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Mental Health Care in Indonesia

The Challenges of Expatriate Life and Cognitive Behavioural Therapy

Expatriate life holds many promises; a new environment, new challenges, new friends, new experiences and quite often sunshine and a slower pace of life.

It is easy to believe that changing our environment will change our inner selves. To some extent this is true; to some extent a ‘fresh start’ can invigorate and inform us. What moving country cannot do though is fundamentally change our thinking or indeed our learned behavioural patterns.

We take our ‘selves’ with us; all our thought patterns, all our ingrained beliefs and behavioural nuances. So at home or abroad we remain equally vulnerable to repeating our life patterns in relationships with ourselves, the world and other people.

In many ways we can become more vulnerable; our social network changes, we can easily lose touch with the people we rely on and when things go wrong we can end up feeling very isolated.

A new country means a new culture and all cultures have a base of demands, demands on how we behave and on how we react to situations. If anything, expatriate life for many people can lead to an increased feeling of frustration and stress, especially initially as you learn to live and work in a new cultural setting. In order to live healthily a lot of work has to happen to let go of learned culturally based patterns of thought from your old culture.

In ways ex-patriots face heightened stress and problems, not less. Many long term relationships suddenly face extra pressure and a usually calm partner can become stressed and angry. Unfortunately many partnerships do not survive these stresses. Many people begin new relationships not fully understanding the culture of their partner; so leading to relationship problems. Many find themselves victims of crime simply because we have a general idea of values and when and how to trust people. We tend to expect social norms to be the same everywhere; they are not.

When we change our environment we often have to let go and change ourselves; not doing so can lead to misery. What was a healthy belief in our home country may be completely maladaptive in another. A simple example is that of time keeping, some countries (like Indonesia) have a slower more relaxed pace than others. Demanding everyone follow our time keeping rules will not make them do so and the insipid drip, drip, drip of everyday disagreements on such things can, if we don’t adapt, ruin our relationships and our mental health.

As Albert Einstein said “We cannot solve our problems with the same thinking we used when we created them”. Thinking is often the real source of our problems.

Asian culture and therefore thinking, is markedly different from western culture and probably the most common source of stress for ex-patriots is ‘Culture Shock’.

What is Culture Shock?

Culture shock is a recognisable psychological phenomenon; usually occurring within a few months of arriving in a new culture.

It is a normal reaction to conflicts of social views, norms, and values. It is common for people to feel homesick, disorientated, isolated, anxious, angry and confused when entering an unfamiliar culture.

Psychological research on the matter suggests there are 3 basic causes of culture shock:

1. The loss of familiar social cues like body language, conversation tone, customs and manners.
2. The breakdown of interpersonal communication such as language barriers, logic and linguistic faux pas
3. An identity crisis involving feelings of isolation, confusion and loss of emotional and social stability. (Weaver et al 1994)

The severity of this however very much depends on how different the new culture is from our home culture and a persons’ ‘cognitive flexibility’; in other words the minds ability to switch from thinking in one way to another. Persistent negative attitudes towards differences can lead to pent up and inappropriate anger, anxiety and sadness. Some of these differences in culture can be minor annoyances building up over time, for example spitting in public, public displays of affection or loud talking in public and some are rather more upsetting such as treatment of animals or aggression and racism.

Part of respecting and adapting to a new culture is understanding that culture occurs over a long period of time, not overnight or even in our lifetime. It is an accumulation of many factors including social, economic, environmental, religious, political and historical experiences. We are born into this and judging others unfairly and without having their experiences will lead to agitation and failure to adapt. Accepting a culture is not the same as agreeing with it and it does not have to entail a loss of self or personal values.

The good news is with the right attitude and acceptance we can adjust and after a while we feel less out of place, things begin to feel normal again and the ‘shock’ to our sense of self passes, if we let it. In fact research suggests that living in new cultures can, in the long term, increase our sense of self efficacy and esteem. It certainly broadens our experience of life and can lead to a freer more informed sense of self, the world and other people.

Many people turn to Cognitive Behavioural Therapy (CBT) to overcome the challenges they face abroad and at home, to lower stress and to ultimately live happier lives.

What is Cognitive Behavioural Therapy?

'We are disturbed not by events, but by the views which we take of them'. Epictetus

Cognitive Behaviour Therapy (CBT) is one of the major approaches to helping people overcome emotional problems and achieve their goals. It is underpinned by extensive research on the role of behaviour and cognitions (thinking patterns) in the development and maintenance of emotional disorders.

Clinical trials support the effectiveness of CBT in the treatment of a wide range of psychological disorders, including but not limited to: depression, bipolar disorder, anxiety, eating disorders, obsessional disorders, substance abuse, anger, pain management and trauma. It has been proven effective with children, adolescents and adults in both group and individual forms of treatment. CBT works on the premise that we 'learn' to think or act in counterproductive ways, and so can also unlearn them.

CBT does not promote 'positive thinking'. The aim is to become more realistic and self-helping in thinking. Unfortunately, life experiences are not always positive, but interpreting them to mean that they prove that we are inferior, bad, or useless for example will lead to even greater upset.

We tend to blindly believe our own thoughts but the fact is two people in the same situation will think and react differently. CBT aims to identify the beliefs each individual has that may be causing one distress where another remains calm. Through re-considering our initial 'automatic,' negative thoughts about a situation it is possible to come to a more fact-based interpretation and change our reactions. CBT in a way takes a person's thoughts to court. We are usually very good at prosecuting others and ourselves, but often forget the alternative defence!
Collaborative in approach, the client and therapist work together to identify and understand the relationship between thoughts, feelings and behaviour. The focus is usually on problems in the 'here and now'.

Timeline for Therapy

Unlike other types of therapy that can last for years, CBT is a time-limited process. In fact it is estimated that the average number of sessions required across all types of problems is only 16. The rapid improvement during treatment is due to the directive nature of the therapy and 'homework assignments' where the client puts into practice what they have learned during the session. The client is encouraged to become their own therapist, acquiring skills to reflect on the meaning of their experiences to them, reinterpret these in a more rational way and implement change.

As Shakespeare wrote: 'There is nothing either good or bad, but thinking makes it so.'

Why Come to Bali for Therapy?

Bali is often referred to as ‘Paradise Island’ for good reasons. The Daisy Retreat has hosted and healed people from all over Asia, Europe, America, North and West Africa and Australia and every one of them have loved the island and the atmosphere.

In this ever more accessible world many visit Bali for the culture, beauty and the numerous array of ‘alternative’ healing therapies. Sometimes though, we need more than alternative healing. Cognitive Behavioural Therapy (CBT) is a research based clinical method of healing, the National Institute of Clinical excellence (UK NICE Guidelines) recommends CBT as the frontline treatment for emotional and psychological disorders of all types and it is proven more effective than medication in long term follow up studies. The Daisy Retreat Bali offers this therapy in a non-clinical setting.

The sun and warmth of the Bali climate, natural beauty and laid back culture all combine to ensure a tranquillity and openness of the mind. The sun is an important part of the therapeutic journey. The brain responds to sunlight by releasing serotonin, a neurotransmitter that is involved in sleep, mood, memory and other neurological processes. Just as darkness stimulates the production of melatonin which establishes sleep cycles, serotonin promotes wakefulness and helps elevate mood.

The sunrise and sunset in Bali are spectacular and the practices learned during a stay at The Daisy Retreat can be applied anywhere – after all, the sun rises and sets wherever you are.

Ellie Donnelly, BA MSc, Cognitive Behavioural Therapist
Founder and Owner; Daisy Retreat Bali, Indonesia.
©Ellie Donnelly 2017