Mental health in Expatland: The elephant in the examination room begins to get noticed
Even the most well-grounded, mentally stable individuals can find the business of moving to a foreign country stressful – and that’s before you add in such variables as spouses and children, ageing parents back home, overseas start-up ventures that don’t succeed as they’re supposed to, unforeseen economic crises in the new country, and even the threat of terrorism or kidnapping.
Here, Charlotte Beugge talks to insurance experts who specialise in the little-talked about mental health elements of iPMI coverage, and how iPMI providers are increasingly working with their expat clients to ensure they stay mentally healthy – even before they leave to take up their overseas posting.
Mental health, long in the shadow of physical illness, is starting to be treated just as seriously: and, many experts say, it’s not before time.
Initiatives such as the involvement of Princes William and Harry in the new, UK-based Heads Together Charity – and their brave admissions of their own mental health issues – are being seen as helping British society to begin to treating mental health as seriously as physical well-being.
Outside of the UK, though, the traditional British “stiff upper lip”, when it comes to mental health, seems to persist, at least to the extent that it is still common in many parts of the world for people to believe that such manifestations of mental troubles as stress, depression, anxiety and so on should be kept well hidden.
And yet, as noted earlier, maintaining one’s mental equilibrium can be a particular challenge for expats. Moving abroad for work can be extremely stressful, what with adjusting to a new job, finding a home, and making friends.
The simple fact that one is in an unfamiliar environment often magnifies the intensity of the ordinary pressures of daily life, which can in themselves be challenging even for those who remain at home.
If the expat in question has a family, then there are the added concerns over settling one’s children and partner into the new home and country; and if the family members are being left behind instead, there are the worries and pressures of the separation and often, loneliness.
‘2.5 times more likely to suffer stress’
It’s hardly surprising, therefore, that, as Damien Lenihan of Aetna International points out, it’s been estimated that expatriates are 2.5 times more likely to suffer stress than those living at home.
A US study published a few years ago by Chestnut Global Partners and the Truman Group, meanwhile, found that expatriates faced “a higher overall risk for mental health problems, including internalising and externalising problems”, in addition to substance use disorders.
More broadly, the study found that more than 50% of the expatriates in the study were at high risk for internalising problems, such as anxiety and depression, a rate 2.5 times that of their US-based counterparts.
It is consequently also not surprising, then, to discover that “family-related issues” have been found to be of the most common reasons for overseas placements failing.
This, at least, was among the key findings in a recent report by Brookfield Global Relocation Services, an Illinois-based company that advises companies and governments on relocating their staff.
Mark Winwood, director of Psychological Services for AXA PPP Healthcare, pictured left, noted that the 2016 edition of Brookfield’s annual Global Mobility Trends report “found that family-related issues are the most common factors for [overseas] assignments not going as planned”.
“For non-working partners especially, as well as common feelings of loneliness because they are missing their support network, they may also feel a loss of identity, due to the fact that they may not be able to work,” Dr Winwood added.
“Overcoming this challenge to fit into a new role within the family, in a completely new country [and therefore] without their usual support network, can be difficult – however, not impossible to overcome, with sufficient pre-trip planning.”
Being far from one’s family ‘difficult’
In particular, expats struggle with the fact that being abroad means that they are far from friends and family, Dr Winwood said, citing a recent AXA PPP report, which was based on a survey of some 500 expats and their families, in an effort to find out how they were adapting to their new lives in the countries in which they now found themselves.
AXA PPP is the international private health insurance arm of the giant, Paris-based AXA insurance group.
“The most difficult transition was, by far, being away from close friends and extended family,” Dr Winwood said.
“Forty percent of the adults we spoke to said this was a struggle [for them].”
In addition, 30% reported they found coping with a foreign language hard, and 26% said handling local tax and legal requirements was stressful, Dr Winwood noted.
Soren Carstens, head of clinical operations for Bupa Global, the iPMI arm of the London-based Bupa insurance group, shares many of Dr Winwood’s observations about the stresses many expats face, including the difficulty of having to face life’s challenges when far from one’s network of acquaintences and family.
“The expat assignment can be an exciting journey of exploration and of personal and professional growth, which [often] includes getting to grips with a new language and learning more about cultural differences, both socially and business-wide,” Dr Carstens said.
“But moving to a new country for an extended period of time can also bring some challenges, and displace the balance between the demands of life and the resources you have in hand to deal with these – such as local knowledge and family.
“The imbalance of demand versus resources is one of the main causes of stress.”
The duty of the employer
One point the experts agree on is that employers planning to send staff members abroad need to consider these staffers’ mental well-being in advance, alongside making such other arrangements as helping them to find a place to live, health insurance and a bank account into which their salary will be paid.
Among them is Adam Harding, international business development manager of Jelf, the UK-based insurance and employee benefits broker and consultancy.
“While sending employees overseas can be daunting” for the individuals involved, it is also “essential for individuals and businesses’ development and creating a global proposition and more forward thinking business world,” Harding noted.
However, he stressed, it is “just as important” that employers consider all the issues potentially affecting their employees “to ensure they are meeting their duty of care” as it is for them to lay the groundwork properly for the overseas operation itself.
The ‘economic sense’ argument
Not that employers should need to be told this, since making sure their employees settle down well and are happy when they move overseas actually makes economic sense, Aetna International’s Lenihan, pictured right, pointed out.
“Most overseas placements which fail do so because the family does not settle. Given that it could reasonably cost a company US$1m for all that is involved in sending someone abroad on a three-year contract, it can be [an expensive mistake]”.
The US study referred to above points out that the rate of expatriate assignment failure ranges from 16% to 40% due to a range of factors, including heavy workloads, cultural differences – and stress and psychological conditions.
This is where pre-departure help comes in – and iPMI providers say they are standing by to help individuals and employers out in this area, if asked.
Planning for the overseas posting
Given that, as we have just learned, a big part of settling in to a new life for most expats is learning to deal with the day-to-day minutiae of life – whether this involves sorting out an agreeable and safe place to live, finding a convenient and good international school for one’s children or figuring out what options there are for playing tennis or otherwise staying fit – iPMI industry executives say they can help expatriates-to-be to plan, and to learn areas to watch out for they might not themselves yet have considered might present a challenge down the road.
At Generali Global Health, mental health considerations are included as part of the “comprehensive healthcare benefits” Generali GH offers, via its provision of employee assistance programmes (EAP), second opinion services and “virtual health” measures, according to commercial director Stuart Leatherby.
All of these, he noted, are seen as working together to help reduce stress levels for relocating expatriates.
(An EAP is telephone or face-to-face advice service for staff and their dependants who are moving or who have moved abroad, who may be experiencing stress, isolation, homesickness or encountering a specific problem in their lives, according to Leatherby, who added that confidential counselling is also usually available 24/7.)
Leatherby echoes Aetna International’s Lenihan in noting that employees benefit from having mentally-healthy expat employees, because such employees are also more productive than those who are struggling to cope.
Jelf’s Harding, meanwhile, pointed out that while being able to access psychiatric care is vital, “it alone cannot solve [all] the problems” that may arise.
“Many international insurers now offer bolt-on EAPs which can be invaluable, and provide a support line to employees and their families, helping towards the success of overseas assignments – which can be very costly [for the employees’ companies] if they fail,”, he said.
AXA’s Winwood points out that AXA’s online hub offers help with those relocating, including how to find accommodation, adapting to new cultures and help with financial arrangements.
Generali GH also offers pre-relocation medical support, ’s according to Leatherby, who said this typically included such information as “drug translations and how to source medication safely” in the new country.
What’s the policy?
As for what sort of actual insurance cover is out there for expatriates, in the event of a genuine psychiatric illness – and what the conscientious employer might be on the look-out for – Bupa Global’s Dr Carstens points out that the first thing to be considered is what the individual employee’s specific needs are likely to be, as these will vary.
“For instance, if the employee will be accompanied by their family, they will require iPMI cover which offers flexible, tailored packages that provide support for any health challenges – mental or physical – for the whole family, [and] ensuring it is in place before any issues arise,” he said.
Just having access to “a high-quality network of medical professionals, who can guide them through their medical journey in a new country, is [in itself] reassuring”, he added, as it “will give them greater peace of mind”.
How much cover?
How much cover there is in an individual’s insurance policy for psychiatric illness, meanwhile, depends on the policy in question.
Jelf’s Harding says that generally speaking, inpatient and day patient cover for psychiatric conditions are often covered in full, up to an annual limit of 30 to 45 days.
In addition, there is usually a separate outpatient limit.
But employers and employees are advised to read the fine print of their policies with respect to pre-existing conditions and waiting periods as they pertain to the psychiatric coverage: Harding says that sometimes members need to have been covered by their policy for 10 to 12 months before they are able to file a claim for such afflictions.
He further warned that in many countries, “psychiatric illness is not really recognised as a proper condition, such as in the Middle East, so awareness is not the same as [would be the case] across Europe, for example”.
AXA PPP’s Dr Winwood agreed, noting that because mental health issues are still taboo or not spoken about as openly in some parts of the world as they are in countries like the UK and USA, mentally unwell individuals in these countries may not normally seek direct treatment for anxiety or depression.
“While this is partly cultural, it is also driven by highly competitive and often stressful work environments,” he added.
One result of this is that psychiatric problems tend to be presented by individuals in these areas in the form of physical symptoms normally associated with mental health or stress, such as neck and back pain, headaches, insomnia and so on.
Whether the underlying psychiatric disorder is ever recognised in such cases may depend on the doctor, and on whether the patient either recovers or worsens to the extent that their mental trouble becomes obvious.
At least, say the iPMI industry officials, the issue of mental health issues in Expatland is at least now coming out in the open, and no longer quite the elephant in the room it has sometimes been in the past.