the health care system and are well placed to deal with these issues. OBJECTIVE: This article examines strategies that GPs can use to support the Australian cross cultural worker on re-entry, and focuses on recognition of re-entry adjustment, the role of loss and grief issues, and the importance of dealing with these issues. DISCUSSION: Australian cross cultural workers are valued members of their communities. However, their loss and grief issues associated with re-entry adjustment on return are often unrecognised and may lead to significant morbidity. Acknowledgment of their disenfranchised grief and appropriate therapy may be part of the role of their GP. Further research is needed to equip GPs to manage this important group in the Australian community.Susan Selby, Alison Jones, Sheila Clark, Teresa Burgess and Justin Beilb

Beilby, J.

Burgess, T.

Clark, S.

Jones, A.

Selby, S.

Adelaide Research &amp; Scholarship

Reprinted from Australian Family Physician Vol. 34, No. 10, October 2005 4 863Over 90 000 Australians left Australia in 2001–2002 intending to stay away for 12 months or more, but planning to return eventually.1 Of these, approximately 4000 left Australia to work in other cultures for missionary organisations.2 An increasing number of workers for humanitarian aid organisations are also working in other cultures with AusAID listing 34 fully accredited nongovernment organisations with workers overseas.3 On their re-entry to Australia, these workers experience re-entry adjustment or reverse culture shock which may be more severe than the culture shock they experienced on entering another culture.4 Of key importance is the initial recognition of re-entry adjustment, the associated loss and grief issues, and the provision of support for patients to deal with this. Recognition of  re-entry adjustmentRe-entry adjustment is the transition back into one’s home culture after living for a time in another.5 This may involve physical, emotional, cognitive, behavioural, social and spiritual changes for the individual. Cross cultural workers leave their country of origin, move to a new host culture where they may be part BACKGROUND  Re-entry adjustment affects Australian cross cultural workers returning home; and for many, loss and grief issues arise. General practitioners are often the first point of contact in the health care system and are well placed to deal with these issues. OBJECTIVE  This article examines strategies that GPs can use to support the Australian cross cultural worker on re-entry, and focusses on recognition of re-entry adjustment, the role of loss and grief issues, and the importance of dealing with these issues.DISCUSSION  Australian cross cultural workers are valued members of their communities. However, their loss and grief issues associated with re-entry adjustment on return are often unrecognised and may lead to significant morbidity. Acknowledgment of their disenfranchised grief and appropriate therapy may be part of the role of their GP. Further research is needed to equip GPs to manage this important group in the Australian community.Susan Selby, MBBS, FRACGP, FACPsychMed, is a general practitioner and PhD student,  Department of  General Practice, The University of  Adelaide, South Australia. susan.selby@adelaide.edu.auAlison Jones, BA, PhD, is Senior Lecturer, Department of  General Practice, The University of  Adelaide, South Australia.Sheila Clark, MD, MBBS, BSc, DRCOG, FRACGP, FACPsychMed, is a general practitioner, and former Senior Lecturer, Department of  General Practice, The University of  Adelaide, South Australia.Teresa Burgess, MPHC, GDipNursMan, RN, RCNA, is Senior Lecturer, Department of  General Practice,  The University of  Adelaide, South Australia.Justin Beilby, MD, MPH, MBBS, FRACGP, DRACOG, DA, is Head, Department of  General Practice,  The University of  Adelaide, South Australia.Re-entry adjustment of   cross cultural workersThe role of the GPCase study – Mrs KDMrs KD, aged 55 years, presented after a number of  years as a cross cultural worker involved in missionary work in a third world country. She had various health issues and felt like ‘a fish out of  water’. She described herself  as having no sense of  belonging, feeling angry, not really wanting to relate to people but knowing she had to, and not wanting to be home. This was affecting her ability to function with her daily tasks and she complained of  insomnia.‘It is like swimming through mud’ ‘It’s kind of  like being... on the deck of  a ship in a storm... if  you don’t even know what to call what’s going on it’s extremely frightening’ Clinical update • CLINICAL PRACTICE864 3Reprinted from Australian Family Physician Vol. 34, No. 10, October 2005Clinical  practice: Re-entry adjustment of  cross cultural workers – the role of  the GPof another subculture, and then return to their own culture again, sometimes multiple times. During the time they have been away, their own culture has again altered, transforming it into another changed culture to which they need to adjust. Re-entry adjustment was identified as a separate process to culture shock in the early 1960s by Gullahorn and Gullahorn.6 The process of re-entry was assumed to be the same as that of culture shock with the sequence of elation, depression and recovery or adaptation being repeated on return to the home country. However, more recent authors summarising the literature have highlighted the differences between culture shock and re-entry adjustment including the lack of anticipation of re-entry problems, different perceptions of self, home, family and friends, and the lack of interest in the returnee’s foreign adventures by those in the home country.7 Both reviews8,9 and personal accounts10 indicate that there is significant distress during re-entry which may have a complex aetiology and explanation.Symptoms of  re-entry adjustmentThe cross cultural worker may present with a range of symptoms such as difficulty relating to friends and family, difficulty with job performance, problems with identity, and issues of loss and grief.11 Clark12 lists a number of physical, emotional, cognitive and behavioural phenomena of grief (eg. headache, mood fluctuations, poor memory, sleeplessness). Gardner13 lists symptoms of anxiety and depression as part of transition stress, and Pirollo10 lists suicide, which may be a complicated outcome of loss, as one of the re-entry behavioural patterns. These are all important scenarios that may be part of the cross cultural worker’s presentation to their GP on returning to Australia.The role of  loss and grief  issues Current theories to explain re-entry adjustment include dealing with the changed meaning of ‘home’,14 and shifts in the re-entrant’s cultural identity9 as they journey back into their ‘home culture’. These theories do not emphasise the issues of loss and grief in re-entry adjustment, however some authors acknowledge the importance of these aspects in the literature. Austin8 emphasises a sense of loss as ‘another prevailing motif of re-entry’. He includes losses for returned missionaries such as the loss of status, underutilisation of field skills and experiences, and loss of some degree of independence.  Others explain their observations as part of the grief process. Stringham15 proposed that individuals’ experiences during re-entry included profound grief for the loss of social reinforcers, and found sojourn outcome is also a predictor for grief reactions, successful outcomes of overseas assignments being associated with facilitation of the grieving process. Foyle16 defines re-entry adjustment as ‘reverse bereavement’, implying the role of grief, and naming loss of role as one of the most stressful factors. Pirolo10 records a number of short accounts of missionaries’ experiences on re-entry, mainly to the USA, with acknowledgment by some that ‘there was a lot of grief to work through’. Lester17 provides the key concepts and missing link in re-entry adjustment research. She asks ‘what is missing?’ and answers the question in terms of loss and grief concepts. She particularly emphasises the need to mourn the loss of cultures and identity, but also identifies the issue of disenfranchised or unacknowledged grief for those experiencing re-entry adjustment. Her model acknowledges that one of the key factors in facilitating re-entry adjustment is the legitimising of grief issues.The importance of  dealing with loss  and grief  Why should the GP address loss and grief issues for returning Australian cross cultural workers? There is a large body of literature from the studies of the effects of bereavement that supports morbidity as an outcome of the grief process. Stroebe and Stroebe18 surveyed the literature and concluded that the loss of a partner is associated with the deterioration of health of the surviving partner. Rando19 lists psychological, behavioural, and physical symptoms as potential outcomes of loss, and complicated mourning with diagnosable mental and physical disorders being further outcomes. If this concept is extended to the effects of loss and grief on the returning cross cultural worker, there is an opportunity for the GP not only to prevent poor health outcomes but also to recognise the emotional causes for physical symptoms, prevent somatisation and minimise unnecessary investigations and referrals. There has been little research into the effectiveness of brief counselling and therapy in this area, however Powell20 discusses the usefulness of these techniques in dealing with loss and transition in cross cultural workers. Brief counselling is easily incorporated into the general practice setting. The GP who is aware of the adjustment process may also have a role in legitimising the grief issues for re-entrants. At present there is no comprehensive program available for use in general practice to detect and manage these issues.ConclusionGeneral practitioners are often one of the first points of contact for cross cultural workers returning to Australia. They play a significant role in exploring the health issues surrounding re-entry by understanding the process and recognising the presentations of re-entry adjustment, exploring and acknowledging the loss and grief issues for these workers, and undertaking brief therapy and counselling to manage and prevent further morbidity. Further research to clarify the loss and grief issues of the re-entry experience and to develop a management plan is needed to enable GPs to support cross cultural workers as they journey back into Australian society.Conflict of interest: none declared.AcknowledgmentsThe PHCRED Program (Commonwealth Department of Health and Ageing) and The University of Adelaide Faculty of Health Sciences in supporting the PhD Thesis: The Development of a Repatriation Program to Deal with Issues of Loss and Grief in Adult Australian Cross-Cultural Workers. ‘It’s like... being like a yacht pushed before the wind with your keel down and you’re ploughing along and all of  a sudden someone comes along and pulls the rudder off  and all of  a sudden the boat’s just spinning around, at a loss to know what to do...’ Australian Family Physician Vol. 34, No. 10, October 2005 4 865Reprinted from References1. Australian Bureau of Statistics. International migration. Available at: www.search.abs.gov/servlet/SearchDocuments.2. Johnstone P, Johnstone R, Mandryk J. Operation world. 6th ed. Cumbria: Paternoster Lifestyle, 2001. 3. Australian Government AusAID. Nongovernment organizations. Available at: www.ausaid.gov.au/ngos/accredited.cfm.4. Black JS, Gregersen HB, Mendenhall ME. Toward a theoretical framework of repatriation adjustment. Journal of International Business Studies 1992;23:737–60.5. Olson L. Home again! (cross cultural re-entry). Student Leadership Journal, 2004. Available at: www.intervarsity.org/slj/topics/crossingcultures/.6. Gullahorn JT, Gullahorn JE. An extension of the U-curve hypothesis. J Soc Issues 1963;19:33–47. 7. Onwumchili C, Nwosu PO, Jackson II RL, James-Hughes J. In the deep valley with mountains to climb: exploring identity and multiple re-accultura-tion. International Journal of Intercultural Relations 2003;27:41–62. 8. Austin CN. Cross cultural re-entry: a book of readings. Abilene, Texas: Christian University, 1986. 9. Sussman N. The dynamic nature of cultural identity throughout cultural transitions: why home is not so sweet. Personality and Social Psychological Review 2000;4:355–73.10. Pirolo N. The re-entry team. San Diego, California: Emmaus Road International, 2000. 11. Missionary Outreach Support Services. Common struggles, re-entry issues. Regent University, Virginia. Available at: www.missionaryoutreach.net/common.asp?Action=re_entry_issues.12. Clark SE. Loss and grief in general practice: the develop-ment and evaluation of two instruments to detect and measure grief in general practice patients (dissertation). Adelaide: University of Adelaide, 2003.13. Gardner LM. A practical approach to missionary transitions. In: Powell J, Bowers J, editor. Enhancing missionary vitality. Colorado: Mission Training International, 2002. 14. Storti C. The art of coming home. Maine: Intercultural Press, 2001.15. Stringham EM. The re-acculturation of missionary fami-lies: a dynamic theory. J Psychol Theol 1993;21:66–73.16. Foyle MF. Honourably wounded, stress among christian workers. London: Monarch Books, 2001.17. Lester JC. Strangers in their own land: culture loss, disenfranchised grief, and re-entry adjustment (disserta-tion). New Hampshire: Antioch University, 2001.18. Stroebe W, Stroebe MS. Bereavement and health. The psychological and physical consequences of partner loss. Cambridge: Cambridge University Press, 1987.19 Rando TA. Treatment of complicated mourning. Champaign, Illinois: Research Press, 1993.20. Powell JR. Brief counselling and therapy during over-seas visits. In: Powell J, Bowers J, editors. Enhancing missionary vitality. Colorado: Mission Training International, 2002. CorrespondenceEmail: afp@racgp.org.auAFPClinical  practice: Re-entry adjustment of  cross cultural workers – the role of  the GP

Re-entry adjustment of cross cultural workers

https://digital.library.adelaide.edu.au/dspace/bitstream/2440/17224/1/hdl_17224.pdf

Re-entry adjustment of cross cultural workers

Abstract

Similar works

Full text

Available Versions

Adelaide Research & Scholarship

Re-entry adjustment of cross cultural workers

Abstract

Similar works

Full text

Available Versions

Adelaide Research &amp; Scholarship

Adelaide Research & Scholarship