Working as an expat psychologist

Imagine walking into a clinic where people from all across the world sit in the waiting room: American, Chinese, Brazilian, British, Moroccan, Italian, German, you name it. These 'expatriates', highly skilled migrants who have temporarily moved to a foreign country (often for work reasons) expect culturally sensitive therapies in their preferred language. With the world becoming increasingly globalised, expats and expat psychology are not a peripheral phenomenon any more. As an expat psychologist I currently offer outpatient therapy (CBT, psychodynamic and client-centred) at the largest mental health institution of the Netherlands, whilst pursuing my postgraduate training at the University of Antwerp, Belgium.

The typical expat may be flown in by a multinational company, work for the government (e.g. a diplomat) or for a NGO. Often the expat's family moves to the new country too, with expatriate children frequently attending international schools. Children that spend a significant portion of their development years in a culture different from their parents have been called 'third culture kids' (Pollock & van Reken, 2009), as they tend to assimilate various influences and create a culture of their own.

I provide treatments in English, Spanish, German, Dutch, Portuguese and Catalan for expat adults and children. Since our department specialises in a population and not a specific mental health issue, our work is not only very linguistically diverse (offering treatments in 13 languages), but we come across all sorts of psychological problems. I work in a multidisciplinary team, together with psychiatrists, clinical psychologists, and other specialists. Most expat psychologists work in private practices in cosmopolitan areas across the globe, so our centre is quite unique in offering this on a larger scale. Though our services are tailored to expats, at times I do see immigrants, who do not fit the expat definition but who cannot access other care facilities because they do not speak English or Dutch. All in all, this makes my job very interesting and challenging.

I am a bit of an amalgamation of cultures myself, being brought up in Ibiza, Spain, by a German Buddhist family (with a Polish ancestry). Learning languages has always been a joy, so it makes sense that I now work as a psychologist providing treatment for expats, in the diverse cities of Amsterdam and The Hague, as I can easily identify with them. When I moved to the Netherlands seven years ago to finish my studies, I did not speak Dutch yet, so it was easier to work using my other languages. I was initially trained as a child psychologist and started working with expat children; in the last two years I have worked with adults too.

Expats frequently suffer from adjustment problems and depression (see, for example, Aycan, 1997; Foyle et al., 1998), and have more mental health difficulties than the average non-expatriate population (Truman et al., 2011). Stressors can include anxieties related to their work, their home country, acculturation and physical illnesses. Moving to a new country can often come with a 'culture shock', the feeling of disorientation experienced by someone when they are suddenly subjected to an unfamiliar culture, way of life or set of attitudes. However, as people try to cope they may develop a dual identification with both their home and their host country, and slowly adapt to their new surroundings (Sanchez et al., 2000).

In fact, when people move back to their home country they may not feel like they fit in there any more: living abroad can change their values and ways of behaving. Cross-cultural skills training and a good repatriation plan can act as necessary buffers to cope with the stress of an identity conflict during the time abroad. If need be, we can continue to provide online therapy such as video calls once they migrate back home or to a new country. This is important because frequent travel and relocation can lead people to fall out of regular healthcare systems.

Challenges

I work in a very broad client setting with diverse mental health problems and diagnoses making it an exciting but demanding task. I learn a lot from the vastness of issues that are presented, and when feeling overwhelmed I make sure to discuss it within the team.  Moreover, speaking several languages during the day is fun yet at times tiring as my 'inner dictionary' has to use the right words in each session.

Probably my biggest challenge is experiencing the governmental and overall budget cuts in Dutch mental healthcare. This has affected the quality of our provided services as more administrative tasks are being put on caregivers. In order to meet the requirements of Dutch insurance companies (it is mandatory for any working resident to have private insurance), we have to spend a considerable time on paper work. Specific treatments for issues like relationship problems or adjustment disorders may not be covered by insurance companies any more: this is a shame, as adjustment difficulties and tensions within relationships tend to increase if we move abroad (van Erp, 2011). However, we nearly always manage to provide funded care for all clients, even if that means working officially under a different 'insured diagnosis' instead of the one that was originally intended. At times I wonder why we let the insurance oligarchy dictate which treatments ought to be funded, and not unite as caregivers against this.

More and more I notice how important it is to speak the language of a client, and work in a culturally sensitive way. For instance an individualistic therapeutic focus may not be helpful to someone who grew up in a more collectivistic culture. A more systemic approach, taking into account and involving their beliefs, family and social network may be more useful.

Yet in the midst of this jungle of sociocultural complexity I think there may be a certain universal mental hygiene we could all agree on, similar to the established basic medical hygiene practices that can save millions of lives across the world irrespective of one's cultural perspective. Though such factors require further study, a raft or research is showing how certain behaviours and values are perhaps universally beneficial for one's mental health: exercising, eating healthily, the power of ritual and social connection, mindfulness, compassion, friendships (caring for one another), and being creative. Cross-cultural solutions in mental health might not have to be so complex after all.

- Patric Esters is a psychologist at Mending Mind, and a psychotherapist in training at the University of Antwerp. He used to work for PsyQ International.

Key sources

Aycan, Z. (1997). Expatriate adjustment as a multifaceted phenomenon. International Journal of Human Resource Management, 8(4), 434–456.
Foyle, M.F., Beer, M.D. & Watson, J.P.L. (1998). Expatriate mental health. Acta Psychiatrica Scandinavica, 97, 278–283.
Pollock, D.C. & Van Reken, R.E. (2009). Third culture kids: The experience of growing up among worlds. Boston: Nicholas Brealy.
Sanchez, J.I., Spector, P.E. & Cooper, C.L. (2000). Adapting to a boundaryless world: A developmental expatriate model. Academy of Management Perspectives, 14(2), 96–106.
Truman, S.D., Sharar, D.A. & Pompe, J.C. (2011). The mental health status of expatriate versus U.S. domestic workers. International Journal of Mental Health, 40(4), 3–18.
van Erp, K.J.P.M. (2011). When worlds collide: The role of justice, conflict and personality for expatriate couples' adjustment. Doctoral dissertation, Rijksuniversiteit Groningen, The Netherlands.