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

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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/

Depression and expat life: something we don’t talk about enough

I wasn’t going to write a post today. I have a busy week with school assemblies and meetings and work to catch up on. I’m trying to do a final read-through of the Survival Guide before sending it to the proof-reader. The washing needs doing….there’s mouths to feed…you know the score.

But as I scrolled through my Facebook feed this morning, something caught my eye. One of my online ex-expat friends Nicola had posted something about today being “time to talk about mental health” with a supporting campaign called “Take 5“. As I read the post,  I wondered how many expats suffered from depression or other mental health issues – and how many of them (us) ever talk about it.

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According to the Take 5 campaign, one in four of us will suffer from some sort of mental health issue every year. Now, I am no expert on this but knowing what I do about moving and living overseas, I can’t believe that already fairly shocking figure isn’t even higher amongst expats. Some of the sort of things that can lead to depression or mental health issues – isolation, loneliness, change – are all part and parcel of life for many expats, especially those who are newly arrived. And for the partners, this is often magnified by their other half going to work and immediately finding a role, colleagues, friends – while their accompanying spouses stay at home and need to work all of this out for themselves.

But how many people ever admit they have a problem? Who would you admit it to, anyway? Your partner? Many of us don’t want to worry him or her, as they try and get their head around a new job. Or they’re so desperate for you to be happy that you don’t want to upset them.

Friends? You may be lucky and know one or two people when you first move overseas – but even then, they are unlikely to be someone you feel close enough to do talk about things like your mental health. At least not straight away.

Family? Once a week you have those Skype or Facetime discussions. Your mum wants to see the kids and she wants that tour of the house, loves looking at the tropical foliage in the garden or the city view from the upstairs window. How do you start a conversation with her about how down you’ve been feeling?

Professionals? In some countries this will be possible. In others, it will be a lot harder. It all depends on what is available locally.

This is a difficult subject to talk about – but sometimes that is all we need. Someone to discuss it with. I don’t have any magic answers here except to assure you, if you think you are depressed or do have other mental health issues, that this shouldn’t be something to feel ashamed of. And that you shouldn’t be afraid to seek help. DO talk to your partner – he or she needs to know and it’s better they hear about it early on rather than when it’s gone too far. If you don’t have any local friends you can trust enough to open up to, what about online forums? Mumsnet (as an example) will always have a sympathetic ear – whatever time of the day or night it is. There are also specialist expat coaches or counsellors who work over Skype or via email – often they will have been expats themselves and will have a really good idea about what you are going through.

Moving is said to be one of the most stressful things you can do. Moving overseas can be even harder. Being somewhere new, where you don’t know anything, can’t get around easily, have no routine to your day and possibly don’t even speak the local language, it’s not surprising if you don’t feel your normal self.  For most expats, things will get better as they settle in, get to know more people and start to get some routine back into their lives. For others, it make take a bit longer or they may need to get professional help. But for all of you, just remember to go easy on yourselves. This is a big life change – don’t expect it all to be sundowners and pool loungers. And don’t forget to talk!

 

Have you found it harder than your thought to settle in to expat life? What advice would you give to others, especially those who have just moved or are about to move overseas? Any tips for dealing with depression or low mood generally, even if you are not or have never been an expat?

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