In July 2010, my husband and I returned from four years working in Malawi. I had undertaken a Wellcome Trust Fellowship, and Peter worked in the government hospital and medical school. After extending our contracts three times, eventually it was time to return to the UK. Although we had made several visits to the UK during those four years for conferences and the births of two of our children, we were surprised at how difficult we found this final transition. There seemed to be an expectation that we would simply slot back into our old lives of four years ago, whereas in reality both we, and our friends and families, had undergone many significant life events in that time. Now that we were 'back', there often seemed disinterest regarding our time in Malawi and the on-going work there. We often felt misunderstood.

Culture shock and reverse culture shock

Talking to others who had returned from overseas work, I came to realise that our experience was not uncommon, and the challenges and frustrations we experienced were shared by many. On several occasions I was reminded that, 'returning home can be more difficult than the initial transition to overseas life'. The term 'culture shock' was coined by Kalervo Oberg in 1954, (1) describing psychological strain as a consequence of adaptation to a new environment, typically including an overwhelming sense of loss regarding friends, status, profession and possessions; confusion in role expectations, values, and self-identity; and surprise, anxiety, even disgust and indignation towards the new culture. (2) Whilst those who choose to spend time overseas are often prepared in advance for this initial process, individuals are often less well prepared for 'reverse culture shock' on returning to their primary culture. (3) Similarly, those who have a role in supporting the returner may expect them to be delighted at having returned home, not recognising that they may be undergoing a grieving process resembling the aftermath of a bereavement.

Survey of returners

As I considered writing about reverse culture shock, I decided to research the experiences of a range of Christians who had recently returned from overseas work, rather than relying simply on anecdote. Fifty six respondents who had worked in 22 different countries took part in a survey, three quarters of whom had been involved in medical work. The results provide a spectrum of individual experience, and point to recommendations for the future. The full methodology and results of this survey are available via bit.ly/ruPJ3t

The ten most positive and most negative aspects of the return home are summarised in the Table. The most negative experiences for two thirds of respondents were in the realm of inter-personal relationships; feeling misunderstood, having diffi- culty in re-establishing relationships, feeling 'different' and isolated and that others were not interested in the work undertaken overseas. In addition to missing friends and work they had left behind, they also missed other aspects of the overseas community, including a more holistic and spiritual worldview, the incorporation of prayer and worship into daily hospital life and the sense of community. Almost a third struggled with the materialism and consumerism of the society to which they returned.

Work factors

Almost half reported positive work-related factors, such as ease of communication, improved computer facilities, access to training, a clear career structure and improved team-working opportunities. 42 per cent cited negative experiences, including getting reinstated on registers, having work undertaken overseas accredited and becoming accustomed to changes within the NHS. Factors relating to the experience of work included lack of confidence and up-to-date skills, a feeling that work was no longer as satisfying and frustrations at the high expectations of patients with minor medical complaints.

Support for returners

There was no association between the difficulty experienced on return and the length of time overseas, nor with different support structures (independent/ mission organisation/ church support). Those who went overseas via a mission organisation were more likely to undergo debriefing; however these individuals did not experience significantly less difficulty and provided similar comments to those who went overseas as independent professionals.

From informal conversations, I was not surprised to discover that almost half the respondents said that they had no support from their church or sending organisation during the transition home. However, as one individual commented, there is a need to 'give people the benefit of the doubt. They don't ask the right questions because they don't know the right questions to ask. It's not that they don't care'. Friends, family and church members may feel ill-equipped to support the returner, but this survey suggests that simply being available to listen, ask questions and show an interest in the overseas work would help considerably. One respondent suggested a church could 'interview the returners so everyone understands where they came from and what their previous life was like; support the country or place they came from; pray for friends left behind and contacts made'.

Forty per cent of respondents suggested that mentorship, either formal or informal, possibly involving the creation of networks of returners, would be of benefit; 'link people up with a “buddy” – someone who has trodden the path before – to give hints and ideas, but mostly just to listen and be able to understand where the person is at'. Survey respondents gave examples of advice they might give to future returners:

'Take the lead in talking about time away – if you don't, you might never be asked! Likewise, you have to remember a lot has gone on for your friends in the time you have been away'.

'Know that it's going to be difficult. Pray. Talk to people about how you feel. Get involved in new things. Realise that God will use you everywhere.'

'Try to see it as a move from one mission field to another rather than a return home; a Christian should never feel truly at home in this world'.

Conclusions

The results of this survey reveal some of the main challenges encountered by returning overseas workers in addition to providing helpful suggestions as to how the process can be improved.

Catriona Waitt is a NIHR Clinical Lecturer in Clinical Pharmacology and Therapeutics at the University of Liverpool (and an honorary SpR at the Royal Liverpool University Hospital Catriona would like to thank all those who took part in the research project and provided helpful information for this article.