My expat depression article in the WSJ

Last week I had an article published in the Wall Street Journal about expat depression – and in particular about how it affects accompanying spouses. I was extremely grateful to the four women in the article, who agreed not only to be interviewed for the article about their struggle with depression but to do so openly, using their own names. Each of them did so with the hope of helping others in the same situation as there are or were in.

Ms. Pogir has lived in South Africa for eight years and due to family circumstances sees her time in the country as indefinite. This feeling of being trapped just adds to her sadness. She said she looks around and sees a wonderful house and garden, a good life—but said: “I feel my happiness is the price we have to pay for all of this.”

This is such an important subject and I am so happy that it is getting the attention it deserves by being featured on such a well-read media outlet. I have had lots of visits to this blog on the back of the article, as well as seen it shared over and over on Facebook with – so far – not a single negative comment (pretty rare these days, I have been finding!).

If you are affected by this issue then please read the article, look at my other blog posts on the subject, and get help if necessary (one of my posts gives details of some places you can start to look for this help). And if you know someone you think might be suffering from depression, consider sharing the post with them as a way to help them take the first step towards getting help.

This is too important a subject to ignore.

A series on expat depression: round-up

Over the past few months I have been publishing posts about expat depression: a serious and seriously overlooked (in my opinion) issue that affects a lot more people than most realise. I myself learnt a lot while reading and then writing about the responses to a survey I did on the subject – it gave me a wonderful opportunity to reflect not only on my own situation but also on that of many, many expat friends I have known and still know all around the world.

I have now come to the end of my series but I didn’t want to finish without a summing up: links to all the posts and a conclusion. But this doesn’t mean for a moment I have finished with the topic – it’s something I feel I will come back to, will be a backdrop to many of my posts, will always be there when I think and write about expat life. I hope that by posting on this topic I have been able to help others, even if it has just given them an opening to discussion or a pause to reflect. As always, comments and feedback are welcome.

Introduction

I started the series with an introduction to the topic, explaining the reason I had decided I needed  this series was because an older post about depression I had written last year was one of my most read blogs – getting hits on it almost every day. This proved to me that a lot of people were putting the words “expat” and “depression” together into search engines – and looking for help.

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What is expat depression?

In my second post, I tried to unpick what was actually meant by the term “expat depression” but realised in the end that although there definitely is such a thing as “situational depression” caused by the situations we find ourselves in, depression is depression however or whatever it is caused by and needs to be treated accordingly. I did conclude however thar there are definite commonalities amongst expats who fall into the “depressed” camp one way or another and it was these commonalities I wanted to focus on.

When and why does it happen?

My third post started using some of the real-life experiences told to me in the survey I used as a basis for this series. This is where commonalities really started to become apparent. From the shock of the move to isolation and lonliness, loss of identity and control to repatriation – the same causes or at least catalyst of depression came up over and over again. As I said in this post:

Hopefully by recognising possible danger points in the expat cycle, I can help you be more prepared

What does expat depression look like?

Next I asked (and hopefully answered) the question: what does expat depression actually look like, how to recognise it for what it is and thus start to seek the help you need? Again, there were a lot of commonalities in my responses – from very emotional reactions (anger, tearfulness, frustration) to listlessness and feelings of wanting to shut yourself away. Food and alcohol issues were also two themes that came through in the survey.

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Overeating or eating unhealthily – one of the possible symptoms of depression.

Could it just be culture shock?

“I definitely knew and understood the concept of culture shock. By this point we had been there almost two years so I think I had gotten over the culture shock part and was resigning myself to the fact that no matter what I did I would never be able to thrive in this environment.”

My fifth post posed the question how to distinguish between culture shock – the emotional roller coaster that many of us go through at the start of a new expat life – and depression. This is a subject I had already tackled in my book the Expat Partner’s Survival Guide as I thought it was important for people to realise that very intense emotions are likely to be a normal part of their expat experience – but then also to understand when what they are feeling is something more.

Through researching for this post, I reached the conclusion that actually the two are so tightly intertwined that it’s often hard to say when culture shock ends and depression starts. But at the same time I truely believe that a really good starting point for any expat (or expat-to-be) is to read up on and gain a proper understanding of culture shock. We all know ourselves better – hopefully – than anyone else does. So you are in the best place to understand whether what you are feeling is simply down to the stresses of living in a new and alien environment….or whether it’s moved past this and heading into depression.

Help

Having now thoroughly tackled what expat depression looks like and how to recognise that is what it is, I turned to the question of how to help yourself. I did this over the course of two separate posts – the first discussed self-help methods, and the next how to look for professional assistance.

The self-help post had lots of good ideas, from finding a routine to getting a dog. Many people though agreed that these methods should be done alongside seeking the help of a professional such as a counsellor or therapist and the second post discussed the sort of help people looked for and where they found it. I included a list of therapists who specialise in helping people who love overseas in this post.

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Helping  others

I wanted to look at what to do if it wasn’t yourself you were worried about but rather a friend, a partner or anyone else you knew in your expat life. We often get close to people very quickly when we first relocate – but still it can be very hard to know when someone needs help because depression isn’s something that gets talked openly about very often. This post talked about how important it can be simply to be there, to invite people out, to talk and to listen to them. Even if you never actually touch on the subject of depression, just being there for someone might be helping them more than you would ever realise.

What about the employers?

My penultimate post in this series (if you ignore this one) looked at the role of employers. The verdict was split as to whether they should have a role at all in this area – especially when it comes to the partners of their employees rather than the employee itself. But after reflecting on this subject, my feelings are that so much of what we experience is tied to the situation we find ourselves in so perhaps the employers should be more aware of this issue? Maybe by being more proactive in this area they could stymie some of the problems before they escalate to the point where problems are going to lead to things like relationship breakdown or even their employee leaving the post. There was certainly a lot of food for thought in this one.

Repatriation

Finally, I felt I couldn’t leave this topic altogether without talking about repatriation. Frequently overlooked as a catalyst for depression, returning to your home country is often said to be the hardest part of relocation. Maybe because people don’t expect to feel this way and are therefore underprepared, maybe because the changes that happen to someone when they become an expat can make returning to your old life very hard indeed or maybe just because it is another flash point in the expat cycle I don’t know. But what I do know from all the informal research I have undertaken in this subject area is that repatriation is something that should be ignored at your peril.

And the conclusion is?

So that in a nutshell was expat depression. Or at least, it was my take on the subject. What can I take away from my experience of writing these posts? That although there certainly is no one-size-fits all approach to an illness like depression, there are commonalities. That we can all help each other just by being aware what others may be going through. Becoming an expat – especially if it is for your first time, and even more especially if you are the non-working partner – can be a difficult and frightening thing. Knowing that you are not alone, that others have gone through and continue to go through the same feelings that you are can e a huge help. On top of that though often what you need is more – and don’t be afraid to seek help from a professional if you think you may be depressed, even if you are not 100 per cent sure. The lines between normal feelings and clinical depression are very blurred so don’t leave it to chance or hope it will go away. Get that help earlier rather than later and then, hopefully, you can start to enjoy your expat life. Most of all though, never be ashamed of what you feel.

 

Expat depression and repatriation

I am not going to write a hugely long post about this because I think so much has already been written on this subject (see links at the end of the post). But I couldn’t close my series on expat depression without at least mentioning this topic.

When I was reading through the survey results from which I initially gathered people’s experience of overseas life and depression, one thing that stood out was the number of people who said the hardest thing for them hadn’t been moving abroad….but moving back home again. But why is this so tough? Surely you are returning to the bosom of your friends and family, to a culture you feel familiar with, to a place where you can understand what people say and find food you like in every shop?

Well, let’s start by having a look at some of the reasons why moving home isn’t always as straightforward as you may at first think it will be:

You’ve changed. They haven’t.

Of course, this isn’t entirely true as everyone changes as they grow and age. Things do happen back home just as they happen “abroad”. People get married, have babies, get sick….but these are “normal” things experienced by all; what you have gone through is very likely something out of the usual bubble of life, something out of the ordinary and something most of your friends will quite possibly never experience. And this will have changed you in ways you perhaps don’t even yet realise yourself. You will see the world differently, things that were important to you before won’t be now and vice versa. You will probably see that there is more than “one way”, that the world is a more complicated place than you possibly realised it was. And you will bring all of this with you into back into your old life – which will probably be just as you left it…

No-one will be very interested in where you have been.

Okay at first they will be. They will want to hear your stories of paddling down the Congo in a dug-out canoe or sleeping under the desert stars. They will start by asking you questions but these questions will soon run dry as they run out of understanding about your life and what you actually did on a day-to-day basis (which probably isn’t that much more exciting than theirs, despite what they may think). Eventually they will stop asking questions, start avoiding you in the street, “forget” to call you back. Not because they don’t like you but because they can’t really relate to this new version of you. And avoiding you is their best way of dealing with this.

You will have to start again.

And yes it could be just as hard as starting again in a foreign location. So you need to find schools, dentists, possibly a home, a job….you may have a group of supportive friends or you may not but many repats find themselves looking for a new support group who has more of an understanding of what life has been like for you over the past few years. So you need to find these people, get to know them, reach the point where you feel comfortable with them…You will also almost certainly find yourself going through the same culture shock cycle as at the start of your posting and as I described in my book The Expat Partner’s Survival Guide: the honeymoon period, negotiation, adjustment, acceptance.

If you have children they may very well be grieving their old life.

Whilst we may feel like we are returning home, this may not be so easy for children who have been out of the country for a long time and don’t really know anything but living in your foreign home or maybe even several foreign homes. For them, the things that are familiar and comforting to you may be very alien to them. They will probably also be missing their friends and wondering how or if they will ever see them again.

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And that is just for starters. You will read it over and over again but you probably won’t believe it until you experience it for yourself – moving home can be just as hard as moving away. In fact, many would say that it can be a lot harder – to the extent that one great piece of advice is to treat this as another foreign posting and adjust your actions and emotions accordingly.

In fact, this is why repatriating can very often lead to depression – because you are not expecting it to be so hard. You think there is something wrong with you. You feel ungrateful or guilty….you should pull yourself together, you can’t blame living in a foreign country for your feelings anymore….

So if this is you stop. Just stop. And give yourself some time. Ask for help. Do all the things people have recommended in my earlier posts on expat depression. See a professional. Don’t blame yourself, don’t think you are being weak. Just like you hopefully did when you first moved abroad, you will eventually settle back in, life will eventually get back to normal. You will be happy again. And if you don’t? Well, there is a whole world waiting out there!

Further info/reading:

Link to a free webinar on 26 May called Eeek I’m Repatriating – all about “finishing well and preparing to go home” – http://events.wattsyourpathway.co.uk/eek-i-m-repatriating-event-registration/

http://blogs.wsj.com/expat/2015/04/15/repatriation-blues-expats-struggle-with-the-dark-side-of-coming-home/

http://www.worldwideerc.org/Resources/MOBILITYarticles/Pages/0212-Dean.aspx

https://iwasanexpatwife.com/2012/01/16/repatriation-5-mistakes-i-wish-i-hadnt-made/

 

 

A Series on Expat Depression #9: What role should our employers play?

So I am nearly at the end of my voyage through the sea of expat depression. It has certainly been an interesting exercise and actually very useful for me who has found writing these blog posts to be a very reflective process. I hope others have also found them helpful, or at least to have given them pause for thought about their own situation. Today, I look at an area that I haven’t seen much discussion on – that of the role of the employer. Do they have a responsibilty to our mental welfare? Should they? What do you think?

“I think companies who move people abroad should consider their employees’ and their families’ mental health situation and be encouraging and supportive” – “V”.

Sending someone abroad to do a job is a risky strategy. But how many employers ever think to screen their workers for mental health issues before they go, or to help them once they are there?

This was the question I posed in my survey on expat depression, curious to know whether people thought employers had a responsibility for their workers overseas – and if so, what they should be doing about it.

Anecdotally, I have heard of some companies or agencies making sure anyone they send abroad (including the partners and families of their employees) are mentally fit for the stress they are fairly likely to encounter when they get there. This could include anything from having to deal with a totally new working culture to the loneliness and isolation of a non-working partner.

But in reality, most people confirmed what I had already suspected – the majority of employers either don’t even think about depression or mental health issues as a potential problem, or they do nothing at all about it.

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First the good news

“Our organisation (a church) had been sending missionaries overseas for over 100 years by the time we went overseas with them. They tried to screen for it before agreeing to send people overseas, provided a wide variety of support while you were overseas and would spend the money to send you home if you really needed help…” Missionary Kid.

It’s not all doom and gloom though. There were sporadic reports of attempts to help both employers and partners/families. One person said their employer was very aware of depression and that they could have accessed professional help through them. Another that her partner worked at a university where they had “monthly workshops for spouses”.  And Robyn told me:

“The HR manager in one location certainly attempted to stay in contact with workers and their spouses on a regular basis and tried to help with …problems related to settling in and certainly made herself available to help if any other problems arose during our stay….”

As mentioned above, I have heard reports of employers carrying out psychological screening of not just their employer but also their family before deciding where to send them (or sending them anywhere at all). This might seem like taking things a little too far until you consider how many people probably are unsuited to certain destinations. Although I would prefer to see proper support in place for everyone rather than stop people going “just in case”.

But more realistically…

Despite the isolated reports of caring employers most said this wasn’t something they had come across. Of course there was often “awareness” of the issue – as one person put it, they “must be aware as there as so many”. But awareness doesn’t always mean anything is actually done about it.

Not everyone thought the employers necessarily had a responsibility to their employees in this area – one saying “we put out hands up for the move and we were aware of the challenges we would face”. But the vast majority believed that not only was it “nice when they did”, but that it also made business sense for them to do so.

“I do think it is in their best interest to offer resources. It’s expensive to move families overseas. A failed assignment is more costly than counselling resources”.  Mary.

Unfortunately it seems many (most?) employers still have not understood the importance of making sure not only the person who is working for them is happy but their partner and family is as well. As Alison put it:

“I don’t think the employer does much to tackle the problems a trailing spouse might have. They just throw a huge chunk of money at you hoping that’s enough to entice you to go…and then you are on your own. I guess they feel that if they’re paying you so much more (in extra benefits and stipends) that it’s up to you to seek your own help”.

Which is a good point – even if an employer is aware of the issue, what can they actually do to help? Isn’t it better to leave things to the professionals?

How can they help?

Suggestions for what people thought their employers could do to help them ranged from the very simple – “even just asking after me a bit would have made me feel less irrelevant” (I will back her on this one!!), to the more ambitious eg “offering the benefit of some therapy sessions for their employee and/or partner”. Others said just having the employer be more open and communicative on the subject would help – I wonder how many people are briefed on this issue before they leave home? But practical help was also suggested – like this from Mary:

“Simple things that don’t cost a lot like a phone list would help, sponsoring a coffee morning every six months, info on working with the local internet and phones would be a great help. Providing several hours of translation services to spouses every 2-3 weeks after arrival to ask questions of local shopkeepers, apartment staff or tech service people would be a godsend”.

I might add to that list – wouldn’t it be great if every employer provided a copy of my book to anyone taking their partner overseas?

What do you think – is it the responsibility of a global employer to care about the mental health of their workforce? What can they – or should they – do to help? Have you got any stories, good or bad?

Picture credit: Jlhopgood

A Series on Expat Depression #5: Culture Shock or Something More?

“This was definitely more than culture shock. Though perhaps if I’d taken the culture shock more seriously and spent time dealing with it, the depression might not have occurred” Anne.

Just before I move on from understanding a bit more about what expat depression might look like and on to how people have started to help themselves, I wanted to consider what people understood about the term culture shock – and what they thought about its links with depression. As ever, thanks to expat mental health specialist Anita Colombara for looking over this post before publication.

When writing my book the Expat Partner’s Survival Guide I decided the subject of culture shock was such an important one that it deserved a whole chapter to itself. In the end, I also included a section at the end of the chapter on depression because I realised as I was writing it how closely linked the two are. And also how blurred the edges the two can be. How do you know if what you are experiencing is really just part of the normal experience of many (if not most) expats when they arrive in a new destination, and when it is something more serious?

Well I would say often you don’t – and that may be the problem. Because who is to say whether what you are going through is “normal” or not? If it is bringing you low should we label it “culture shock” and tell you that you will get over it? Or should we label it “depression” and recommend you seek advice.

To help answer these questions I decided to ask people what they understood about culture shock, whether they recognised it as part of their experience of moving abroad, or whether it felt like something more. The answers, predictably, were as varied as the experiences of those giving them – and helped to show how tied up in each other culture shock and depression are.

For background information, here is the definition of culture shock I came up with for my book:

‘Culture shock could be defined as disorientation on moving somewhere new, a rollercoaster of emotions. It is said to have four phases and each phase is described differently by different people but generally they are wonder/honeymoon, negotiation, adjustment and acceptance. You can move between the four stages in order or back and forth between them; you might skip some of the phases or not experience any of them.’

An understanding of culture shock?
Most people who answered this section of the survey I used as the basis for this series said they did understand what was meant by the term culture shock – although for many this came later rather than at the time they were going through it. Although this in itself is heartening (as I think it should be part of everyone’s preparation for a move abroad to read up on culture shock), it is also worth noting that most of those who responded to my questions were already experienced expats. I wonder how many who have yet to move have ever considered a need to read up on this subject. Certainly a lack of knowledge about what is normal is one of the more common reasons people state for falling into depression – and thinking you are somehow doing something wrong by not being happy in your new home is also one of the reasons people fail to climb out of it.

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Part of their depression
For some people, their depression either started as culture shock or it was part and parcel of the same thing. Perhaps instead of moving through the cycle, they got stuck at a very negative stage. It is probably impossible to tell whether this was because the culture shock was preventing them from moving away from depression or the depression was preventing them moving through the culture shock cycle. Whichever was true, many found that the shock of moving to a new country pushed them lower than they had been before.

“The culture shock was one of the motives. Dutch people are way colder than Brazilian people. Sometimes I would feel so lonely that it was hard to make it through the day.” PKF

“Yes and no. Yes, because I’d briefly lived in the same country years earlier and my husband is native. But I discovered more things that drove me crazy and honestly, for the first three years, was desperate to move home no matter what it took. I knew it would get better but there are some things I will never like. So much of how I felt was tied up in being depressed and it was hard to separate the two”. V

Shock at the shock
Others found that they weren’t prepared for how severely they would be hit by culture shock, which in itself led to their depression. This included people moving to a new location for a second or subsequent time – not realising that culture shock doesn’t just happen the first time you leave your home country. It also includes people moving home and not realising you can get reverse culture shock.

“Having lived in Asia before I thought I understood culture shock, but China is so different that part of my problem is culture shock. Also I had never lived in a Communist, repressive, censored place before – that was a huge one we had never thought of”. Mary

“I understood the concept of culture shock. I lived right next door for five years beforehand. I just didn’t realise how different it would be here.” Sarah

“I expected to notice cultural differences and hoped to learn about different cultures and looked forward to that part of the cultural experience. I guess I was not prepared for the effect that cultural differences would have on me. In Mongolia, Indonesia and Mexico I feel that the cultural differences I saw or learned of have added to my education and enriched me. In India, the cultural differences I saw and experienced were far more extreme and made me realise that some of the core beliefs that I thought were universal were in fact not and this really unstabilised me”. Robyn.

“I did realise that part of my loneliness, isolation and frustration was the culture shock of returning home after so many years abroad” Nancy

More than culture shock
For many, especially those who understood culture shock and the effect of moving to a new environment, these feelings were definitely something more. Some recognised that they had had culture shock at some point in their expat lives and therefore knew this wasn’t that. Others worked it out when things didn’t seem to improve after a few months. As Catherine said:

“I definitely knew and understood the concept of culture shock. By this point we had been there almost two years so I think I had gotten over the culture shock part and was resigning myself to the fact that no matter what I did I would never be able to thrive in this environment.”

And from Nicky:

“This happened a long time after the initial culture shock! My friends were like family and I felt they had all abandoned ship and left me which was an irrational fear after so many years abroad”.

A good starting point: understanding culture shock
In my next post about expat depression I intend to start looking at some of the self-help methods people have used to help tackle their feelings. But a good starting point, whether you already have depression or as one of the weapons you can use against it, is to read up on culture shock.

Realising what is “normal” and what is perhaps something more can help us cope with what we may be going through. And if you believe that you have passed the stage when you should have been starting to adjust to your new life but you find yourself still struggling this could be the time to seek more help.

Further reading:

Culture Shock: What it is and How to Deal With It.

An interview I did for the podcast Tandem Nomads on Culture Shock

An article about the origins of the term Culture Shock

Photo credit: Republic of Korea

Did you suffer from culture shock? Did you understand what it was – and if so, do you think this helped? Do you wish you had known more about it before you left home?

Please don’t forget to read the other posts on this subject: Introduction to expat depression, what is expat depression, when and why does it happen and what does expat depression look like?

Expats and depression: a survey

Following on from my interview on Monday with an expert on expat depression, I thought I would like to find out more about the reality of how mental health issues can actually affect people living overseas. I am keen to find out more about how it manifests itself, what people have done to help themselves if they feel they may be depressed, what works and what doesn’t.

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The more we bring this issue into the open the easier it will be to help each other. I doubt many of us have entirely escaped some form of at least culture shock, if not low mood or even full-on depression while they have been living overseas. Whilst it is easy to see why this might be (isolation, loss of self, huge life changes, possibly loss of career or independent means of making money, distance from your usual support network, loneliness, fear of crime, loss of intellectual stimulation, boredom…the list could go on and on), what doesn’t seem to be talked about openly is what people have done to combat their depression.

People never like to admit to being anything more than “down”, and I think for expats this is compounded by the expectations of others that we are “living the dream”. And for those of us living in the developing world or in places where they are surrounded by people much worse off than they are, this feeling that we “shouldn’t complain” is made worse by guilt. How can we feel so unhappy when there are people who literally have to sleep on the streets because they can’t afford shelter? How about their mental health?

In fact, that guilt is yet another thing that can lead to depression and another thing we have to learn to deal with. It can be very hard in particular for those living in a developing world country for the first time, or who have otherwise lived a sheltered life. But it is important to remember that you need to think about yourself and your own family as well as others. After all, how are you going to save the world if you can’t even get out of bed in the morning?

Anyway, in order to help me understand a bit more about depression and the impact it has on expats I have put together a short survery that I hope as many people as possible will fill in. It is as anonymous as you want it to be.  Please share with others and add any experiences you have had, whether they be first hand, second hand or thirty-third hand. I am hoping to write at least one blog post with the information and possibly some articles as well. Let me know if you have any questions in the comments section below but otherwise, thankyou for your anticipated participation.

Go to the survery HERE

Expats and depression: Interview with an expert

The post on my site which gets the most hits is one I wrote about depression back in February. It wasn’t a long post or a particularly informative one – but what it did say was that depression in expats is common, it’s not something to be ashamed of and it’s something that we should all acknowledge as a very real part of expat life. What the reaction to the post – both the immediate reaction at the time of writing, and the amount of hits that post has had since – told me is that this is a subject that needs a lot more attention.

So I extremely grateful when an expert in this area agreed to be interviewed for this blog, and not only to discuss some of the reasons why expats are so vulnerable to depression but also to help with some advice for those who think they may be affected. Anita Colombara is a mental health specialist with a particular interest in the International Community. Her own background and experience, as well as her training, has helped her set up her on-line counselling service and to be in a great position to offer advice to the globally mobile. I hope many people will read her advice – please share this post if you can because I know, from how many people find my blog by typing in the words expat and depression, that this is a topic more people need to be aware of.

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Anita, thank you for agreeing to this interview. First of all could you tell me a bit about yourself, your background.
I grew up in Washington D.C. with Asian parents. I enjoyed both the American and immigrant experience as I felt part of both and neither worlds at the same time. I also had friends who hailed from every corner of the globe. As an adult, I married an Italian/Ecuadorian who spent summers with family on two different continents. You could say that, since childhood, I’ve been embracing the world, determined to be a global nomad when I grow up.

I’ve had the privilege of visiting and living in over a dozen countries. For four years I lived in Cambodia, gave birth to my second child in Malaysia, and later, enrolled my children in public school in Beijing. Throughout these adventures, I’ve experienced both the joys and challenges of being an expat. I love acquiring new languages, assimilating to new cultures, and feasting on new cuisine. However, I have also struggled with adjustment issues – cultural shock, loneliness, and confusion; with mental health issues – post-partum depression, anxiety, and vicarious trauma; and with relational issues – misunderstandings with locals and colleagues, marital strain, and difficulties parenting my two young children. I’m guessing many of your readers can relate.

How did you come to be working in mental health and why do you think it’s important for the ex-pat community?
I started out as a social worker in the States about 20 years ago. I worked in a variety of settings focusing on issues related to domestic violence, sexual assault, human trafficking and refugee resettlement which I then implemented with my work in Cambodia.

However, during my years in Cambodia, and later in other settings, I saw that ex-pat and humanitarian worker’s needs were being severely neglected. As I mentioned, I’ve struggled living overseas. And I know I’m not alone. I’ve heard numerous accounts from those experiencing trauma, disillusionment, confusion, compassion fatigue, depression, anxiety, loneliness, etc. I’ve also seen too many marriages broken and families strained due to ignoring conflicts rather than addressing them in a healthy way. I saw the vital need for my peers, who live and work internationally, to have access to quality, professional counseling.

When I returned to the US in 2008, I enrolled in the University of Washington School of Social Work, focusing on trauma intervention and therapy.Since graduation, I’ve have been serving as a mental health therapist at a community based agency in Seattle, WA. However, my heart is still with the international community. That is why I founded Remote Access Mental Health. My vision is to see globally mobile people thrive no matter where they are. My mission is to provide on-line professional mental health counselling for this unique population.

Why remote counselling? How would the globally mobile benefit from it?
When I lived in Cambodia, there were few counselling services for ex-pats. The few professional therapists in town were often booked. Moreover, with the ex-pat community being so tight, there was a high probability that the potential client and therapist already knew one another. This made professional boundaries difficult and therapeutic relationships awkward. This is an issue in many locations, not just Cambodia.

Services offered by host or sending agencies have their own set of potential complications. A typical scenario is that of a field staff person being assigned an agency affiliated counselor when supervisors become concerned regarding mental health or other issues in that individual. Many times, since the counselor is employed by the agency, they give their assessment to the supervisor. This is not always a bad thing. However, more often than not, I’ve heard from field staff who have been hurt by their agencies when they felt that client-therapist confidentiality was violated. In some cases, this resulted in the sudden expulsion from the international arena in order to receive “treatment” for unresolved mental health issues, family conflict, moral failure, etc. Individuals and families are left feeling like they’ve failed, betrayed by their employer, further isolated, and sink deeper into disillusionment, depression, or resentment.

With that said, I know a lot of ex-pat individuals and families who would benefit from an unbiased professional who could provide support where they are. With high speed internet service becoming increasingly available, even in the most remote places, this is becoming a possibility. Although in-person counselling may be preferable, video conferencing is a viable alternative given the hectic travel schedules and lack of local services that many expats experience. Professional counselling is now within reach!

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What kind of mental health services do you provide specifically for the globally mobile?
First off, I realize the term “mental health” often turns people away. They automatically assume I’m talking about crazy people with paranoia or are detached from reality. On the contrary, most of the people I work with are completely normal.
In short, I apply the same evidence-based therapeutic approaches that I use with my clients in my in-person practice. I first perform a thorough assessment to determine what the client’s needs, goals, strengths and natural resources, and desired treatment modality are. I then work together with the client to flesh out a treatment plan accordingly. I provide tools to address struggles as well as help create a plan for long term self-care.

The difference with my remote access clients is that I tailor to the unique needs of those who travel or live internationally. I am particularly interested in supporting the globally mobile population, including TCKs and ATCKs, that want to address trauma, panic attacks, anxiety, depression, and stress due to unresolved issues or culture shock and re-entry (reverse culture-shock) adjustment.

What are the signs that expats need to look out for if they think they might be suffering from depression, PTSD or other mental health issues?
Depression is different than sadness and normal life’s lows. It involves intense feelings of despair with little or no relief. It interrupts one’s life, work, relationships, eating, sleeping, and ability to engage in once enjoyable activities. Typical signs of depression are:

  • Loss of interest in relationships or activities you once enjoyed
  • Loss of energy, feeling tired all the time
  • Sleeping more than normal or inability to sleep
  • Change of appetite, overeating or lack of eating
  • Difficultly concentrating or finishing tasks
  • Lack of motivation
  • Lack of personal hygiene
  • Ruminating on negative thoughts
  • Feelings of hopelessness, helplessness, emptiness, apathy, failure
  • Feeling more irritable, short-tempered, angry, aggressive
  • Loathing – overly critical or self and/or others
  • Consuming more alcohol than normal or increased drinking alone
  • Engaging in reckless or unhealthy behavior

PTSD, or Post-Traumatic Stress Disorder, is a condition following a traumatic event that leaves one with intense feelings of fear, anxiety, or loss of control. One may feel trapped in a constant state of danger or in a painful memory. Others may feel unable to “snap out of it” and feel disconnected from others and present reality.

Many of my colleagues engaged in aid and development work experience what is called vicarious or Secondary Traumatic Stress Disorder (STSD). Through repeated or long-term exposure to stories or observations of those suffering from traumatic events, one may develop symptoms similar to PTSD. These symptoms come in three main categories and can arise suddenly, gradually, or re-occur over time:

  1. Re-experiencing the traumatic event:
  • Intrusive, upsetting memories
  • Flashbacks (feeling like the event is happening again)
  • Nightmares
  • Feelings of intense distress
  • Intense physical reactions when reminded of the event (pounding heart, rapid breathing, nausea, vomiting, muscle tension, sweating)

2. Avoidance and numbing:

  • Avoiding activities, places, thoughts, or feelings that remind you of the trauma
  • Inability to remember important aspects of the trauma
  • Loss of interest in activities once enjoyed
  • Feeling detached from others
  • Feeling emotionally numb
  • Lack of motivation
  • Sense of a hopelessness or assuming premature death

3. Increased anxiety and emotional arousal

  • Difficulty falling or staying asleep
  • Irritability or angry outbursts
  • Difficulty concentrating
  • Hypervigilance (on constant “red alert”)
  • Feeling jumpy and easily startled

Before reaching the point of needing to seek help from a counsellor like yourself, what can we do to help ourselves if we do find we are in this situation?
Self-care, self-care, self-care! I know too many good hearted people who are constantly looking out for others but neglecting to take care of themselves. Development workers, missionaries, and those on the front end of disaster relief for sure! The most important thing is to develop healthy habits and a personal Wellness Action Plan (I call these WAP for short). The second most important thing is follow through with your plan.

Your WAP should be comprehensive, including all aspects of your wellbeing – physical, emotional, recreational, relational, financial, spiritual, etc.

Your WAP should also be specific. It’s not enough to say, “I will exercise regularly.” What kind of exercise? How often? What time of the day? Where? This is especially important for the globally mobile since settings change and new locations may not accommodate to previous routines.

Lastly, your WAP should be realistic. For example, there is no point making a plan to exercise everyday if you know you’ll be on a plane two days out of the week. Make your plan attainable. Otherwise, you will find yourself giving up in frustration for not sticking to it.

Oh, and be kind to yourself. I tend to work with a lot of driven folks who are hard on themselves. Give yourself a break once in a while.

At what point would you recommend we need to seek further help from a professional such as yourself?
Negative feelings such as sadness, frustration, or stress are normal. But when they become overwhelming and interrupt daily function or lead to relational problems, it is important to seek professional help.

With that said, many people wait too long. It doesn’t hurt to seek professional help sooner than later. After all, even the healthiest among us receive physical check-ups. That is why I love assisting people in their personal WAPs to promote long-term wellbeing.

How can we support others if we start to recognize some of the symptoms of depression in them? In particular, how can we help our partners?
Often times, when a loved one is struggling, we may feel distraught or frustrated ourselves. It’s easy to go into advice giving mode or to withdraw due to feeling at a loss regarding how to help. However, the most important thing is your presence – being with them even if it just means holding them, crying with them, or sitting beside them in silence. Validate feelings instead of try to reason with them. Watch out for minimizing their pain, blaming and shaming. Educate yourself on the disorder so that you can better understand your partner, but be careful not to lecture them.

If your partner is reluctant to seek professional help, that does not mean you cannot seek help for yourself. A good therapist will be able to guide you through the process of assisting a loved one struggling with mental health.

Do you have any particular advice for children who might be showing signs of depression? How would this manifest in them differently than in adults?
The answer to this important question deserves an article itself. In short, children often act out what they cannot put into words. Often times, symptoms of depression, anxiety or PTSD in children are misdiagnosed as ADHD. Children often manifest troubling behavior such as difficulty focusing, defiance, difficultly regulating their emotions, hyperactivity, inability to calm down when aroused, lack of boundaries or risky behavior. They may engage in violent or self-harming behavior such as cutting themselves or hitting their head against a wall. Other children, may retreat, fall silent, even becoming mute. This is often the case for someone with PTSD. Again, disturbing behavior is a sign of a more significant, underlying issue that needs to be addressed.

Anita Colombara MSW, LSWAIC
Anita is a licensed Mental Health Professional by the State of Washington. After spending many years in Asia, she currently resides in Seattle, WA where she lives with her husband and two children and enjoys the natural beauty of the Pacific Northwest. She is the founder of Remote Access Mental Health LCC, providing on-line counseling for the globally mobile. www.remoteaccessmentalhealth.com

If you are or think you may be suffering from depression, or are vulnerable to depression, then please do talk to someone close to you and/or consider seeking help. As well as counsellors like Anita, charities like MIND can also offer online support and advice. I list other forms of support in my book the Expat Partner’s Survival Guide.

Photo credits: woman with key: Mary Lock at https://www.flickr.com/photos/wijen/; woman at table: Adi Sujiwo at https://www.flickr.com/photos/wijen/