Expatriates At Risk; Stress and Mental Health…

…Ensuring expatriate health, both mental and physical, is of concern to all effective human resource professionals…
Sean D. Truman, Ph.D., LP; David A. Sharar, Ph.D.; John C. Pompe, Psy.D., LP, SPHR
Global mobility professionals intimately understand the high stakes of an international assignment, and are all too familiar with the potential sources of stress facing an expatriate moving beyond his or her borders. Truman, Sharar, and Pompe detail the findings of a recent study that examines mental health risk in U.S.-based and expatriate employees, and describe how these findings have implications for clinicians, EAPs, global medical benefit plans, and human resources staff.

A number of studies have estimated that American expatriates have rates of assignment failure that range from 16 percent to 40 percent. There are a variety of factors that increase the demands on expatriates. They range from heavy workloads to extensive travel schedules and cultural differences—all of which contribute to stress and increase the probability that they will return home before their assignment is complete.

During the course of the last 25 years, published reports have suggested that living overseas as an expatriate conveys risk for stress that exceeds those for individuals living in their home country. The vast majority of these accounts are anecdotal, case reports, or autobiographical histories of living overseas. Experts also have suggested that the rate of mental health problems for expatriates is higher than for their counterparts living at home. However, there has been no empirical study of whether expatriates living overseas actually do experience higher levels of stress that contribute to a range of problems—including adjustment and affective disorders, depression and anxiety, marital issues, and substance abuse.

The study highlighted in this article was designed to empirically compare mental health risk in U.S.-based and expatriate employees. We hypothesized that the rate of mental health diagnoses among expatriates would be greater than that of a non-expatriate working population. In particular, the expectation was that problems such as depression, anxiety, and substance abuse would be higher for expatriates than for employees based in their home country. The results of the study indicated that this was the case; expatriates experienced significantly higher risk for anxiety, depression, and substance abuse problems than did their domestic counterparts.

Study Specifics
The study used a survey to compare the mental health status of global expatriate employees to domestic U.S. non-expatriate employees. The two groups were drawn from separate and distinct multinational employers headquartered in the U.S. The expatriate group was made up of 455 expatriates, all residing in their host location for a minimum of six months; the typical duration of their international assignments ranged between one and three years. The expatriates’ host locations were spread throughout the world, with the highest concentration in Latin America, Asia, Europe, the United Kingdom, and the United States. The U.S.-based comparison group consisted of 1,460 individuals, and were a mix of office-based management and production-based manufacturing workers across the country, but were primarily located in the Midwest and the Southern regions, mainly in suburban and rural areas.

The study used an online, scientifically based survey known as the Gain Short Screener (GSS). The survey is a 20-item questionnaire, which has been shown to accurately identify individuals with a variety of psychological problems including anxiety, depression, and substance abuse. This type of information can then be used to develop programming or to provide services to individuals through referral to an Employee Assistance Program (EAP), as well as to individual providers or health care systems.

The tool measures responses in three primary areas:

1. internalizing (e.g., depression, anxiety, sleep issues, traumatic stress, suicide);

2. externalizing (e.g. attention deficit, hyperactivity, conduct and impulse control); and

3. substance abuse and dependence.

Both groups (expatriates and U.S.-based) completed the GSS. In addition, the expatriate group completed a scale that asked respondents about their degree of satisfaction with marital, family, and social relationships, as well ratings for their job satisfaction and job performance.

Study Results
The study yielded several significant findings: Expatriates had a higher overall risk for mental health problems, including internalizing problems, externalizing problems, and substance use disorders.

These results are largely consistent with the notion that living as an expatriate involves very significant stress and high demand for adjustment. While these demands can be— and frequently are—exciting, engaging, and interesting, they also can converge to the point where they become impairing and result in significant problems.

Internalizing Problems
We hypothesized that expatriates would be particularly prone to internalizing problems, which is consistent with the notion that relocation, cultural dislocation, stress, and high demand for adjustment and adaptation can lead to issues such as anxiety and depression.

The study provided the following results:

** Three times as many expatriates as U.S.-based workers expressed/endorsed feelings of being trapped/depressed.

** Twice as many expatriates as U.S.-based workers expressed/endorsed feelings of being anxious/nervous.

More broadly, the study found that more than 50 percent of the expatriate sample was at high risk for internalizing problems (such as anxiety and depression), which was a rate 2.5 times their U.S.-based counterparts. Taken together, these findings suggest that anxiety and depression play a central role for expatriates experiencing emotional problems. In contrast, in the U.S.-based group, less than a third of the non-expats were assessed as being at risk for internalizing problems.

Externalizing Problems
Surprisingly, the study showed that the expatriate community was at higher risk for externalizing problems than U.S.-based employees. The survey tool assesses less controlled symptoms (i.e., fighting with family members), and we expected that both the overall rates of externalizing problems, as well as the difference between the groups to be very small. This was not the case. The study is consistent with the view that expatriate communities experience a globally stressful existence where emotional, professional, and relationship demands are exceedingly high. This finding suggests that expatriates are feeling emotionally disrupted and that their behavior reflects this emotional state.

Substance Abuse and Dependence
Anecdotal evidence and clinical experience suggest that substance abuse and dependency risk would be higher for expatriates than U.S.-based workers; the results of this study supported the position that expatriates are at higher risk than U.S.-based workers for substance abuse problems. In this study, a larger proportion of expatriates were in the high and moderate risk categories for substance abuse problems than were the U.S.-based employees. This indicates that individuals in the expatriate group use substances at higher rates and in greater amounts, and with more negative consequences than do their U.S.-based counterparts.

This is likely related to several factors. Standards in many expatriate communities are frequently more liberal regarding alcohol use, which might reduce the stigma and social pressure that would otherwise limit high levels of use. In addition, living as an expatriate often is associated with high levels of stress that in other studies have been linked to higher substance use. These factors work synergistically to create an environment that elicits more frequent and more intense substance use among expatriates.

Impact on Expatriate Job Performance and Relationships
Participants in the expatriate group completed a questionnaire about their satisfaction with work, work performance, social relationships, family relationships, and marital relationships. Again, the pattern of findings remains consistent: individuals who were at high risk for internalizing problems (e.g., depression and anxiety) disproportionately rated their work as being “below average” and “average” when compared to the low risk group. Similarly, expatriates with high/moderate risk for internalizing were markedly less satisfied with their work than their low risk counterparts.

This is particularly important given the consequences of “washing out” from postings overseas as it represents a very significant disruption for individuals, families, their employers, and their careers. It also suggests that high risk for internalizing problems such as anxiety and depression may be related to the ways in which individuals experience their work lives.

Satisfaction with relationships (social, marital, and family) also was highly related to internalizing risk. Expatriates with high and moderate risk were dramatically less satisfied with their relationships compared to individuals who were low risk for internalizing problems. Again, this suggests that there are meaningful and powerful links between each individual’s internal experience of stress and the ways in which they relate to people in their life.

Services in Support
In sum, the study found that individuals living as expatriates experience a range of risk at rates that exceed their U.S.-based counterparts. In this study, expatriates experienced higher risk for internalizing and externalizing problems, as well as higher risk for substance abuse. However, this is not limited to emotional experiences. High-risk internalizing problems also were related to greater rates of dissatisfaction with work, marital relationships, family relationships, and job performance.

Living overseas as an expatriate is difficult and demanding; living far from home is stressful, and a variety of factors such as reduced social support, cultural dislocation, increased family disruption that results from high work demands, and a variety of other factors can cause a host of problems, including emotional disruption. These findings have implications for clinicians, EAPs, global medical benefit plans that cover mental health services, and human resources staff that work with expatriates and their families.

The authors of this study have many years of experience implementing specialized expatriate family support programs. While more development and research is still needed in the arena of expatriate wellness and support programming, the following practical suggestions can help in the design of programs or services that more effectively target the needs of expatriates and their families:

 Do not rely on a passively available EAP or global mental health benefit, which are the norm for U.S.-based programs. Expatriates rarely use these services proactively or have confidence in their effectiveness. Proactive outreach to “check-in” with expatriates and spouses by phone and e-mail is key to linking them with needed mental health services.

 Disseminate regular health media information, educational content, and program promotions specifically designed for the expatriate population as a part of a more assertive outreach effort.

 Even if an international EAP or global benefit plan is available, do not assume that expatriates have access to qualified or competent professionals in many parts of the world.

 Create access to mental health services in a way that is easy, “hassle-free,” and, of course, completely confidential.

It is clear the mental health needs in the expatriate community are significant, and more prevalent than previously known or documented. It follows that multinational organizations should consider ways in which they can appropriately identify individuals at risk to proactively provide services that reduce the disruption that stress and related mental health problems can cause for their expatriate workforce.

The authors
Sean D. Truman, Ph.D., LP, is director of clinical services at the Truman Group, St. Paul, MN. He can be reached at (651) 964-0224 or e-mail struman@truman-group.com.

David A. Sharar, Ph.D., is managing director at Chestnut Global Partners, Bloomington, IL. He can be reached at (309) 820-3570 or e-mail dsharar@chestnut.org.

John C. Pompe, Psy.D., LP, SPHR, is manager of disability and behavioral health programs at Caterpillar Inc., Peoria, IL. He can be reached at (309) 675-6263 or e-mail (pompejc@cat.com).