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TrajectoriesofSpiritualChangeAmongExpatriateHumanitarianAidWorkers:AProspectiveLongitudinalStudy

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DOI:10.1037/a0037703

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Psychology of Religion and Spirituality

Trajectories of Spiritual Change Among ExpatriateHumanitarian Aid Workers: A Prospective LongitudinalStudyCynthia B. Eriksson, Jason M. Holland, Joseph M. Currier, Leslie M. Snider, Alastair K. Ager,Reinhard E. R. Kaiser, and Winnifred S. SimonOnline First Publication, August 18, 2014. http://dx.doi.org/10.1037/a0037703

CITATIONEriksson, C. B., Holland, J. M., Currier, J. M., Snider, L. M., Ager, A. K., Kaiser, R. E. R., &Simon, W. S. (2014, August 18). Trajectories of Spiritual Change Among ExpatriateHumanitarian Aid Workers: A Prospective Longitudinal Study. Psychology of Religion andSpirituality. Advance online publication. http://dx.doi.org/10.1037/a0037703

Trajectories of Spiritual Change Among Expatriate Humanitarian AidWorkers: A Prospective Longitudinal Study

Cynthia B. ErikssonFuller Theological Seminary

Jason M. HollandUniversity of Nevada, Las Vegas

Joseph M. CurrierUniversity of South Alabama

Leslie M. SniderWar Trauma Foundation, Amsterdam, The Netherlands

Alastair K. AgerColumbia University

Reinhard E. R. KaiserCenters for Disease Control and Prevention, Nairobi, Kenya

Winnifred S. SimonAntares Foundation, Amsterdam, The Netherlands

Expatriate humanitarian aid workers are often exposed to traumatic events and human suffering in thecontext of their deployments. Internal resources, such as having recourse to a transcendent spiritualframework, may play an important part in creating a meaningful perspective on the work and developingcoping strategies to overcome challenging experiences. Aid workers from agencies based in NorthAmerica and Europe participated in a longitudinal study of stress and mental health between 2005 and2009 (Lopes Cardozo et al., 2012). Participants completed assessments of spiritual transcendence, traumaexposure, psychiatric distress, and posttraumatic life changes at predeployment (n � 212), postdeploy-ment (n � 170), and a 3- to 6-month follow-up assessment (n � 154). Latent class growth analysisindicated 3 distinct trajectories of spiritual changes across the sample: (1) a group with high spiritualtranscendence at predeployment with small, but significant, decreases over time; (2) a group with moderateand stable spiritual transcendence scores; and (3) a group with low and slightly decreasing spiritual transcen-dence scores over the study period. Participants who reported a religious affiliation were more likely to be inthe high spiritual transcendence group, and different trajectories were not associated with likelihood ofpsychiatric distress at postdeployment or follow-up. However, those reporting higher spiritual transcendencewere more likely to report positive life changes following their deployments. Findings suggest that spiritualtranscendence was relatively stable in this sample, and that aid workers with greater spiritual transcendencemay be more oriented toward personal growth after trauma exposure in their work.

Keywords: humanitarian aid, posttraumatic growth, spirituality, trauma exposure

Humanitarian aid workers are deployed to settings where theyare confronted by tragic conditions of human-made and naturaldisasters. They can experience trauma through direct victimization

and/or threat of harm, as well as indirect trauma as they work withimpacted local communities recovering from war, disaster, andother emergencies. This direct and indirect exposure to highly

Cynthia B. Eriksson, Graduate School of Psychology, Fuller TheologicalSeminary; Jason M. Holland, Department of Psychology, University ofNevada, Las Vegas; Joseph M. Currier, Psychology Department, Univer-sity of South Alabama; Leslie M. Snider, War Trauma Foundation, Am-sterdam, The Netherlands; Alastair K. Ager, Mailman School of PublicHealth, Columbia University; Reinhard E. R. Kaiser, Center for GlobalHealth, Division of Global HIV/AIDS, Centers for Disease Control andPrevention, Nairobi, Kenya; Winnifred S. Simon, The Antares Foundation,Amsterdam, The Netherlands.

The data collection for this article was funded by the U.S. Centers forDisease Control and Prevention (CDC) and the Antares Foundationthrough a cooperative agreement. The protocol and instruments used instudy were based upon work by the CDC/Antares Foundation Cooperativeagreement research consortium which consists of the following individu-

als: Alastair Ager, Columbia University; Carol Gotway Crawford, CDC;Cynthia Eriksson, Graduate School of Psychology, Fuller TheologicalSeminary; David Foy, Pepperdine University; Miranda Olff, University ofAmsterdam; Barbara Lopes Cardozo, CDC/Emergency Response and Re-covery Branch; Reinhard Kaiser, Center for Global Health, Division ofGlobal HIV/AIDS, Centers for Disease Control and Prevention, Nairobi,Kenya; Willem Scholte, University of Amsterdam; Leslie Snider, WarTrauma Foundation; Miriam Sabin, World Health Organization.

The findings and conclusions reported in this article are those of theauthors and do not necessarily represent the views of the US Centers forDisease Control and Prevention.

Correspondence concerning this article should be addressed to Cyn-thia B. Eriksson, Graduate School of Psychology, Fuller TheologicalSeminary, 180 North Oakland Avenue, Pasadena, CA 91101. E-mail:eriksson@fuller.edu

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Psychology of Religion and Spirituality © 2014 American Psychological Association2014, Vol. 6, No. 4, 000 1941-1022/14/$12.00 http://dx.doi.org/10.1037/a0037703

1

stressful events has been associated with several negative mentalhealth outcomes (e.g., depression, anxiety, and posttraumatic stressdisorder [PTSD]) in aid workers in a variety of cultural contexts(e.g., Ager et al., 2012; Cardozo et al., 2005; Eriksson, VandeKemp, Gorsuch, Hoke, & Foy, 2001; Jones, Müller, & Maercker,2006; Lopes Cardozo et al., 2013; Shah, Garland, & Katz, 2007).Beyond the inherent risk of exposure to trauma and violenceduring deployment, research has demonstrated a number of vari-ables, such as social support, team cohesion, trauma history, andhistory of mental illness, which can function as significant risk orresilience factors in posttraumatic adjustment in this population(Lopes Cardozo et al., 2012). However, one underresearched areaof proposed resilience is the spirituality of the humanitarianworker (Eriksson, Bjorck, & Abernethy, 2003).

There is recognition among behavioral scientists that spiritualitycan have a profound influence in promoting resources for copingwith life’s difficulties (Gall & Guirguis-Younger, 2013). Human-itarian aid work in particular is founded on acts of service, respon-sibility, and values, irrespective of whether the organization isembedded in a spiritual tradition (e.g., faith-based nongovernmen-tal organization [NGO] with a stated mission) or more generallywithin the ethics of the humanitarian imperative (e.g., enshrined inthe United Nations framing of human rights and dignity; Fawcett,2003; Sphere Project, 2011). Aid staff may choose to participate incross-cultural aid missions as a “calling” or as a means of makinga contribution that transcends their own self-interest in some way(Dik, Duffy, & Tix, 2012, p. 113). This spiritual orientation to thework may create a context of resilience and support for many aidworkers. For example, a sample of 111 expatriate aid workers froma faith-based NGO generally indicated supportive relationshipswith a divine figure (Eriksson et al., 2003), and this support hasbeen associated with lower levels of burnout (Eriksson et al.,2009). In another study of 398 national aid workers (those em-ployed in their own country) in Sri Lanka, participants similarlyindicated their religion was an important coping resource (LopesCardozo et al., 2013). Spiritual beliefs and values could influencemany aid workers’ appraisal of and ability to cope with traumaticevents during deployment as well. Drawing on a group of expa-triate aid workers who completed deployments in a range ofinternational settings, the main goals of this study were to examine(1) the role of spiritual transcendence in postdeployment adjust-ment and (2) how trajectories of changes in their spiritual experi-ences predict levels of psychiatric distress and personal growth.

Spiritual Transcendence as a Construct

Although spirituality has been described as a “numinous” con-struct (Piedmont, Ciarrochi, Dy-Liacco, & Williams, 2009, p.162), researchers have operationalized several key behavioral,affective, and cognitive components (Monod, Brennan, Rochat,Martin, Rochat, & Büla, 2011). For example, a number of scholarshave reflected on the importance of transcendence as the center ofunderstanding spirituality (e.g., Piedmont et al., 2009; Seidlitz etal., 2002). From this perspective, spirituality represents “an indi-vidual’s understanding of, experience with, and connection to thatwhich transcends the self” (Drescher, Ramirez, Leoni, Romesser,Sornborger, & Foy, 2004, p. 330). However, spirituality and reli-gion are closely intertwined in infusing many individuals’ liveswith purpose, meaning, ritual, beliefs, relationships, and motiva-

tion. As such, Hill and Pargament (2003) have suggested that it isvitally important for behavioral scientists to recognize the complexand often interrelated nature of these two constructs, particularlywhen research on spiritual transcendence occurs in real worldsettings and relationships.

Many service organizations have recognized spirituality as apossible resilience factor for their members. For example, the U.S.Army adopted the understanding that “an individual’s spiritualcore forms the foundation of the human spirit and comprises anindividual’s most central values and beliefs concerning purposeand meaning in life, truths about the world, and vision for realizingone’s full potential and purpose” (as cited in Pargament &Sweeney, 2011, p. 61). This idea of a core is also reflected inresearch where spirituality has been conceptualized as more of astable trait and yielded unique effects on psychological outcomeswhen controlling for personality variables (e.g., well-being; Pied-mont et al., 2009). Spirituality was measured using nontheisticitems from the Spiritual Transcendence Index (STI) in the currentstudy, which is a brief instrument that highlights internal, personalprocesses related to one’s spirituality (Seidlitz et al., 2002). Ac-cording to Seidlitz and colleagues (2002), spiritual transcendencecan be defined as “a subjective experience of the sacred that affectsone’s self-perception, feelings, goals, and ability to transcenddifficulties” (p. 441). Given the nature/context of international aidwork, it is anticipated that this approach to defining and measuringspirituality would figure prominently in workers’ reasons for ex-posing themselves to human suffering and possible trauma, as wellas possibly predicting adjustment following their deployments.

Changes in Spirituality Over Time

Theoretical and religious literature has long asserted that spiri-tuality and religious experience are dynamic variables that cangrow, stagnate, and decline over one’s life span (Fowler & Dell,2006; Hagberg & Guelich, 2005). For example, a 50-year longi-tudinal community study also using growth mixture modelingidentified three distinct trajectories of religious commitment in asample of North American adults (ages 27 to 80 years): (1) onewith increasing levels of commitment until midlife, and a decreasewith older age (a parabolic curve), (2) early low levels of com-mitment which declined with age, and (3) high level of commit-ment in early adulthood which increased with age (McCullough,Enders, Brion, & Jain, 2005). A study of North American youth(aged 10 to 25 years) demonstrated six distinct trajectories forreligious participation, including three groups of stable rates ofparticipation (high attendance, occasional attendance, and lowattendance) and three groups showing declines in attendance (earlyin adolescence, late in adolescence, and gradually over time; Petts,2009). Both of these studies identified factors such as gender,marital status, family make-up, religious upbringing, and religiousaffiliation to be associated with membership in the different groupsof trajectory groups (McCullough et al., 2005; Petts, 2009).

Spirituality and Trauma

Spiritual traditions have long provided a context for makingsense of trauma and coping with life’s difficulties. In addition tothe general aging process, significant life experiences may influ-ence changes in spirituality as well. In fact, theoretical writing on

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2 ERIKSSON ET AL.

spiritual development has often associated experiences of loss,trauma, existential questioning, and interpersonal betrayal as im-portant times for reassessing and making critical changes in one’sspiritual identity and commitment (e.g., Fowler & Dell, 2006;Hagberg, & Guelich, 2005). Traumatic events may lead individu-als to make transformative changes in their spiritual identity whenlife experiences contradict one’s assumptive worldviews or under-standings of the divine or the sacred (Janoff-Bulman, 1992; Hall &Johnson, 2001). The importance of meaning making (Wortmann,Park, & Edmonson, 2011) could be particularly applicable for aidworkers, given the poverty and injustice, widespread suffering, andhuman-perpetrated violence that many will confront during de-ployment (Fawcett, 2003; Laidig & Speakman, 2009).

Consider the challenge of meaning making in the humanitarianaid context, when workers may be confronted with child soldiersor government corruption that creates starvation for its people.Situational meaning from these specific events might contradictaspects of the worker’s global beliefs and values (e.g., the good-ness of humankind, fairness in the world, justice), thereby creatinga painful sense of dissonance. The conflict in situational and globalmeaning might be managed through the weakening of spirituallyoriented aspects of one’s identity and relationships. It may beanticipated that such a process would result in greater psychiatricdistress given that these aid workers may no longer be able to relyon resources previously crucial for addressing life challenges.However, this may not always be the case. Given other findings onthe stability of this construct (e.g., Piedmont et al., 2009), many aidworkers could experience little to no change in spiritual transcen-dence in the face of extreme stress and violence by assimilatingsituational meaning into existing global meaning structures. Inthese instances, posttraumatic adjustment may be predicted moreby one’s spiritual transcendence at the start of deployment, ratherthan by trajectories characterized by changes over time.

Cross-sectional research assessing the impact of trauma onspirituality has retrospectively identified separate trajectories ofchange (Falsetti, Resick, & Davis, 2003; Seirmarco, Neria, Insel,Kiper, Doruk, Gross, & Litz, 2012). Focusing on a group of 608adults bereaved from the 9/11 terrorist attacks, Seirmarco et al.(2012) found that 78% retrospectively reported no change in theimportance of religious beliefs. In addition, 11% indicated thattheir religious beliefs had become more important, and 10% re-ported assigning lesser importance to religion. Seirmarco et al.(2012) found that a decrease in the importance of religious beliefswas more common in survivors with more severe trauma exposure(e.g., losing a child or watching the terrorist attacks live on TV)and that psychiatric distress symptoms tended to be higher in thesecases. Reporting an increase in the importance of religion aftertrauma was more common in non-White participants and in col-lege graduates and was not related to mental health (Seirmarco etal., 2012). In another study of 120 trauma survivors, Falsetti et al.(2003) similarly found that the majority (69.7%) indicated nosignificant changes in religious beliefs since their traumas, and16.7% reported negative changes in their religious beliefs. Of note,participants with a PTSD diagnosis were more likely to report achange in religious beliefs, with 30% saying they became lessreligious (Falsetti et al., 2003).

Although aid workers are at risk for psychiatric distress (Er-iksson et al., 2001; Eriksson, Lopes Cardozo, Foy, et al., 2013;Lopes Cardozo et al., 2012, 2013), research also suggests that the

experience of deployment and its related struggles may promptconstructive life changes (e.g., improved relationships, more open-ness toward the future, deepened self-perception of strength,greater appreciation of life (for reviews, see Helgeson, Reynolds,& Tomich, 2006; Zoellner & Maercker, 2006). Posttraumaticgrowth is thought to occur when stressful events overwhelm one’sadaptive resources and the individual successfully struggles torevise aspects of his or her global meaning system in ways that canenhance functioning and quality of life (Tedeschi & Calhoun,2004). These types of life changes may occur via a range ofcognitive, social, and emotional processes. Having recourse to aspiritual tradition or meaning framework might also promote per-sonal growth in the context of trauma and adversity, for example.In keeping with religious/spiritual teachings on the possible re-demptive power of suffering, a review of 11 studies by Shaw andcolleagues (2005) found that trauma exposure was associated witha deepening of spirituality and that spirituality variables werelinked with greater perceptions of personal growth. However,these studies relied upon concurrent reports of spirituality andgrowth assessed subsequent to trauma exposure.

Study Aims

The present longitudinal study provides a unique extension tothe research literature by assessing spiritual transcendence pro-spectively—starting from predeployment, upon returning homepostdeployment, and at 3- to 6-months follow-up assessment—among a sample of expatriate humanitarian workers employed byNorth American and European aid organizations. Given existingtheories about trauma and spiritual development (Fowler & Dell,2006; Hagberg, & Guelich, 2005) and retrospective reports ofdifferent patterns of change in spirituality following trauma (Fal-setti et al., 2003; Seirmarco et al., 2012), it was hypothesized thatdistinct trajectories regarding spiritual transcendence would existamong the sample. First, it was anticipated that substantial minor-ities of aid workers would show stable levels of spiritual transcen-dence and decreasing spirituality. Further, it was expected that theextent of trauma exposure would predict membership in the spe-cific trajectories. In addition, it was hypothesized that aid workerswith distinct patterns of changes (or lack thereof) in spiritualtranscendence would report differing levels of psychiatric distressand posttraumatic life changes. Specifically, aid workers withlower spiritual transcendence at baseline and/or significant de-creases during deployment would be at greater risk for psychiatricdistress following deployment. In contrast, it was hypothesizedthat participants with higher transcendence scores would be morelikely to report personal growth following their deployment.

Method

Participants

Participants were aid workers employed by one of 17 humani-tarian agencies based in Europe and North America to work incountries other than their own country of citizenship. Agencieswere selected based on the following criteria: in existence for morethan 5 years; an established record of international funding; workbased on a humanitarian imperative (rather than a religious orpolitical agenda); agency projects based in at-risk countries; and

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3CHANGE IN SPIRITUALITY IN HUMANITARIAN DEPLOYMENT

deploying at least 20 expatriate staff to international field postingseach year. Previous publications outline the procedure for identi-fying and recruiting these agencies, as well as the process oftraining and supporting a focal person within each agency todistribute initial survey packets (Eriksson, Lopes Cardozo, Foy,et al., 2013; Lopes Cardozo et al., 2012).

The average age of the aid worker participants was 34 years(SD � 8.54), and 59% of the sample was female. They represented41 different countries of citizenship, with slightly over half comingfrom European countries. The participants were highly educated(66% with university degrees and 22% with postgraduate degrees).Participants were predominantly single (54%), 18% were married,23% were in a committed relationship, and 6% were divorced,separated, or widowed. Participants were recruited for deploymentto an overseas posting, with an expected contract of between 3 and12 months. They all had sufficient English to complete the surveymaterials. The recruitment generated 212 participants who com-pleted study assessments at predeployment, 170 (80%) were re-tained at postdeployment, and 154 (73%) retained for the 3- to 6-month follow-up assessment.

Measures

The measures used in the overall longitudinal study assessed arange of background variables, work characteristics, potentiallytraumatic stressors, support and team cohesion, coping, physicaland mental health, spirituality, and burnout (see Eriksson, LopesCardozo, Foy, et al., 2013; Lopes Cardozo et al., 2012). Given theaims of the current study, this article focuses on specific back-ground and work-related variables (at predeployment),deployment-related trauma exposure (at postdeployment), spiritualtranscendence (at all three time points), deployment-related lifechanges (at postdeployment and follow-up), and mental healthsymptoms (at postdeployment and follow-up).

Background demographics. Participants reported demo-graphic information prior to deployment including age, gender,marital status, education, country of citizenship, and religiousaffiliation. Religious affiliation was scored dichotomously for sta-tistical analyses, with those individuals indicating membership inany religious or faith tradition making up one group versus thoseindicating no affiliation.

Deployment-related trauma exposure. Direct and indirectexposure to potentially traumatic events during the deploymentperiod was assessed in the postdeployment survey. A measure of34 items including trauma events that aid workers may directlyexperience or witness (e.g., serious road or motor vehicle acci-dents, knife attacks, life threatening illness and/or limited access tonecessary medical care, shootings) was adapted from previoushumanitarian aid research (Lopes Cardozo & Salama, 2002; Er-iksson et al., 2001). For each of the 34 items, participants indicatedif they personally experienced and/or witnessed the type of event.An additional nine items (endorsed as 0 � no or 1 � yes) detailedindirect exposures or witnessing events that can be common inhumanitarian settings (e.g., seeing a mass grave, seeing children oradults die from disease or malnutrition). A score for direct expe-riences of trauma events was then calculated by summing the itemsparticipants had indicated personally experiencing during theirdeployment (possible range 0 to 34). The measure of indirectexposure was calculated by summing events a participant indicated

witnessing (possible range 0 to 43). To provide an index of therange of deployment-related exposure, a total exposure variablewas created by summing responses to both direct and indirectexposure items with each item weighted equally (observed range 0to 47).

Spiritual transcendence. The importance that participantsplaced on spirituality in their lives was assessed at all threeassessment points by four items from the STI (Seidlitz et al.,2002). Incorporated in a number of studies, the STI is consideredto be a measure of general spirituality, assessing cognitive andaffective aspects of spirituality with robust validity (Monod, Bren-nan, Rochat, Martin, Rochat, & Büla, 2011). The original measureincludes eight items, with four using the term God. Only itemsusing nontheistic phrases of “spirituality” were included, due to thepossibility of participants not ascribing to a theo-centric under-standing of spirituality. These four questions assessed whether theparticipant finds a sense of “fulfillment” in spirituality (an affec-tive experience), whether spirituality is a priority in the partici-pant’s life (motivation), if the participant can find “spiritual peace”in possible difficulties in life (transcendence), and whether spiri-tuality aids in understanding “life’s purpose” (cognitive expres-sion; Seidlitz et al., 2002, p. 451). The participants responded toeach of these statements on a 6-point scale ranging from 1(strongly disagree) to 6 (strongly agree). Cronbach’s alpha for thisscale ranged from .93 to .95 across the three assessment points,which was consistent with levels of internal consistency for thesefour items at the time of scale development (�s ranging from .81to .96; Seidlitz et al., 2002).

Posttraumatic life changes. Change in perceptions of an in-dividual’s sense of relationships, self-mastery, spirituality, priori-ties, and possibilities in life were measured by an adaptation of thePosttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun,1996) at the postdeployment and follow-up assessments. To assesspossible negative changes that may occur following stressful lifeevents, the response scales for 15 of the original PTGI items werereworded to allow for both negative and positive changes resultingfrom deployment. For example, participants responded to itemssuch as “Openness to new interests” or “My priorities about whatis important in life” using a response scale from �2 (highlynegative change) to �2 (highly positive change), with 0 (nochange) as the midpoint. This adapted response scale was based onwork by Milam, Ritt-Olson, and Unger (2004). Given that theparticipants had the option of reporting negative life changesresulting from deployment-related stressors, we label this outcomeposttraumatic life changes rather than posttraumatic growth. The15 adapted items—which included the 10 items used in a shortform of the instrument (Cann et al., 2010)—represented the orig-inal five domains of the PTGI comprising: relating to others, newpossibilities, personal strength, enhanced sense of spirituality, andappreciation of life. Cronbach’s alphas for the scale were .82 and.85 at postdeployment and follow-up, respectively.

Psychiatric distress. Psychiatric symptomatology was mea-sured at predeployment, postdeployment, and follow-up assess-ments using the Hopkins Symptom Checklist-25 (Derogatis, Lip-man, Rickels, Uhlenhuth, & Covi, 1974). This well-establishedmeasure includes 10 items assessing anxiety (e.g., “feeling fear-ful,” “nervousness,” “trembling”) and 15 items assessing depres-sive symptoms (e.g., “feeling low energy,” “crying easily,” “feel-ing hopeless”). Participants rated how “bothered or distressed”

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4 ERIKSSON ET AL.

they were by each item on a 4-point scale whereby the anchorpoints were 1 (not at all) and 4 (extremely). So as to obtain a broadassessment of psychiatric distress, we relied on the aid workers’total scores from the Hopkins Symptom Checklist-25 in the studyanalyses. Internal consistencies for these psychiatric distress scoresranged from .86 to .92 for this measure across the three assessmentpoints.

Procedures

The procedures for data collection and communication withparticipants are detailed in earlier publications (Eriksson, LopesCardozo, Foy, et al., 2013; Lopes Cardozo et al., 2012). The datacollection for this project was approved by the institutional reviewboard for the Centers for Disease Control and Prevention inAtlanta, Georgia. To summarize the method in brief, the originalsurvey was completed in three stages. Each organization identifieda focal person for the study who distributed survey packets to alldeploying staff from the organization. Aid workers who partici-pated in the predeployment stage of data collection were thencontacted for Stage 2 and Stage 3 of the data collection by aresearch assistant employed by the Antares Foundation in theNetherlands. All data were entered into a database and de-identified. Proposed analyses for the current study were reviewedand approved by the institutional review board at the first author’sinstitution. To assess possible differences in study variables atpredeployment between participants who were retained in thestudy, a series of independent samples t tests (for continuousvariables) and chi-square tests (for categorical variables) wereperformed. When considering the 20% of the predeployment sam-ple who did not participate in postdeployment assessments, thesepersons tended to be of younger ages (p � .033). However, therewere no additional differences in demographic factors or othervariables assessed at predeployment (spiritual transcendence andpsychiatric distress, ps � .05).

Plan of Analysis

Using MPlus Version 6.1 (Muthén & Muthén, 1998–2010), wefirst performed latent class growth analysis (LCGA) to identifygroups of participants (i.e., classes) with distinct trajectories ofspiritual transcendence from predeployment to follow-up. Timewas modeled as months since deployment, with predeployment setat 0 and postdeployment and follow-up occurring on average at9.599 (SD � 4.802) and 14.012 (SD � 5.123) months, respec-tively. We examined a 1-, 2-, 3-, and 4-class solution, using avariety of fit indices to determine the best-fitting model.

In particular, we considered the Bayesian information criterionand Akaike information criterion, for both of which lower valuesindicate a better fit, and the Vuong-Lo-Mendell-Rubin likelihoodratio test (VLMR-LRT), which tests the relative merits of a givenmodel against a model with one fewer class (e.g., a 3-class modelvs. a 2-class model). The VLMR-LRT produces a p value, whichrepresents the probability that a more complex model fits the datajust as well as a simpler model with one fewer class. Thus, aVLMR-LRT with a p � .05 indicates that adding another class tothe model significantly improves fit. In a simulation study, Tofighiand Enders (2007) found that the VLMR-LRT was one of the mostpromising (among a number of indices) in determining the appro-

priate number of classes to account for varieties of trajectoryrepresented within a dataset. We also report values for entropy,which is a measure of classification uncertainty. Although there isno clear cutoff for acceptable levels of entropy (Jung & Wickrama,2008), values closer to 1 indicate clearer delineation of classes andvalues closer to 0 indicate greater classification uncertainty (Ce-leux & Soromenho, 1996).

Several covariates were included in the model—age, gender(0 � men, 1 � women), religious affiliation (0 � no religiousaffiliation, 1 � has religious affiliation), predeployment psychiat-ric distress—as well as the total degree of trauma exposure (bothdirect and indirect forms) during the deployment. Multinomiallogistic regression was used to determine which covariates signif-icantly predicted class membership. We also examined mean dif-ferences between latent classes derived in the LCGA on the twostudy outcomes, psychiatric distress and posttraumatic life change.The equality of means across latent classes was tested usingposterior probability-based multiple imputations, expressed as aWald test with a chi square distribution. Missing data was handledusing full information maximum likelihood.

Results

Exposure to Potential Traumas During Deployment

Means and standard deviations for study variables are outlinedin Table 1. On average, aid workers reported rates of total expo-sure to 15 stressors during their deployments. The most commonlyendorsed direct stressors experienced by the study participantsincluded being in the vicinity of gunfire (42.4%); being caught ina riot, coup, or religious/political uprising (10.1%); having theirhome or apartment broken into (8.8%); being in a dangerous airplaneflight or crash (7.6%); having a life-threatening illness (7.1%);unexpected death of a colleague (7.1%); being in a serious motorvehicle accident (5.3%); and being threatened with serious phys-ical harm (5.1%). The most commonly endorsed indirect stressorsincluded seeing a dead body (47.1%), witnessing people dying ofmalnutrition (47.1%), and witnessing people dying of maltreat-ment or neglect (36.5%). Substantial subsets of participants alsoreported the life-threatening illness of someone they knew ondeployment (17.1%), witnessing a serious motor vehicle accident(15.3%), observing severe physical discipline of children (14.7%),being involved in hostage negotiation (12%), experiencing mate-rial loss from natural disaster (11.2%), being in the vicinity of ariot, coup, or uprising (10.6%), and witnessing other types ofserious accidents (8.2%).

Spiritual Transcendence and Study Variables:Preliminary Bivariate Correlations

Prior to the main analyses examining trajectories of spiritualtranscendence over the study period, a series of bivariate correla-tions were conducted to preliminarily assess the relations betweenparticipants’ reports of spiritual transcendence and other studyvariables. These results are also presented in Table 1. Drawing ona corrected alpha for correlations between spiritual transcendencescores and study variables (� � .002 [.05/27 tests]), those partic-ipants who indicated a religious affiliation at baseline reportedgreater spiritual transcendence across the three time points, ps �

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5CHANGE IN SPIRITUALITY IN HUMANITARIAN DEPLOYMENT

.001. In addition, although the magnitude of the correlations didnot reach statistical significance with a more conservative alpha,higher spiritual transcendence scores at all three assessments werecorrelated with greater positive life changes at both postdeploy-ment and follow-up, ps � .05. No additional statistically signifi-cant associations emerged between spiritual transcendence andother study variables in these bivariate analyses.

Trajectories of Spiritual Transcendence

After testing a 1-, 2-, 3-, and 4-class model in the LCGA, a3-class model was clearly found to provide the best fit to the data(see Table 2). The development of the latent class model was basedon the three time points of assessment; therefore, the slope of thetrajectories represents the report of spiritual transcendence acrosstime. As shown in Figure 1, 43.79% of the aid workers exhibiteda trajectory characterized by relatively high levels of spiritualtranscendence that declined significantly from predeployment tofollow-up (Intercept � 20.456, p � .001; Slope � �0.069, p �.001). Participants with this trajectory were considered to havehigh decreasing transcendence. A smaller subset of individuals(23.67%) showed moderate initial levels of spiritual transcendencethat remained fairly stable from predeployment to follow-up (In-tercept � 14.270, p � .001; Slope � �0.002, p � .967). Thisgroup was labeled as the moderate stable transcendence group. Athird group of participants (32.54%) showed relatively low initiallevels of spiritual transcendence that decreased slightly over time(Intercept � 8.368, p � .001; Slope � �0.087, p � .051), and

these individuals were labeled as the low slightly decreasingtranscendence group. Means and standard deviations for spiritualtranscendence are presented in Table 3 for each of these trajecto-ries.

Examination of the covariates included in the model revealedthat only religious affiliation predicted class membership in themultinomial logistic regression analysis (see Table 4). In particu-lar, compared to the low decreasing transcendence group, having aspecific religious affiliation predicted membership in the highdecreasing transcendence (B � 2.364, p � .001) and moderatestable transcendence (B � 1.537, p � .008) groups. Both of thesewould have been statistically significant with a corrected alpha aswell for this analysis (� � .01 [.05/5 tests]).

As shown in Table 5, these three groups did not significantlydiffer in terms of their levels of psychiatric distress at postdeploy-ment or follow-up. There were, however, differences in reportedposttraumatic life changes. At postdeployment, those in the highdecreasing transcendence, �2(1) � 13.415, p � .001, and moderatestable transcendence, �2(1) � 4.293, p � .038, groups eachshowed significantly higher levels of posttraumatic life changesthan the low slightly decreasing transcendence group. However,the latter finding would have failed to reach statistical significancewith a more conservative alpha across these tests (� � .004 [.05/12tests]), Although the overall test only trended toward statisticalsignificance at follow-up, �2(2) � 5.126, p � .077, pairwise testsrevealed significantly higher life changes scores for those in thehigh decreasing transcendence group, �2(1) � 5.479, p � .019,and marginally higher life changes for those in the moderate stabletranscendence group, �2(1) � 2.831, p � .092, compared to thelow slightly decreasing transcendence group.1

Discussion

The current study prospectively examined trajectories in spiri-tual transcendence within a context of international aid deploy-ment, as participants were tracked from before leaving on their

1 When two items relating to religion and spirituality were removed fromthe life change measure, no significant differences in this outcome wereobserved among the three spiritual transcendence trajectories at thefollow-up assessment. However, even when these two items were removedfrom the life changes measure, postdeployment findings remained intact.

Table 2Goodness of Fit Indices for Latent Class Growth AnalysisExamining Spiritual Transcendence From Predeployment toFollow-Up (N � 169)

Model AIC BIC EntropyVLMR-LRT

p value

1-class2-class 2781.829 2822.517 0.919 �.0013-class 2710.557 2776.285 0.890 .0034-class 2693.700 2784.467 0.861 0.295

Note. AIC � Akaike information criterion; BIC � Bayesian informationcriterion; VLMR-LRT � Vuong-Lo-Mendell-Rubin likelihood ratio test.

Table 1Bivariate Correlations Between Spiritual Transcendence Scores and Study Variables

Variable M (SD) Predeployment Postdeployment Follow-up

Age 33.54 (8.09) .05 .05 .07Gender (0 � women, 1 � men) .61 (.49) .10 .10 .11Religious affiliation (0 � no, 1 � yes) .72 (.45) .37��� .42��� .42���

Total trauma exposure 15.00 (9.88) .10 .08 .01Psychiatric distress

Predeployment 33.21 (6.30) .04 .04 �.08Postdeployment 36.60 (7.90) .12 .09 .03Follow-up 35.63 (8.88) .04 .01 �.04

Life changesPostdeployment 9.70 (5.66) .23�� .31�� .18�

Follow-up 9.57 (6.28) .17� .23�� .25��

M (SD) — 15.13 (5.74) 14.21 (6.20) 14.49 (5.92)

� p � .05. �� p � .01. ��� p � .001.

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6 ERIKSSON ET AL.

deployment, to the end of their deployment, and then to afollow-up assessment occurring 3 to 6 months after returning fromabroad. International aid work can entail considerable exposure tohuman suffering and trauma (Eriksson et al., 2001; Lopes Cardozoet al., 2012, 2013) and could be associated with weakening ofspirituality or could be a possible catalyst for personal growth(Shaw et al., 2005). As such, the current longitudinal assessmentallowed for the examination of changes in spiritual transcendenceas well as testing possible predictors and outcomes associated withthese trajectories.

Trajectories of Spiritual Change

Study findings revealed high levels of exposure to possibledeployment-related traumas for this sample of expatriate human-itarian aid workers as well as three distinct trajectories of spiritualtranscendence across deployment and return. The largest group,representing those with a high level of spiritual transcendence(mean item scores closest to agree), showed a small, but significantdecrease over time. The next largest group reported low levels ofspiritual transcendence (mean item scores closest to disagree),which also demonstrated a small, but not significant, decline overthe three time points. Finally, the smallest group represented thosewith moderate levels of spiritual transcendence (mean item scoresbetween slightly disagree and slightly agree), which then remainedstable over the three time points. Although there may have beenindividual participants experiencing growth in spiritual transcen-dence over time, in the latent class analysis these patterns in

cognitive and affective expressions of spirituality did not showevidence of a trajectory of general increase over the study period,nor was there a latent class that represented large fluctuations inspiritual transcendence. Therefore, there was mixed support forour hypotheses in that we failed to identify a group of aid workerswith dramatic negative changes in this variable.

These findings both augment and challenge the literature onchanges in spiritual or religious experiences. First, the latent classmodel did support the presence of distinct trajectories in reports ofspiritual transcendence over time. Similar to previous longitudinalstudies assessing religious variables—such as religious commit-ment and religious participation (McCullough et al., 2005; Petts,2009)—the best fitting model reflected slight to no significantchanges across all trajectory groups. As such, these findings sup-port a conceptualization of spiritual transcendence as a variablemore akin to a trait (Piedmont et al., 2009). However, it wasnotable this relative stability or transcendence scores occurred inthe context of considerable direct and indirect exposure to trau-matic events. These results also generally align with researchamong other trauma-exposed groups that relied upon retrospectivereports of change in religious beliefs or the importance of religion.Notwithstanding subsets of individuals that noted changes in spir-ituality resulting from their traumatic experiences, the majority ofsurvivors in these studies similarly indicated little to no change inthis domain as well (Falsetti et al., 2003; Seirmarco et al., 2012).

In contrast to other studies (McCullough et al., 2005; Petts,2009), personal demographic variables (e.g., gender and age) were

Table 3Spiritual Transcendence Means and Standard Deviations for Different Trajectories Across Time

Spiritual transcendence

Predeployment Postdeployment Follow-up

M SD M SD M SD

High decreasing transcendence (n � 74) 20.446 2.184 19.851 2.470 19.354 2.944Moderate stable transcendence (n � 40) 14.282 2.564 13.667 2.474 14.833 2.864Low slightly decreasing transcendence (n � 55) 8.519 2.853 6.891 2.813 7.880 3.895

Figure 1. Graphical depiction of the 3-class solution for spiritual transcendence from predeployment tofollow-up. Solid lines represent trajectories based on estimated means. Dotted lines represent trajectories basedon actual means in the sample.

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7CHANGE IN SPIRITUALITY IN HUMANITARIAN DEPLOYMENT

not significantly correlated with the trajectories of spiritual tran-scendence. Consistent with study hypotheses, religious affiliationemerged as a significant predictor of membership in the highdecreasing transcendence group, highlighting the interplay be-tween religion and spirituality (Hill & Pargament, 2003) and isconsistent with other results for a positive association betweenreligious affiliation and STI scores (Seidlitz et al., 2002).

Spiritual Transcendence and Adjustment

In contrast to study hypotheses, scores on the STI and member-ship in the spiritual trajectories were also not predictive of psy-chiatric distress. These findings do not align with Falsetti et al.(2003) and Seimarco et al. (2012), each of which found concurrentassociations between distress symptomatology and reports of neg-ative changes in spirituality variables. Despite suggestions thatstrong spirituality facilitates resilience in the face of deployment-related stress and trauma (Fawcett, 2003; Laidig & Speakman,2009), the three spiritual transcendence trajectories identified inthis study were not found to significantly differ with regard topsychiatric distress. This finding is consistent with a large-scale,longitudinal study of the general population in Canada that also didnot find a significant relationship between reports of spiritualityvariables and depression (Balbuena, Baetz, & Bowen, 2013), aswell as a 17-year study of devout Mormons that showed norelationship between intrinsic religiosity and psychopathology(Bartz, Richards, Smith, & Fischer, 2010).

In support of study hypotheses, however, those in the highspiritual transcendence group reported more positive posttrau-matic life changes at both postdeployment and follow-up whencompared to the low decreasing transcendence group. Thesefindings support conclusions reached on the basis of cross-sectional research regarding the link between spirituality andgrowth (Shaw et al., 2005). In addition, Piedmont et al. (2009)similarly demonstrated the incremental influence of spiritualtranscendence on personal growth (operationalized throughmeasures of self-actualization and purpose in life), over andabove personality factors and religious involvement. Given thatwe did not find evidence for dramatic fluctuations in the spir-itual transcendence variable, we could not directly test notionsabout the role of rebuilding global meaning structures related tocurrent theories about how personal growth occurs (e.g., Tede-schi & Calhoun, 2004). However, our study design allowed usto establish a longitudinal association between spiritual tran-scendence and the likelihood of survivors experiencing post-traumatic life changes. These findings are particularly notewor-thy given that aid workers had the option of endorsing possiblenegative changes associated with their deployments as well aspositive changes.

Practical Implications

In light of these findings, NGOs would be wise to consider thelikelihood of their staff (whether religious or not) experiencing

Table 4Multinomial Logistic Regression Analysis Predicting Class Membership for the 3-Class Model (N � 169)

High decreasing transcendence vs. low slightlydecreasing transcendence

Moderate stable transcendence vs. low slightlydecreasing transcendence

Variable B SE Odds ratio B SE Odds ratio

Age 0.031 0.029 1.032 �0.052 0.041 0.949Gender 0.548 0.422 1.730 0.371 0.547 1.449Religious affiliation 2.364 0.514 10.633��� 1.537 0.581 4.649��

Baseline psychiatric distress 0.006 0.036 1.006 0.047 0.039 1.048Total trauma exposure 0.023 0.021 1.023 �0.012 0.029 0.988

�� p � .01. ��� p � .001.

Table 5Mean Differences Between Spiritual Transcendence Trajectories in the 3-Class Model for Psychiatric Distress and PosttraumaticGrowth (N � 169)

Psychiatric distresspostdeployment

Psychiatric distressfollow-up

Life changespostdeployment

Life changesfollow-up

M SE M SE M SE M SE

High decreasing transcendence (#1) 37.362 1.017 35.533 0.966 11.078 0.694 10.628 0.795Moderate stable transcendence (#2) 36.868 0.991 36.551 1.433 9.944 0.917 9.971 0.908Low slightly decreasing transcendence (#3) 35.425 1.146 35.131 1.542 7.556 0.665 7.750 0.940

�2 df �2 df �2 df �2 df

Overall test 1.449 2 0.412 2 11.907�� 2 5.126 2#1 vs. #2 0.112 1 0.326 1 0.928 1 0.278 1#1 vs. #3 1.597 1 0.049 1 13.415��� 1 5.479 1#2 vs. #3 0.876 1 0.441 1 4.293� 1 2.831 1

� p � .05. �� p � .01. ��� p � .001.

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8 ERIKSSON ET AL.

some weakening in their spirituality over the span of an interna-tional deployment. Although this reduction may not lead to psy-chiatric distress, study findings suggest that trajectories of spiritualtranscendence could have important implications for how workersfind purpose in ongoing work in difficult environments. Namely, itappears that workers who begin with high emotional and cognitiveassociations to spirituality will be most likely to approach theirhumanitarian experience with a potential for personal growth.Work to bolster humanitarian staff resilience would benefit fromencouraging staff to consider their “starting point” regarding spir-ituality as a motivator or affective and cognitive resource, andattention to related religious behaviors and beliefs could broadenthe perspective on factors which aid in positive adjustment. Ourdata suggests that humanitarian aid organizations would usefullyfacilitate time for the exercise of spiritual practices as part ofrecreational life and well-being for staff. Finally, while moreresearch is needed, attention to spiritual transcendence may not bea particularly helpful construct for identifying traumatized or dis-tressed persons who may be in need of clinical intervention. Evenstaff reporting high spirituality may be experiencing high levels ofdistress potentially requiring mental health intervention.

Limitations

The current study represents a prospective longitudinal design,with a multinational sample of expatriate aid workers completingmeasures across three time points (Lopes Cardozo et al., 2012).This data set offers the unique opportunity to examine a spiritualityvariable over time, in the context of trauma exposure, along withthe assessment of positive and negative posttraumatic outcomes.There are limitations, however, in the brief assessment of spiritualtranscendence, in that we strictly incorporated the four nontheisticitems of the STI. Although the internal consistency of the scalewas strong across the three time points, the measure representedone particular conceptualization of spirituality (assessing cognitiveand affective aspects, rather than behaviors), which may not havebeen as sensitive to changes across time or that might bear onposttraumatic adjustment. In addition, this sample of expatriate aidworkers is of moderate size, and caution should be taken inassociating these findings to other populations exposed to trauma.First, they overrepresent a religious sample, as more than twothirds of the sample indicated a religious affiliation. Second,trauma exposure occurred in the context of work settings withmany anticipated stressors (and an average experience of 15trauma events), reflecting experiences similar to first responders,rather than civilian trauma survivors. In addition, trauma exposurewas measured as exposure to the range of types of events, ratherthan an estimate of all occurrences of each type or a qualitativeassessment of severity of personal impact. This method allowedfor a measure of the extent of trauma exposure but did not accountfor the cumulative impact of multiple exposures to the same event,or specific personal appraisal of the experience. Therefore, the lackof significant relationship between trauma exposure and spiritualtranscendence may be due to the type of measurement, as well asthe highly exposed sample.

Future research will do well to address these possible issues ofpower and sample size, as well as incorporating more sophisticatedassessments of spirituality that include questions regarding partic-ipation in spiritual/religious behaviors (e.g., meditation, prayer,

and reflection on specific spiritual issues), each of which haveshown unique clusters of variables and trajectories across time inother longitudinal work (Good, Willoughby, & Busseri, 2011).Finally, in the observed and estimated means of the STI in Figure1, the observed means for the moderate and low trajectories almostseemed to approximate a U-shape, which might suggest a qua-dratic association between time and spiritual transcendence forsome aid workers. Future research that includes four or more timepoints may wish to test this possibility.

Conclusion

Overall, the findings suggest that the construct of spiritualtranscendence acted as more of a character trait and was generallystable through the course of humanitarian deployment and return.The slight, but significant, decreases experienced by the groupswith high and low initial transcendence scores may reflect a slightrefinement of, or a challenge to, workers’ cognitive, affective, andmotivational experience of spirituality. In addition, there was noevidence of spiritual transcendence being either a protective or riskfactor for psychiatric distress in this sample. This does not meanthat persons may not use coping strategies based upon their spir-itual understandings, but rather that those for whom such construc-tions are not meaningful may use other effective mechanisms toprotect well-being. Finally, a stronger sense of spiritual transcen-dence was linked to perceptions of personal growth through hu-manitarian deployments. While deployment may include exposureto considerable direct and indirect trauma events, these findingssuggest that they may also afford the worker with experiences ofchanged sociocultural perspectives, inspiration from dedicated andcompassionate community members, as well as exposure to resil-ience despite hardship. Understandings informed by spiritual tran-scendence appear to serve as a foundation to support positivereappraisal and personal transformation.

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Received October 4, 2013Revision received June 2, 2014

Accepted June 20, 2014 �

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11CHANGE IN SPIRITUALITY IN HUMANITARIAN DEPLOYMENT

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