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Anumber of studies have estimated that American expatriateshave rates of assignment failure that range from 16 percentto 40 percent. There are a variety of factors that increase the

demands on expatriates. They range from heavy workloads to exten-sive travel schedules and cultural differences—all of which contributeto stress and increase the probability that they will return homebefore their assignment is complete.

During the course of the last 25 years, published reports have sug-gested that living overseas as an expatriate conveys risk for stress thatexceeds those for individuals living in their home country. The vastmajority of these accounts are anecdotal, case reports, or autobio-graphical histories of living overseas. Experts also have suggested thatthe rate of mental health problems for expatriates is higher than fortheir counterparts living at home. However, there has been no empir-ical study of whether expatriates living overseas actually do experience

Stress and Mental Health: Expatriates At Risk

B Y S E A N D . T R U M A N , P H . D . , L P , D A V I D A . S H A R A R , P H . D . , A N D J O H N C . P O M P E , P S Y . D . , L P , S P H R

Global mobility professionals intimately understand the highstakes of an international assignment, and are all too familiarwith the potential sources of stress facing an expatriatemoving beyond his or her borders. Truman, Sharar, andPompe detail the findings of a recent study that examinesmental health risk in U.S.-based and expatriate employees,and describe how these findings have implications for clinicians, EAPs, global medical benefit plans, and humanresources staff.

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higher levels of stress that contributeto a range of problems—includingadjustment and affective disorders,depression and anxiety, maritalissues, and substance abuse.

The study highlighted in this arti-cle was designed to empirically com-pare mental health risk in U.S.-based

and expatriate employees. Wehypothesized that the rate of mentalhealth diagnoses among expatriateswould be greater than that of a non-expatriate working population. Inparticular, the expectation was thatproblems such as depression, anxi-ety, and substance abuse would be

higher for expatriates than foremployees based in their homecountry. The results of the studyindicated that this was the case;expatriates experienced significantlyhigher risk for anxiety, depression,and substance abuse problems thandid their domestic counterparts.

Study SpecificsThe study used a survey to com-

pare the mental health status of glob-al expatriate employees to domesticU.S. non-expatriate employees. Thetwo groups were drawn from sepa-rate and distinct multinationalemployers headquartered in the U.S.The expatriate group was made up of455 expatriates, all residing in theirhost location for a minimum of sixmonths; the typical duration of theirinternational assignments rangedbetween one and three years. Theexpatriates’ host locations werespread throughout the world, withthe highest concentration in LatinAmerica, Asia, Europe, the UnitedKingdom, and the United States.The U.S.-based comparison groupconsisted of 1,460 individuals, andwere a mix of office-based manage-ment and production-based manu-facturing workers across the country,but were primarily located in theMidwest and the Southern regions,mainly in suburban and rural areas.

The study used an online, scientifi-cally based survey known as the GainShort Screener (GSS). The survey is a20-item questionnaire, which hasbeen shown to accurately identifyindividuals with a variety of psycho-logical problems including anxiety,depression, and substance abuse.This type of information can then beused to develop programming or toprovide services to individualsthrough referral to an Employee

uto Relo-cation

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Assistance Program (EAP), as well asto individual providers or health caresystems.

The tool measures responses inthree primary areas:

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

2. externalizing (e.g. attentiondeficit, hyperactivity, conduct andimpulse control); and

3. substance abuse and dependence.

Both groups (expatriates and U.S.-based) completed the GSS. In addi-tion, the expatriate group completeda scale that asked respondents abouttheir degree of satisfaction with mari-tal, family, and social relationships, aswell as ratings for their job satisfac-tion and job performance.

Study ResultsThe study yielded several signifi-

cant findings: expatriates had a higher overall risk for mental healthproblems, including internalizingproblems, externalizing problems,and substance use disorders.

These results are largely consistentwith the notion that living as anexpatriate involves very significantstress and high demand for adjust-ment. While these demands can be—and frequently are—exciting,engaging, and interesting, they also can converge to the point where they become impairing andresult in significant problems.

Internalizing ProblemsWe hypothesized that expatriates

would be particularly prone to inter-nalizing problems, which is consis-tent with the notion that relocation,cultural dislocation, stress, and highdemand for adjustment and adapta-tion can lead to issues such as anxiety

and depression. The study providedthe following results:

• Three times as many expatriatesas U.S.-based workers expressed/endorsed feelings of beingtrapped/depressed.

• Twice as many expatriates asU.S.-based workers expressed/

endorsed feelings of beinganxious/nervous.

More broadly, the study foundthat more than 50 percent of theexpatriate sample was at high risk for internalizing problems (such asanxiety and depression), which was a rate 2.5 times their U.S.-based

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counterparts. Taken together, thesefindings suggest that anxiety anddepression play a central role forexpatriates experiencing emotionalproblems. In contrast, in the U.S.-based group, less than a third of thenon-expats were assessed as being atrisk for internalizing problems.

Externalizing ProblemsSurprisingly, the study showed

that the expatriate community was athigher risk for externalizing problemsthan U.S.-based employees. The sur-vey tool assesses less controlledsymptoms (i.e., fighting with familymembers), and we expected thatboth the overall rates of externalizingproblems, as well as the differencebetween the groups to be very small.This was not the case. The study isconsistent with the view that expatri-ate communities experience a global-ly stressful existence where emotion-al, professional, and relationshipdemands are exceedingly high. Thisfinding suggests that expatriates arefeeling emotionally disrupted andthat their behavior reflects this emo-tional state.

Substance Abuse and DependenceAnecdotal evidence and clinical

experience suggest that substanceabuse and dependency risk would be

higher for expatriates than U.S.-based workers; the results of thisstudy supported the position thatexpatriates are at higher risk thanU.S.-based workers for substanceabuse problems.

In this study, a larger proportionof expatriates were in the high andmoderate risk categories for sub-stance abuse problems than were theU.S.-based employees. This indicatesthat individuals in the expatriategroup use substances at higher ratesand in greater amounts, and withmore negative consequences than dotheir U.S.-based counterparts. This islikely related to several factors.Standards in many expatriate com-munities are frequently more liberalregarding alcohol use, which mightreduce the stigma and social pressurethat would otherwise limit high levelsof use. In addition, living as an expa-triate often is associated with highlevels of stress that in other studieshave been linked to higher substanceuse. These factors work synergistical-ly to create an environment that elic-its more frequent and more intensesubstance use among expatriates.

Impact on Expatriate Job Performanceand Relationships

Participants in the expatriate groupcompleted a questionnaire about

their satisfaction with work, workperformance, social relationships,family relationships, and marital rela-tionships. Again, the pattern of find-ings remains consistent: individualswho were at high risk for internaliz-ing problems (e.g., depression andanxiety) disproportionately ratedtheir work as being “below average”and “average” when compared to thelow-risk group. Similarly, expatriateswith high/moderate risk for internal-izing were markedly less satisfiedwith their work than their low-riskcounterparts.

This is particularly important giventhe consequences of “washing out”from postings overseas as it repre-sents a very significant disruption forindividuals, families, their employers,and their careers. It also suggests thathigh risk for internalizing problemssuch as anxiety and depression maybe related to the ways in which indi-viduals experience their work lives.

Satisfaction with relationships(social, marital, and family) also washighly related to internalizing risk.Expatriates with high and moderaterisk were dramatically less satisfiedwith their relationships compared toindividuals who were low risk forinternalizing problems.

Again, this suggests that there aremeaningful and powerful links

On the WebEnsuring expatriate health, both mental and physical, is of concern to all effective human resource professionals. View these and other resources on www.WorldwideERC.org for further information:

The Struggle for Work/Life Balancewww.WorldwideERC.org/Resources/MOBILITYarticles/Pages/1107lambelet.aspx

Change, Stress, and Relocation: a Wellness Approach www.WorldwideERC.org/Resources/MOBILITYarticles/Pages/1109-connelly.aspx

Global Health Risk Assessments-Pipe Dream or Reality? www.WorldwideERC.org/Resources/MOBILITYarticles/Pages/0309rizk.aspx

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between each individual’s internalexperience of stress and the ways inwhich they relate to people in theirlife.

Services in SupportIn sum, the study found that indi-

viduals living as expatriates experi-ence a range of risk at rates thatexceed their U.S.-based counterparts.In this study, expatriates experiencedhigher risk for internalizing andexternalizing problems, as well ashigher risk for substance abuse.However, this is not limited to emo-tional experiences. High-risk inter-nalizing problems also were relatedto greater rates of dissatisfaction withwork, marital relationships, familyrelationships, and job performance.

Living overseas as an expatriate isdifficult and demanding; living farfrom home is stressful, and a varietyof factors such as reduced social sup-port, cultural dislocation, increasedfamily disruption that results fromhigh work demands, and a variety ofother factors can cause a host ofproblems, including emotional dis-ruption. These findings have implica-tions for clinicians, EAPs, globalmedical benefit plans that cover men-tal health services, and humanresources staff that work with expa-triates and their families.

The authors of this study havemany years of experience implement-ing specialized expatriate family sup-port programs. While more develop-ment and research is still needed inthe arena of expatriate wellness andsupport programming, the followingpractical suggestions can help in thedesign of programs or services thatmore effectively target the needs ofexpatriates and their families:

• Do not rely on a passively avail-able EAP or global mental health

benefit, which are the norm for U.S.-based programs. Expatriates rarelyuse these services proactively or haveconfidence in their effectiveness.Proactive outreach to “check-in”with expatriates and spouses byphone and e-mail is key to linkingthem with needed mental health ser-vices.

• Disseminate regular healthmedia information, educational con-tent, and program promotions specif-ically designed for the expatriatepopulation as a part of a moreassertive outreach effort.

• Even if an international EAP orglobal benefit plan is available, donot assume that expatriates haveaccess to qualified or competentprofessionals in many parts of theworld.

• Create access to mental healthservices in a way that is easy, “hassle-free,” and, of course, completelyconfidential.

It is clear the mental health needsin the expatriate community are sig-nificant, and more prevalent thanpreviously known or documented. Itfollows that multinational organiza-tions should consider ways in whichthey can appropriately identify indi-viduals at risk to proactively provideservices that reduce the disruptionthat stress and related mental healthproblems can cause for their expatri-ate workforce.

Sean D. Truman, Ph.D., LP, is director ofclinical services at the Truman Group, St.Paul, MN. He can be reached at +1 651 9640224 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 +1 309 820 3570 or e-mail dsharar@chestnut.org.

John C. Pompe, Psy.D., LP, SPHR, is manager of disability and behavioral healthprograms at Caterpillar Inc., Peoria, IL. Hecan be reached at +1 309 675 6263 or e-mailpompejc@cat.com.

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