The mental health challenges of life as expats

Living abroad, whether if for a short-term adventure or as a permanent move, can be an incredibly eye-opening experience, offering significant opportunities for personal growth.

In 2021 nearly 16% of the UK’s population was non-native, while this figure rises dramatically in London, where around 40% of residents were born abroad.

Life as an expat comes with a unique set of opportunities but also some peculiar challenges. Moving abroad can bring all the excitement of exploring a new country, meeting new people, embracing fresh experiences and often accessing career opportunities that may not be available at home. Starting fresh can also allow us to experiment other sides of our personality, break free of the expectations and perceived images of old friends and family, giving us a sense of freedom that is sometimes difficult to experience back home.  

Nonetheless, life as an expat isn’t always a bed of roses and it can come at a high price. 

Firstly, building new friendships takes time, in terms of quantity and quality. Expats can often face, especially at the beginning of their life abroad, feelings of loneliness, isolation and disconnection. It’s not always easy to build meaningful social connections that can turn into a resource in case of need. Many of us are unused and sometimes unequipped to deal with this initial isolation. 

The distance from family and friends can be hard to bear, and often is accompanied by the guilt of having chosen to live abroad. 

Even after several years of living in another country, our sense of belonging and feeling “home” can be torn in two. 

The question whether to keep living abroad or going back home will recurrently pop up in your mind, bringing the uncomfortable feeling that the answer will be difficult to formulate. Furthermore, it’s likely that none of the two choices will truly satisfy you or fully resonate with you. 

Regarding work, working in another language and in another culture can bring important cultural clashes.  

An interesting 2023 report by AXA, conducted across 16 countries, focussed on the mental health challenges faced by non-natives. The study revealed a decline in mental well-being among non-natives compared to the previous year, with one in three reporting a mental health condition—a rate comparable to that of natives. However, non-natives experience higher levels of work-related mental health issues. In fact, 80% reported negative mental health impacts due to their work environment, and nearly half of them experienced burnout.

Adapting to a new workplace presents indeed its own set of difficulties. 

Working in a different language and cultural context may lead to misunderstandings that can potentially affect both mental health and work productivity. 

There are several factors influencing the workplace, that significantly vary across countries. 

Our communication style, for instance, is partially shaped by the culture we grew up in. For example, some cultures tend to favour a direct approach, while others rely on more indirect communication, requiring messages to be interpreted between the lines. Similarly, the expression of emotions, the delivery of feedback, and perceptions of hierarchy and time can vary significantly across countries (E. Meyer, 2014).

In general, we are all unconsciously influenced and biased by the culture we were raised in. When these cultural influences go unrecognised, the risk of miscommunication is high. Unfortunately, many professionals working in multicultural environments lack the necessary support to navigate these differences, making adaptation more challenging.

AXA’s report further revealed that more than half of non-natives feel their mental health needs are not adequately addressed, with only two in five receiving professional support. 

Culturally sensitive psychotherapy and counselling can be useful resources for expats, providing a tailored and sensitive support to help them navigate these challenges while living abroad.

References:

“The Culture Map”, E. Meyer, 2014 

“A Globale state of mind”, Axa Global Healthcare, 2024 

Bibliotherapy during quarantine

If you can’t go outside…go inside!

What better occasion than quarantine to use our precious time for a little (or not so little) reflection on ourselves, new awareness and personal growth? I believe bibliotherapy is a useful tool in my work, as I often recommend some reads to my patients as support to their psychotherapy. 

Here are some interesting reads to start your inner journey, as they may inspire the changes you were longing for by shedding light on mental functioning.

The courage to be disliked by Ichiro Kishimi and Fumitake Koga

An imaginary conversation between a wise philosopher and a young adult on how to achieve freedom from our mental schemas and increase our happiness, through the lenses of Adlerian psychology. 

A good prompt for reflection on the desire to be accepted and recognised by others, self-confidence and how sometimes we can be the very saboteur to our own happiness.

Emotional intelligence by Daniel Goleman

Daniel Goleman explains why emotional intelligence can actually be much more useful than IQ. 

Emotional intelligence implies the ability to read our and other people’s emotions in order to understand them and use this information as a guide to behaviour and thinking. This emotional muscle is indeed one of the keys to success in interpersonal relationships, both in our private life and the workplace.

The choice by Edith Eger

Dr Edith Eger shares her personal story as a survivor of concentration camps in the Second World War, delving into her struggle healing from trauma and the path to becoming a psychologist to help veterans suffering from post-traumatic stress disorder. An inspiring and heart-touching story delivering an important life lesson: even in the worst possible situation, we can always choose our thoughts and attitude and change the way we perceive reality. 

 The power of now by Eckhart Tolle 

When approaching the concept of mindfulness, being and living in the present moment exerts the ability to stay in the here-and-now, while observing from a detached and non-judgmental point of view what’s going on inside us.

Eckhart Tolle outlines the power of Now, a concept deeply embedded in Eastern philosophies, yet still so foreign and little-known in Western societies. 

Come as you are by Emily Nagoski

Dr Nagoski takes us on a journey into women’s sexuality, debunking false beliefs (and believe me ladies, there are plenty!), as well as inspiring a reflection on what are the brake and accelerator factors in our sexual life. An excellent read to get to know yourself better, understanding how culture, early experiences and stress impact on sexuality by learning that we are all normal, made of the same parts but organised in different ways.

Overcoming low self-esteem by Melanie Fennell

If self-confidence is your Achilles’ heel, this self-help book is for you! 

Melanie Fennell explains how self-esteem develops across the lifespan, starting from early experiences with our caregivers as well as school-peers, and how our beliefs about ourselves influence and mediate almost every aspect of our daily life, such as our attitude in the workplace, with our partner, friends, and so forth. The book contains several practical exercises, based on Cognitive Behavioural Psychotherapy to effectively increase self-esteem.

Staring at the sun by Irvin Yalom

I would recommend literally every book written by Irvin Yalom, yet this may actually be the one that touched me the most. In this book, Yalom offers a little window to his therapy room, sharing true stories of patients dealing with such a sensitive topic like the fear of death. 

Given our human nature, we may well relate to Yalom’s patients, as they live life coping with the certain fact that time on this planet is limited.

Yalom gives us food for thought, drawing on his vast experience in existential psychology and ancient philosophy. 

Covid-19 and online psychotherapy

How can we take care of our mental health while in quarantine? Online psychotherapy could be an important tool.

Until a couple of months ago, no one would have imagined that half of the world was soon going to be in lockdown, that we would be stuck at home with no chances to meet our loved ones, unable to travel and visit friends or family, without an office to rush to in the morning, or schools to leave the kids at … 

Our habits have been turned upside down and after an initial reaction of denial, shock and anger perhaps, now we’re doing our best to adapt to the current situation. 

Coronavirus is an invisible new inhabitant of our world that has altered our perception of time, relationships and sense of security. However, this ‘break’ could really represent a good opportunity to reshuffle our routine and think both our life and habits through.

Is there anything that you wish to leave behind in the pre-Coronavirus times? Were there things you may have taken for granted and not appreciated enough? Was the pace of your life too fast? Were you missing out on the important things? 

The impact of quarantine on our mental health

With quarantine underway, fear of contracting the virus, economic instability, fear of losing or actual loss of our loved ones, forced and prolonged isolation are all significant risk factors that may take a significant toll on our mental health.

Prolonged lockdown is indeed presenting different challenges within different age groups. Apparently young people are mostly struggling with boredom, family conflicts and in complying with social distancing rules, whereas the most vulnerable (the elderly and people with health problems) are struggling with solitude. People in their 40s and 50s seem to find it difficult to handle home-schooling and work altogether (S. Barari et al, 2020). 

Scientific research suggests that the main effects of prolonged quarantine consist in increased anxiety, depression and irritability, plus an increase of post-traumatic stress symptoms in healthcare workers that are exposed to emotionally-charged situations on a daily basis. 

The longer the quarantine lasts, the worse the impact on our mental health may be.

In these difficult times, mental health support becomes even more vital and, given social distancing measures, online psychotherapy is the only viable way to therapy.

How does online psychotherapy work?

Online psychotherapy works exactly like face-to-face therapy.

In parallel with the massive use of technology in our daily lives, mental health support has been recently delivered in non-traditional ways, other than the classic face-to-face offline approach. Phone and video calls, emails and also instant messaging are being used as the means to deliver therapy.

Consultation via video call is the most frequent one and, as I personally believe, the best way to access online counselling. Several GDPR compliant platforms can be used, such as Skype and FaceTime.

The sessions work exactly like face-to-face therapy in terms of duration, frequency, confidentiality and how therapy is held.

Is it more difficult to open up online compared to face-to-face meetings?

Not necessarily. Research suggests that young people feel more comfortable with internet-based counselling, especially via instant messaging compared to other traditional forms of psychological support. Anonymity seems to promote more direct communication while reducing feelings such as shame and embarrassment (Kuka, 2014).  

Will the relationship with the therapist feel different compared to face-to-face therapy?

The idea of talking about inner struggles with a therapist never physically met before may raise concerns in some of us. ‘How can I trust a person I have never met? Will the therapist be able to get a full picture without body language cues?’ are indeed common questions.

The screen may sometimes represent a barrier when reading non-verbal cues, but research suggests that online therapy is as useful as face-to-face therapy and that patients report good rates of satisfaction by using this method. 

After all, if you think about it, nowadays there is an abundance of things happening online. We take on new hobbies, make new friends, exchange ideas with like-minded people, hold group meetings and, sometimes, fall in love, too!

In my personal experience, it is possible to establish a solid therapeutical relationship with a therapist online, despite the traditional face-to-face experience still being the preferred method for some people.

Does online psychotherapy work? 

Personally, I believe in the efficacy of online counselling and my experience so far has been promising. 

Data collected in scientific research suggest that online therapy has the same efficacy of face-to-face therapy. In particular, internet-delivered Cognitive Behavioural Therapy has proved its efficacy for treating anxiety as well as depressive disorders and its effects last over time (Wagner, 2014; Andrews, 2018) .

Is online therapy suitable for everyone? 

Online therapy is suitable for most people, yet it may not be for everyone.

It is not recommended for people with suicidal intent, psychosis or acute psychiatric disorders. In general, online therapy is not recommended for people experiencing acute conditions that may require the patient to seek medical help.

If you wish to try online therapy, a good Internet connection and a quiet and private environment to take the call are important. Feeling comfortable opening up is key, therefore you may want to find a suitable time and place where your privacy is protected.

 Which therapist should I choose?

The process of picking your therapist is a very personal one. Check the credentials as well as the qualifications of your chosen therapist to understand whether their area of expertise matches your requirements. 

Then, in the same way as face-to-face therapy, proceed to book an initial session with a couple of therapists or have a quick phone chat with them to address your questions and see how you feel. Your inner guidance will tell you – the best therapist for you is the one you feel comfortable opening up to.

Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, Newby JM.

‘Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis’, Journal of Anxiety Disorders, vol 55, April 2018, Pages 70-78

Wagner B, Horn AB, Maercker A. “Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial”, Journal of Affective Disorders, volumes 152–154, January 2014, Pages 113-121

Barari S, Caria S, Davola A, Falco P, Fetzer T, Fiorin T, Hensel T, Ivchenko A, Jachimowicz J, King G, Kraft-Todd G, Ledda A, MacLennan M, Mutoi L, Pagani L, Reutskaja E, Roth C, Raimondi F Slepoi. “Evaluating COVID-19 Public Health Messaging in Italy: Self-Reported Compliance and Growing Mental Health Concerns”

Kuka DL (2014) “Adolescent Help-Seeking: The Promise of Text Counseling”. Retrieved from Sophia, the St. Catherine University repository website: https://sophia.stkate.edu/msw_papers/350

Past, present and future are the three elements of our timeline that strongly influence our self, mind and our psychological functioning. Our sense of self is shaped by our past history, and our expectations and goals are a sort of compass that orientates our present. Our mind constantly navigates among past, present and future and most of the time we are not completely aware of this.

How many times have we found ourselves trapped by worry regarding the future? And how many times was that scary vision of the future not even close in time as it may potentially happen although we are not even sure when?

Or on the contrary how many times have we found ourselves ruminating over and over again on past episodes, on things that happened and that we would like to change, on our mistakes and people’s behaviours?

While worrying about the future typically leads to anxiety, rumination often causes low mood.

Beyond the negative consequences that this mindset has on our mood, it also involves a specific risk: missing out on the present moment – our today.

Being constantly focused on tomorrow or yesterday doesn’t allow us to be present in what is happening in the now hence to appreciate and enjoy the beauty of what we actually have or are experiencing.

Oriental philosophers have been the first to embrace this thought and to transform it into a real mantra for living, using meditation as a daily activity. In recent years, some principles of Eastern philosophy have been adopted and tailored to the Western lifestyle, and it comes with the name of Mindfulness.

Being mindful means being aware of the present moment, being in the here-and-now and it can be practiced through meditation or simply by asking yourself gentle questions in order to bring awareness to your senses.

Beyond the efficacy of stimulating a state of calm and awareness, mindfulness can be a powerful tool to fight and contrast our mind’s tendency to wander into the past or future when such activity is not needed or useful.

If you recognise yourself in this tendency to focus too much on the past or future instead of the present moment, working on being mindful through psychotherapy can be quite helpful in tackling such inclination.

Counselling and psychotherapy

Psychotherapy and counselling are talking therapies, based on the assumption that talking and reflecting about our own thoughts, emotions and experiences are powerful tools to feel better and change. In particular, the role of emotions is fundamental in our daily life and too often they are not considered, mistreated, denied or swallowed. Emotions on the contrary are our own individual compass that indicates how well we are dealing with our life and our goals. Paying attention and taking care of them is a way of assuring a balanced and mindful psychological life.

Emotions’ psycho-education

In cognitive behavioural psychotherapy and in counselling, if the patient happens to be confused, overwhelmed or simply not used to pay attention to emotions, one of the first steps in therapy is acknowledging them. This process is called “emotions’ psycho-education” and it implies getting to know each of our emotions, their role, aim and physiological activation in order to discover how our mind is functioning. This usually works by monitoring everyday our affective reactions and discovering which thoughts and goals are related. Therefore recognising and labelling the emotions we perceive is the prerequisite for regulating them in a healthy way. 

What scientific research is telling us?

Despite being a technique that has been used since the birth of counselling (and even earlier), it is only in recent times that scientific research has found the biological proofs of the powerful effect of labelling emotions. A research carried out by Lieberman et al. in 2007 clearly showed that affect labelling impacts the functioning of specific areas of our brain that are responsible for emotions’ processing and regulation. Specifically, translating feelings into words decreases the activation of a little region of our brain, the amygdala, that is responsible for automatic emotions activation.

On the contrary, affect labelling seems to increase the activity of a specific region of our pre-frontal cortex (the right ventrolateral area) that is responsible for a high-level processing of emotional information. A decrease of the amygdala’s activity and an increase of that specific aerea of the pre-frontal cortex help alleviating emotional distress.

If you find yourself in a period of strong emotional distress, you may consider talking it through in psychotherapy or counselling; talking therapies are an useful tool to better understand what is going on and to find different strategies to better deal with it.

References:

Lieberman M.D, et al., “Putting feelings into words: affect labelling disrupts amygdala’s activity in response to affective stimuli”; Psychol Sci. 2007 May 18(5):421-8.

First session in psychotherapy

Deciding to start psychotherapy or counselling can bring forth questions and doubts. Above all, most questions permeate in the first session, which is always laden with great expectancy.

Questions like ‘What should I say?’, ‘Should I open up to my therapist straight away?’, ‘Will I feel comfortable speaking to my therapist?’, ‘How can I tell if my counsellor is the right one for me?’, ‘What should I expect from my first session of therapy?’ and so on may arise.

Let’s examine these questions.

Questions and doubts

What should I say? 

Usually the first session is a preliminary consultation that helps both therapist and client introduce each other and see if common ground is found for further collaboration. As the therapeutical process begins during the first interactions in the initial session, the therapist will gather information about the client and the specific reasons that brought them to ask for help. The first session is crucial to the patient too, as they will eventually decide whether the counsellor is a good fit for them.

The therapist will usually guide the client through a series open-ended questions to assess their situation.

Should I open up to my therapist straight away?

There is no straightforward answer to this question as we all tend to follow our own instinct. For example, some try out therapy with a clear idea of their issues while others may feel confused and overwhelmed at the idea of pinpointing their case. Others may have mixed feelings about it and may experience troubles connecting all the dots when outlining their complex inner picture.

Some aspects of our suffering can elicit intense shame or guilt and therefore, building and establishing trust with a therapist has to be an essential prerequisite for opening up.

Some people find it quite easy to open up and talk comfortably from the beginning whereas others may find it tricky as they require more time and trust.

Will I feel comfortable speaking to the therapist? 

Therapists and counsellors are trained to work and help people with psychological issues. They are able to create a comfortable and non-judgmental setting showing an active-listening attitude.

Obviously, each therapist differs from another in personality and type of training, so each counsellor will adopt a slightly different approach to the client. Also, we all have personal preferences when it comes to people.

Some clients prefer a straightforward and direct attitude, others may opt for a female therapist as opposed to a male therapist or vice-versa, or look for a therapist from a specific country or of a specific age.

How can I tell if the therapist is the right one for me? 

The impression you will get from the first consultation will determine whether you want to embark upon the therapeutic journey with that specific therapist.

Beyond the therapist’s qualifications and specialism, the match for you will make you feel comfortable enough to open up by giving you food for thought.

What should I expect? 

From a first session you may expect to start thinking about the reasons that brought you to counselling in the first place, as well as the causes and consequences related to what you regard to as an issue, along with your expectations and ultimately, motivation. Will may expect a welcoming, non-judgemental and confidential setting where you will feel comfortable about expressing your troubles.

But above all, the first consultation will give you interesting insight into the world of psychotherapy as a tool to provide you with a new perspective on and solutions to a particular issue.

Young adults and mental health

Several psychological disorders tend to manifest and strengthen between the end of adolescence and the beginning of adulthood.

In particular, mood disorders have an average age of onset of 25. Conversely, anxiety disorders have a more variable onset: some of them appear fairly early in life, as separation anxiety or specific phobias that tend to manifest during childhood, while others, such as social phobia, obsessive compulsive disorder and panic disorder tend to appear slightly afterwards, during adolescence and early adulthood.

Scientific research has shown that people suffering from a mental disorder usually tend to wait for a long time before seeking help. Sometimes months or even years may elapse without asking for help or a professional like a psychologist, a psychotherapist or a psychiatrist for assistance.

Why does this happen? 

Many reasons may contribute to the avoidance of counselling and the delay of seeking help. Hesitancy and uncertainty about asking for help are often attributable to feelings of guilt and shame. Seeking assistance is not easy for most people as the society we live in today expects us to always be at our best. The act of acknowledging a problem may be perceived as a sign of weakness and vulnerability, hence the fear of exposure and loss of social standing.

We may also think that what we are experiencing is but fleeting symptoms of a transient condition that might well disappear in time. Luckily enough, sometimes this is actually the case and the symptoms will simply and naturally dissolve, whereas some other times, signs and symptoms may lead to an actual mental disorder. In the latter case, it is very likely that the chronicity and severity of symptoms, as well as the consequences that they may cause in our daily life, may be affected and worsened by lack of treatment in individuals with strong help-seeking barriers.

If you experience psychological symptoms that make you feel as something were off, talking to a professional therapist is strongly recommended as a counsellor may help you understand the cause and the severity of the situation and, if necessary, point you in the right direction and towards the best psychological approach to tackle the issue.

If the onset of a mental health condition manifests during adolescence and early adulthood, hesitancy in seeking help may be particularly counterproductive for young adults as in this case it implies an even more delicate scenario.

Why is it important for young adults to seek help? 

The first years of adulthood are a window to our future dotted by several remarkable decisions and events such as diplomas and university degrees, our first job, stable relationships with friends and a partner. Some of us will also start a new family.

While we are young adults, we strive to envision the direction our life will take. Our very attitude towards life and the choices we make will inevitably influence it in the long term, much more than we can imagine.

At such an important and delicate moment, suffering from an untreated disorder may dramatically impact on our future. Mental health clearly can affect how we relate to other people and the social environment we build around us, as well as how we focus on and effectively engage ourselves in study or work-related goals and achievements.

This is why it is so important for young adults not to be afraid to acknowledge any psychological difficulties and not to lock the door to their inner world, but instead open up and ask for help to better understand what’s going on and finally allow a change.