“It was exactly the sort of therapists’ waiting room you would expect: calm, quiet, serene,” Kat* said, thoughtfully. “And there we were, me and two other parents, waiting for our children to finish their appointments. I wondered why they were here. What could have triggered them to get their child who, on the face of it, seemed perfectly at ease and well adjusted, referred for therapy? Were they wondering the same thing about us?”
Mental Health in Third-Culture Kids
by Emma Morrell
She went on to talk about the relief she felt. She spoke about how, regardless of why anyone was there, that they were not alone. She said that it was just the reminder she needed to know it wasn’t just her child who needed help to manage the things that were going on in his head.
Kat is, of course, not alone. The World Health Organization (WHO) estimates that between ten and 20% of children and adolescents experience mental disorders and that half of all mental illnesses begin by the age of 14, with three-quarters occurring by the mid-20s.
Dr Sean Truman, co-founder and Chief Medical Officer of Truman Group, is not surprised by these statistics. Over the last few years, he has spoken extensively on the changing mental health risk in paediatric populations: “One of the things that’s become increasingly clear, particularly in North America, is that we’re seeing significant changes in mental health risk, particularly for depression and anxiety in kids between the ages of 18 and 24.” He says that although this is North American-centric data, similar reports are coming out of Western Europe and some parts of Asia.
Dr Truman notes that the issues reported are primarily related to anxiety and depression, rather than other areas, such as trauma or other kinds of disorders, and that this is expected. The Centers for Disease Control (CDC) data around suicide attempts and completions or presentations for suicidality in emergency rooms also confirms these conclusions. Suicide rates for persons aged ten to 24 had increased from 6.8 per 100,000 persons in 2007, to 10.6 per 100,000 persons in 2017. For people aged ten to 14, the figure nearly tripled during the same timeframe.
This is considered to be especially striking because kids at that age have low mortality as they’re young and often healthy. Dr Truman describes suicide as “a killer of children” and says that it poses a significant risk to communities. He also adds: “Historically, having education and money was a protective factor with regard to risk, which appears to be not the case now. We’re actually seeing education [being] increasingly linked to mental health, which is really powerful and really worrisome.”
But this data is for all children, not just third-culture kids (TCKs). Kate Berger, MSc, a Child and Adolescent Psychologist for The Expat Kids Club, says TCKs may or may not be more vulnerable to mental health issues. “There are some unique circumstances that can translate into unique vulnerabilities for expat and third-culture kids. Maybe they are more prone to struggling with the unresolved grief that comes with relocation and the related loss,” she says. But Berger also says that this risk might also be offset by the fact that expat kids and TCKs often develop resilience and problem-solving skills in these circumstances. “These kids get really good at dealing with adversity and difficulty and processing loss, if they have the right support and if it’s acknowledged. It’s really case-by-case and circumstantial,” she says.
While talking about mental health in adults is less taboo than ever, mental health issues in children remains a spectacularly under-reported and under-discussed topic. Although the majority of families will pass through life without ever needing significant intervention, most—at some time or another—will undergo at least one major life event that will challenge the mental health of the whole family. So, what do the experts say about how we can help our children?
Dr Truman suggests that getting enough good-quality sleep is paramount. He points to the disrupting effect that having phones in bedrooms has on both adults and kids. In fact, the New York Times published a report in 2018 on Silicon Valley employees who notoriously restrict their children’s access to technology while (allegedly) simultaneously hiring developers to ensure that the rest of us cannot manage ourselves effectively with them.
But it is more than just the phones, according to Dr Truman: “We’re seeing sleep disruption in a way that we haven’t seen before. Right now, we’re in a period where there is lots of homework for kids in many communities. Many kids are very under-slept, and they really struggle in terms of managing workload and in managing all the other stuff.”
Dr Truman is also an advocate of giving developmentally appropriate freedom to our children. “It’s this idea of letting kids have the capacity to make decisions for themselves about what they want to do and how they want to do it,” he says.
Dr Truman also believes that the way parents are increasingly monitoring their children and deciding things for them, although well-intentioned, is leaving kids more vulnerable. “A lot of us are raising children [in a way] where we don’t want them to have the experience of failure. But the problem is that truly failing is a really powerful and useful experience to have because it causes you to have to find a way to go forward, even though you’ve had the worst thing happen,” he says.
Vivian Chiona, MSc, founder of Expat Nest, has some more expat-focused advice: “Provide them with a safe place to talk and to express their feelings, without immediately offering solutions, because they need time to process what has happened.”
Chiona says that kids may not necessarily need a solution right away, but instead need someone to listen to them without judgement and validate their feelings. “It’s hard when the whole world as you know it in one country dies. And then you’re busy starting a new life, and there’s no funeral,” she says.
Berger adds to this the importance of focusing on the opportunities that moving can offer: “Anything worth having takes work. We need to teach our kids how to work on coping. Parents should model how we tolerate difficult feelings, experiences, and thoughts that come up in the process of living the life that we want to live and being who we want to be.”
When to get professional help
Berger, Chiona, and Dr Truman all say that looking out for functional impairment is key. It is important to know that functional impairment goes beyond feeling a bit down or having mild anxiety. It is a state when a person’s ability to do the things that they need or want to do is affected. They recommend watching for significant changes in behaviours such as withdrawing or not doing things that the child usually likes to do. Things like conflict at home, changes in friendships, or difficulties in school are also all warning signs that something is amiss. Chiona notes that timing is a key factor for children: “When we talk about early intervention, we can talk about a cure and see remarkable progress.”
Berger, Chiona, and Dr Truman also warn against the dangers of misdiagnosis. They note that this is common in when there are cultural or language differences, or in cases where the therapist is not familiar with third-culture kids. Some people have been referred to them with a depression diagnosis but were, in reality, suffering from culture shock. Others were exhibiting behaviours consistent with attentional difficulties that were actually related to relocation stress.
“It is really important to get the right diagnosis for the right intervention,” says Chiona. Berger agrees and says that the stress related to being in a new situation as a TCK can even affect the cognitive skills necessary to function well in school. “When we get in this emotional space, the brain doesn’t have access to the higher-level cognitive processing that it would have if we weren’t emotional. We can’t use the prefrontal cortex that gives us the concentration, the attention, the memory, the creativity,” she says.
Sadly, in many communities, there simply are too few, or even, no good options for seeking help. This can be due to a language or culture barrier, or even both. Thankfully, there are increasing levels of support in Qatar offered by both the public and private sector.
Online therapy has—in communities with a less-transient population— previously been resisted in favour of face-to-face treatment. “When I started Expat Nest, people thought I was crazy and asked why someone would use online services instead of going to a psychologists office in the host country. I had to explain about [sic] the unique challenges that we face as expats,” says Chiona.
Dr Truman adds: “People frequently ask us about our expertise in telepsychology. But we don’t particularly think of ourselves as experts in teletherapy and telemedicine, even though we’ve used it for more than ten years. We’re really experts in the expatriate community.”
Furthermore, Berger believes that expat kids, of all people, are probably best-positioned to take advantage of online therapy. She says that this because they are already so used to connecting with family and friends all over the world through a computer screen.
While it is easy to find online support for children who are 13 and older, assistance for younger children is much harder to come by. Legal, practical, and ethical reasons preventing the delivery of such services could partially explain this.
It is also generally considered more appropriate for small children to receive in-person therapy. This is due to their lower attentional capacities and tendency to focus less on the person on the screen instead of themselves, plus the fact that they respond better to play-based therapy.
Therefore, at such young ages, finding local support is truly the preferred approach. In extreme cases where this is not possible, Dr Truman goes as far as to recommend going back home or somewhere else where there is more support.
Where to Start and Who to Choose
It is important to find a medical professional that embodies a number of characteristics. These include excellence, diligence, thoughtful and intentional care, and high-quality mental health services delivered ethically with integrity, passion, and love. Look for someone who has devoted their professional life to serving the expat and international communities, so they can really understand your circumstances.
But first and foremost, says Chiona, it is essential to find someone with appropriate qualifications and experience dealing with your situation. “You’re entrusting your child, the most precious thing you have in life, with this person, so you have to be sure that this is a person who has the right experience, the right set of skills, knowledge, and attitude, and the right approach for your issues,” says Chiona.
She also stresses that “one size does not fit all” and acknowledges that sometimes it can be difficult to check someone’s credentials online. Because of this, Chiona recommends asking the therapist about the professional body with which they are registered.
Berger suggests a few places to look, including asking school counsellors or paediatricians, for recommendations. If they are unable to help, the International Therapist Directory (ITD) and Families In Global Transition (FIGT) organisations both have lists of professionals to contact. International therapists can also assist patients in finding appropriate in-country help. If you are looking for background reading for parents, look for literature published by leading TCK experts such as Ruth Van Reken and David C. Pollock.
Most importantly, Dr Truman believes that the number one predictor of a good clinical outcome in psychotherapy is the feeling that you have found “the right fit”—someone who understands your issues and needs. And Berger couldn’t agree more: “make sure you continue to advocate for finding the right person. Because there is a right person out there”.
Advice for parents of TCKs having a hard time
“If you’ve got kids that are struggling, I would say that frequently, kids struggle in families where other family members are struggling; not always, but frequently…People have all kinds of ways of coping when they’re living internationally. For families that are having a hard time, I recommend getting access to supportive resources, because you shouldn’t suffer in silence, and you shouldn’t suffer as a family in ways that degrade your ability to function.”
“I would tell them to have faith that they are the experts when it comes to their kids. We’re there to help them with our knowledge and guidance. But it’s important to empower the parents to feel okay that they made the right choice for their children. I always ask them one question: do you have faith that you will overcome this (regardless of the how—that’s up to them to figure out)? The parents will say yes, that they trust themselves or children to have faith that they will make it, and they do make it in the end.”
“We see a lot of families that are really struggling with that parental guilt that comes from [the] doubt and insecurity [of moving]. We end up trying to focus our attention on remembering why we made these choices for our family in the first place. We do know that with the right support and acknowledgement, the skills that these kids develop as a result of these experiences really does make them uniquely qualified for leadership later in life…Of course, get help when it’s difficult and support them, but remember it’s worth it because they are exposed to this really tremendous and unique opportunity.”
*Name has been changed.