In Europe, mental health support is nowhere near as integrated or respected within the workplace culture as in America. Rob Hyde compares attitudes – and finds out what will work best for expats who need help.

For several years, many US companies have operated Employee Assistance Programmes (EAPs), which aim to identify and resolve problems concerning health, mental health, marital difficulties, family, finances, alcohol, drugs, the law, emotions, stress, or other things that may affect an employee’s work performance.

The programmes vary greatly. Some work on a 'fee-for-service' basis whereby the service is used only when an employee experiences a problem. Conversely, some EAPs operate on a fixed-fee basis and offer additional educational programs and counselling.

While some large employers have in-house EAPs that are staffed by trained counsellors, employers at SMEs use "external" EAPs, which provide services on a contractual basis, either in-house or in a nearby location.

Generally, these schemes provide diagnosis, referral, and sometimes treatment. Employees and/or their dependants can use an EAP via self-referral, where the employee contacts the EAP directly for an appointment.

The final category is supervisory/management referral, where management along with a HR staff member recommends or mandates that an employee see an EAP counsellor because of job performance problems that may be related to a personal problem.

But be it via an EAP or another type of counselling, the culture of providing a form of mental health care for employers within the US is clearly well established while EAPs are just beginning to gain acceptance in Europe.

New England-based Business & Legal Reports company (BLR), specialises in HR and compensation cases. In its 2000 Survey of Employee Benefits, BLR found that among 4,117 employers surveyed, 47 percent offered some form of counselling to workers.

Broken down statistically, this meant that 32 percent of small enterprises (with under 100 employees), 54 percent of SME employers (100 to 500 employees) and 71 percent of large employers (over 500 employees) offered counselling.

Now, with a weakened economy and waning confidence in both job and national security, the amount of employees demanding on-site counselling has rocketed.

US-based EAP provider Behavioral Healthcare Services has had a "massive" amount of calls since the 11 September attacks.

According to US-based VMC Behavioral Healthcare Services, which offers EAP services, on-site visits are now taking place where there has been a death at the workplace or some other traumatic event directly affecting the workplace has occurred.

VMC counsellors will visit the workplace to "talk about people’s reactions" and help employees cope with the situation.

However, while many Americans clearly desire and value such “open-discussion” approaches, some medical experts believe expats might find such techniques more detrimental than beneficial.

UK-based mental health expert, Dr Patricia Abbott is based at Ashworth hospital in Merseyside, outside Liverpool, and specialises in extreme cases of mental health disorder.

Dr Abbott says “open-discussion” counselling will be of little use, and of possible harm to an expat worker, if it is not a practice already well established in his own culture, and moreover, if he does not actually want to participate.

She says: "After a trauma, the patient can go into shock and then for some time after not be able to experience feelings which later results in severe depression — Post Traumatic Stress Disorder (PTSD). However, lots of the latest medical recent from the military reveals that the supposed miracle of trauma counselling can actually make things far worse for the patient."

Dr Abbot says not all US-style approaches should be dismissed, and that a vast amount of stress within the workplace could be reduced if implemented.

"One of the good things about the American workplace is that they make it policy to listen to the workers and what they feel they need, and then to act on it."

"This has resulted in a lot of stress-relieving initiatives like using aromatherapy and having massage therapists coming in on a regular basis. Also, some employers make workers part of a gym so that they get regular exercise, can bond with their colleagues and even managers, and create an 'open team' atmosphere."

Though recognising that it is more difficult to care for the mental health of expats because of geographical separation, Dr Abbott says HR managers still have a role to play.

"People have their own way of dealing with things, which is often the best way, so really counselling should be available if needed, but not forced,” she says.

"Often people just want to talk to those close to them, not specialists, so HR managers should really do all they can to help their expat workers build a social network in the host country."

Dr Abbott also points out that the adjustment to expat life can have mental-health repercussions, too.

"Many expats are not over-eager to learn the language, meaning if they suffer from trauma or work-related stress, they have no means of support available and are likely to thus really suffer.”

Some simple ways she says HR can help in these situations include encouraging contact with friends and family from home by subsidising flights or telephone calls.

British national Leslie Smith is a project leader at the UK-based online independent expatriate medical insurance broker, medibroker.com, which advises companies and individuals on offshore medical insurance plans, income protection, term life insurance , critical illness and personal accident coverage.

Having witnessed several people suffering severe mental health problems while working for GEC in North Africa, he agrees with Dr Abbott's view that “contact and support” with loved ones is of most value to an expat requiring mental health support.

"When someone is really suffering serious mental problems, then they must come home. In this situation they need their family, they need stability, they need love, they need protection."

Smith adds that foreign counselling services are not an ideal solution. “It just makes much more sense to ship the poor guy out — keeping him away from home is not doing any good."

Generally, standard expat insurance coverage does not include mental health, though there is usually a provision for anything if you can afford it.

“'Platinum' health cover schemes, the best and most expensive, can also include mental health provision, but are hard to find for under GBP 50,000,” says Smith.

"I believe there is little market for including mental health provision in an expat medical insurance package. Most taking this cover are going to a different country, or countries for a relatively brief period, and so do not anticipate requiring such services, and if they did encounter them, the natural and sensible solution seems just to return home,” he adds.

"Expats with serious mental problems really don't need the additional worry of struggling for an expensive and complicated area of treatment in a foreign country and maybe also a foreign language."

But some expats seem quite contented with the health system and counselling services provided by their host country.

British expat Deborah de Jonge, who works for Netherlands-based IT company, Blue Lynx, and has been living in the Netherlands for 15 years. She says she is impressed with the policy of sending a hired doctor to visit sick employees.

"At first I was outraged that a doctor was sent to my front door,” de Jonge recalls. “I felt insulted that my company did not trust that I was genuinely ill. However, with time I changed my opinion. Now I realise it is just a routine procedure that workers can actually benefit from."

De Jonge says in terms of mental health, it may also be easier for an employee to discuss social problems such as not getting on with members of staff or worries about internal office politics with a doctor, instead of with an employer, for fear of upsetting them.

Also, a company doctor will be able to support their case by telling the employer that the situation needs to be resolved for the benefit of the worker, and thus the worker’s job will not be risked.

“Workers experiencing severe problems can be helped via a company doctor, as he understands their work and their role in the company, as he has got to know the company and all its workings perfectly,” says de Jonge. “He is therefore far more likely to be of help than an external counselling service, although I would understand if some may prefer the anonymity."

January 2002

UK-based freelance journalist Rob Hyde is a regular contributor to Expatica HR. A British national, Rob has lived and worked in England, France, Germany and Austria. His work has appeared in The Times, The Sunday Express and the Wall Street Journal Europe. He also contributes articles to the BBC Online's German language section.