Psychological and Readjustment Problems Associated with

Emergency 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 foreign
countries, we surveyed t w o groups of recently returned Peace Corps Volunteers.

Methods: Cases were individuals (n = 265) who had been evacuated under emergency circumstances from their countries 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 n o significant age or gender differences between cases and controls. The median length of service
i n the foreign country was 14 months for evacuees and 24 months for regular returnees. Feelings of depression were
self-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 upon
return to ones home country. When forced to depart from ones host country under emergency conditions, the likelihood
of individuals reporting these symptoms markedly increases.

Residing in a foreign country can be psychologically demanding.. One may be required to learn a different language and adapt to a new culture. Collectively,
the process of adjusting to a new sociocultural milieu has
been termed culture hock."^ Each year, many thousands
of individuals relocate temporarily to developing countries for stays ranging from weeks to years. Upon returning to ones country of origin, readjustment to ones home
culture, which involves many of the same psychological
issues faced by departing individuals, is often needed
and may be termed reverse culture ~h0ck.l~
Under
normal circumstances this can be difficult; however,
emergency evacuation under adverse conditions could
potentially cause additional stress to an already vulnerable individual.
The wordreentrybecame part of the American lexicon through the space program. People learned that reentry to the earth was as stressful and dangerous as leaving

Cross-cultural reentry-the experience of facing previously familiar surroundings after living in a different environment-also
can be stressful.h This
experience has been hypothesized to be more difficult
The unexthan the initial move to a foreign ~ulture.~.
pected dificulty with reentry has the power to render
ineffective those involved in the process.6,8Planning for
the return to ones home country after living abroad can
reduce the level of surprise of a di5cult reentry.The Canadian International Development Agency reported that
unexpected changes are much harder to cope with
than expected changes.
This study examines some of the psychological
problems faced by Peace Corps Volunteers who were
abruptly evacuated from their host countries. Outcome
measures are compared to Peace CorpsVolunteers who
had completed their service under regular circumstances.

Background
Jon Mark Hirshon, MD, MPH: Johns Hopkins School of

The Peace Corps of the United States is a federally

funded international development agency that sponsors
adult American volunteers in developing countries. Peace
CorpsVolunteers live and work under conditions similar
to those of the host country people whom they serve. Service is approximately 2 years. Successful involvement
requires the ability to adapt to a new culture which is likely
to include different languages, gender roles, food, housing, sanitation, health risks, and expectations concerning
individual rights, privacy, work, and the possibility for
change. After 2 years, the Volunteers are either reassigned to a new post or repatriated to the United States.

Hygiene 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 and
Washington 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 Bayview
Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224.
J Travel Med 1997;4:128-131.
128

H i r s h o n e t a l . , A d j u s t m e n t P r o b l e m s A s s o c i a t e d w i t h E v a c u a t i o n o f Peace C o r p s V o l u n t e e r s

In the process of adapting,Volunteersoften form deep

attachments to the people with whom they live and
work.At the same time as they form these relationships,
Peace Corpsvolunteers are restricted &om fully integrating
into their new environment. For example, they cannot
use local medical facilities or participate in political
activities.Adjustment to these multiple realities involves
the complex task of maintaining ones own identity
while being open to very different views.
An early study of psychological adjustment patterns of over 1000 former Peace CorpsVolunteers identified what the authors called the crisis of reentry. Two
later studies supported the difficulty of reentry: fifty-one
percent (51%) of formerVolunteers described their readjustment to the United States as somewhat difficult or
very difficult,and in a 1977 survey, 62% percent reported
difficulties with reentry.
In 1990, approximately 6000 volunteers served in
more than 70 developing countries. During that year, three
incidents occurred which necessitated the mass evacuation of individuals serving in three countries. In March
1990,112Volunteers were evacuated fiom Liberia because
of the ongoing civil war. In July 1990,226Volunteers were
evacuated from the Philippines because of security issues
arising from the kidnapping of a Peace CorpsVolunteer.
In August 1990, 44 Volunteers were evacuated from
Yemen due to threats against the American community
during the period prior to the Persian Gulf War. Most
evacuees had less than 3 daysnotice prior to evacuation.
We hypothesized that the disruption of an emergency
evacuation produced more stress than a planned departure. A survey was developed to assess the evacueesperceptions of their experience, the psychological effects of
the 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 cases
in this study. Controls were individuals who had worked
in these same countries immediately prior to the evacuated Volunteers and had departed under regular conditions 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 developed
with the assistance of a clinical social worker to collect
data on Volunteers perceptions of psychological and
support issues.This questionnaire was based on the diagnostic criteria of post-traumatic stress disorder and adjustment disorders from the Diagnostic and Statistical Manual
of Mental Disorders.2It queried the existence and duration of a number of psychological symptoms, including

129

feelings of disorientation; numbing of feelings; feeling

immobilized; disturbing dreams; avoidance of thinking
or talking about country experience; periods of crying;
depression; anxiety; difficulty with sleep; change in
appetite; irritability or outbursts of anger; and difficulty
making decisions.Questions relating to circumstances surrounding the evacuation (e.g., ability to say good-bye to
friends), personal safety, and current activities were also
included. The surveys for evacuees and nonevacuees
were the same except for questions relating to the circumstances of evacuation. Confidentiality of responses
was assured.
The survey was conducted in January 1991, approximately 5 months after the last country evacuation. Odds
ratios (OR) and 95% confidence intervals (CI) were
calculated using an exact method.13

Results
O f 356 questionnaires sent to evacuees, 265 (74%)
were completed, and of 189 sent toVolunteers who had
departed under regular circunistances (regular
returnees), 90 (48%) were returned (Table l).There was
no significant difference in the age or gender distribution amongvolunteers in the three countries.The median
length of stay for cases was 14 months (range: 1-64) and
for controls was 24 months (range: 4-39). Only 27% of
evacuated volunteers had an opportunity to say goodbye to friends, as opposed to 97% of regular returnees
(OR [95% CI] = 78.63 [24.43-396.131).
A higher proportion of evacuees reported psychological symptoms compared to regular returnees. Sixty
percent 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 feelings
of disorientation compared to 33% of regular returnees
(OR [95% CI] = 2.45 [1.45-4.201). Forty-two percent
of evacuees and 12% of regular returnees reported periods of crying (OR [95% CI] = 5.34 [2.66-11.611). In
fact, all psychological symptoms except change in appetite
were significantly more likely in evacuees than in regular returnees. However, the median duration of symptoms
was either the same or shorter for all symptoms among
the 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 been
threatened or harmed during their stay. O n a four-point
subjective 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 or
some degree of threat versus 65% (58/89) of regular
returnees, while 50% (130/262) of evacuees felt no threat

J o u r n a l of T r a v e l M e d i c i n e , V o l u m e 4 , N u m b e r 3

130

Table 1 Characteristics of Evacuated Volunteers and Those Who Departed under Regular Circumstances
~~

~~~~~~~~~~~

~~~~~~~

Liberia

Percent
responding
to survey
Percent
female
Median age
in years
(range)
Median stay
in months

(range)
Percent able
to say

Philippines

~~~~~~~~~~~~~~~

Yemen

Total

Evacuees

Regular
Returnees

Evacuees

Regular
Returnees

Evacuees

Regular
Returnees

Evacuees

Regular
Returnees

85.7
(84/98)

51.2
(21/41)

68.8
(1481215)

43.0
(551128)

76.7
(33/43)

70.0
(14/20)

74.4
(265/356)

47.6
(90/189)

63.0

60.0

50.0

45.3

69.7

28.6

56.5

46.0

25
(22-68)

27
(23-69)

26
(22-72)

27
(23-69)

28
(23-77)

25.5
(24-77)

26
(22-77)

27
(23-77)

I6
(3-64)

24
(24-31)

12
(4-35)

27
(4-38)

14
(1-27)

24
(15-39)

14
(1-64)

26
(4-39)

35.7
(30184)

100.0
(20/20)

13.7
(201146)

96.4
(53/55)

62.5
(20132)

92.9
(13114)

26.7
(70/262)

96.6
(86189)

goodbye
versus only 31% (28/89) of regular returnees. In addition, only 18% (47/263) of evacuees were threatened or
harmed versus 35% (31/89) of regular returnees.
When asked about the return to the United States,
many evacuees found the transition difficult. O n a fourpoint scale (very easy,somewhat easy, somewhat hard, very
hard), 57% (146/254) of evacuees and 39% (34/88) of
regular returnees found the transition at least somewhat
hard. Only 13% (34/254) of evacuees found the transition very easy versus 20% (18/88) of regular returnees.

Discussion
Transcultural stays may be associated with significant
psychological symptoms upon return to ones home
country. In this study, approximately 25% of Volunteers
who returned under regular circumstances experienced
feelings of depressi0n.A significant minority of theseVolunteers self-reported various other symptoms consistent with the diagnostic criteria for post-traumatic stress
disorder or adjustment disorder.
When individuals were forced to depart from their
host country under emergency conditions, however, the
percent of individuals reporting these symptoms markedly
increased. For example, over half of the evacuees reported
feelings of depression or feelings of disorientation, and
over 40% reported other concerning symptoms related
to psychological stress.
There are limitations to this study. Since symptoms
are self-reported and are open to interpretation by the
responders, self-reporting is open to distortions of memory and self-perception. Terms such as depression and
anxiety assume some shared understanding,since no definitions were included with the questionnaire, and therefore were not based on the definitions and distinctions
potentially made by a clinician. During the 2-year tour
of duty, it is common for someVolunteers to return prematurely because of psychological or physical difficulties.

In this study, regular returnees may potentially represent

a more stable cohort of Volunteers since most had completed their 2-year commitment. Only 48% of Volunteers who had completed their service under regular
circumstancesresponded to the questionnaire.Theresponse
rate in this group was partially due to the fact that
returnedvolunteers are a highly mobile group and some
questionnaires never reached the intended person. Evacuees 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 and
controls was similar. However, since the survey was conducted in January 1991, many of the evacuees had been
in the United States for less than 6 months and this
could have affected the duration of their symptoms. Of
additional note, a higher proportion of regular returnees
reported being threatened or harmed. This may reflect
that regular returnees were on average longer in country than evacuees.
The Peace Corps originally initiated this study to
learn more about the psychological impact of emergency evacuation. Because the findings documented the
extent of stress, several important changes have occurred.
Administrative officers now receive training in emergency
evacuation p1anning.A new manual offers a crisis intervention model for managing logistics, improving communications, and anticipating reactions of Volunteers,
such as resistance to the evacuation and intense or contradictory feelings. Immediately aher emergency evacuation, evacuees attend a debriefing workshop. Mental
health professionals conduct these meetings in order to
facilitate group discussions of experiences, individual
consultation, and education about typical stress reactions. This offers opportunities to say good-bye to incountry fkiends and othervolunteers as well as to prepare
for the return to the United States or for possible continuation of Peace Corps service in another country.

H i r s h o n e t al., A d j u s t m e n t P r o b l e m s A s s o c i a t e d w i t h E v a c u a t i o n o f P e a c e C o r p s V o l u n t e e r s

131

Table 2 Frequency and Duration of Psychological Symptoms

~~

Median Duration .f
Symptoms in Weeks (Range)

Percentage Reporting
Symptoms (Number/Tatal)
Symptoms

Evacuees

Regular
Returnees

Odds Ratio
(95% Cl)

Evacuees

Regular
Returnees

Depression
Disorientation
Dificulty making
decisions
Anxiety
Numbing of
feeling
Periods ofcrying
Irritability or
outbursts of anger
Avoidance of talking
or thinking about
experience
Disturbing dreams
Feeling immobilized
Difficulty sleeping
Change in appetite

60.0 (159/265)
55.1 (146/265)
49.4 (1311265)

28.9 (26/90)
33.3 (30/90)
25.5 (23/90)

3.69* (2.14-6.46)
2.45* (1.45-4.20)
2.85* (1.63-5.08)

8.0 (0.5-51.0)
4.0 (0.5-30.0)
8.5 (0.5-64.0)

8.0 (2.0-44.0)
6.0 (0.5-26.0)
12.0 (2.0-28.0)

46.4 (123/265)
43.4 (115/265)

26.7 (24/90)
14.4 (13/90)

2.19* (1.37-2.38)
4.54* (2.35-9.33)

8.0 (0.5-64.0)
4.0 (0.5-40.0)

12.0 (1.0-24.0)
8.0 (2.0-62.0)

42.6 (113/265)
35.1 (93/265)

12.2 (11/90)
12.2 (11/90)

5.34* (2.66-11.61)
3.88* (1 -93-8.48)

4.0 (0.5-40.0)
6.0 (0.5-30.0)

5.5 (0.5-16.0)
16.0 (6.0-26.0)

34.0 (90/265)

15.5 (14/90)

2.79* (1.46-5.64)

8.0 (2.0-64.0)

12.0 (3.5-22.0)

33.2
31.7
28.3
23.4

12.2 (11/90)
18.8 (17/90)
12.2 (1 1/90)
20.0 (18/90)

3.57* (1.77-7.81)
1.99* (1.08-3.83)
2.83* (1.40-6.23)
1.22 (0.66-2.35)

8.0 (0.5-64.0)
6.0 (0.5-40.0)
4.0 (0.5-64.0)
4.0 (0.5-40.0)

12.0 (3.0-19.0)
6.0 (2.0-24.0)
12.0 (2.0-16.0)
12.0 (2.0-62.0)

(88/265)
(84/265)
(75/265)
(62/265)

* statistically significant
Volunteers also receive information about seeking medical and psychological care in the future.
Another important organizational change has been
broader recognition of the importance of the reentry stage
of the usual Peace Corps experience.The findings of this
study emphasized the potential psychological problems
for allVolunteers in rejoining the American culture.The
workshop, which is now routinely offered 2 months
before the end of service, includes information on the
findings of this study, as well as discussion of the strategies for coping with various reactions, indicators of the
need for professional help, and description of returning
Volunteers medical resources and benefits.
It is important to recognize that prolonged service
in foreign countries requires significant adaptation and,
upon returning home, reverse culture shock often occurs.
In addition, when individuals are abruptly forced to
depart from their host countries, increased psychological trauma is likely. Preparation, both through advance
contingency planning and individual and group postcounselling, is a critical support function of sponsoring
organizations.

Acknowledgments
The authors would like to thank Joni Hermann for
assistance with data analysis, and Timothy Baker, MD,
MPH, for final manuscript review.

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