ILLUSTRATIONS BY LIANA BAK
The advent of technology can collapse cross-country divides, even providing therapy to overseas clients.
Healing in the Space Between

I SAW THEM through the second floor window. A family of at least 20 — playing loud music, dancing, singing, eating, laughing at each other's jokes, holding each other's babies. What was that feeling? Resentment? Not quite. Longing? A little closer. Jealousy? Closer still. Loneliness? Yes, definitely loneliness.

Upstairs in our small, one-bedroom, wooden home on stilts, I realized I was dreadfully homesick. Even with my husband and small child, I felt completely alone. A foreigner in an unfamiliar land. I had moved to Cambodia wide-eyed, anticipating serving as an instructor at the Phnom Penh Bible College, participating in community development, and living among the poor. I knew it would be difficult, but I was not prepared for the intense loneliness. I persevered through the years abroad — two in the urban jungle of Phnom Penh, another two in the sleepy village of Kampong Cham. I endured loneliness during the birth of my second child in Malaysia, and later still, as I enrolled my children in a Chinese school in Beijing. 

Living abroad wasn't all bad. Acquiring new languages was stimulating, as was enjoying different cultures and indulging in local cuisine. Yet the adjustment issues were often more than I could bear. I struggled with culture shock and isolation. I fought with mental health issues such as postpartum depression, anxiety, and vicarious trauma. It negatively impacted my relationships and led to marital strain, difficulties parenting my two young children, and misunderstandings with locals and colleagues.

the toll of distance

I felt like I was the only expat who struggled with living overseas. However, as I encountered others working abroad, I heard similar stories recounted time and again — of the missionary family who suffered the impact of marital infidelity, the humanitarian worker who numbed daily pain with alcohol, the aid worker who used her assignment to escape from personal turmoil, and the trailing spouse who felt like she lost her identity. 

Leaving your home culture is disorienting. Any move, even within the same city, is a major stressor and can trigger anxiety or depression. That stress is compounded by moving to another country — one where you don't know the language, are unfamiliar with your surroundings, and lack natural support structures such as family and friends. 

Humans were created to crave belonging, but expats live in the constant tension of being "between worlds". They often feel like they don't belong anywhere. They are foreigners where they live and often continue to feel like an outsider upon their return home. When living in this tension, one is predisposed to feel isolated, lost, lonely, and confused. 

Humans were created to crave belonging, but expats live in the constant tension of being "between worlds".

When I lived in Cambodia, there were few counseling services for expats. The few professional therapists in town were often booked. Moreover, with the expat community being so close-knit, there was a high probability that the potential client and therapist were already acquainted. This made professional boundaries difficult and therapeutic relationships awkward. This is an issue in many locations, not just Cambodia. 

Healing in the Space Between

Services offered by host or sending agencies have their own set of potential complications. Typically, field staff are assigned an agency-affiliated counselor when supervisors become concerned regarding mental health or other issues in that individual or family. Many times, since the counselor is employed by the agency, they give their assessment to the client's supervisor. This is done with good intentions and is oftentimes useful. 

However, I have heard from field staff who have been hurt by their agencies when they felt that client-therapist confidentiality was violated, especially in the instances when they were suddenly expelled from the international arena in order to receive treatment for unresolved mental health issues. Individuals and families are left feeling like failures or betrayed by their employer. They become further isolated and may sink deeper into disillusionment, depression, or resentment. 

wrestling with the distance

When our responsibilities in Cambodia were successfully handed over to the local staff, we wondered what would be next. Prior to moving abroad, I had worked as an advocate and shelter manager at two different domestic violence agencies in Boston. My interest in trauma prevention, intervention, and treatment deepened in Cambodia upon witnessing firsthand how the aftermath of severe, complex, traumatic stress impacted the nation. After much prayer and deliberation, we decided to return to the United States in 2008. 

God took us by surprise, opening doors in Seattle, where both my husband and I received scholarships for graduate study at the University of Washington. I took it as a sign that God was offering me an opportunity to get a master's in social work to focus on trauma intervention and therapy. As a community-based, mental health therapist, I provide trauma-focused therapy for clients, mainly children. I also coach parents, intervene at schools, rush to hospitals, and meet with social workers, probation officers, foster parents, and others to ensure that all the adults in the children's lives have the tools and support to help them thrive. 

I love my day job, but my heart continues to be with the international community. Since returning to the States, I've continued to hear from peers around the world who are struggling with disorientation, trauma, panic attacks, anxiety, depression, and stress due to unresolved issues or culture shock. In the past couple of years, with high-speed internet service becoming increasingly available, connecting with those in even the most remote places has become possible. 

I love my day job, but my heart continues to be with the international community.

bridging the distance

Several years ago, I found myself wondering how I could use my therapeutic skills to bless my international colleagues. I couldn't travel to remote places to provide in-person treatment, leaving my family for weeks at a time. My therapeutic model required consistent, ongoing sessions that a drop-in, drop-out service would not provide. Yet I found myself talking with everyone who would listen — mission agencies, friends, family, co-workers, and God — about the need for overseas workers to have access to professional mental health counseling.

As my conversations increased, so did my passion to support these colleagues. One day, a friend asked me, "Why don't you do it through video conferencing?" The idea intrigued me and I began researching telehealth. About two years ago, I pitched my idea of "online counseling for the globally mobile" to my co-workers as something I would try in the future. One of my co-workers asked me, "Why not now?" In short, I didn't have a good answer. 

One of my co-workers asked me, "Why not now?" I didn't have a good answer. 

I continued to pray and seek out more consultation from lawyers and co-workers. Even my family pitched in to help. One night during dinner, we started brainstorming what the company could be called. Most of the names we came up with were either already taken or just plain silly. When we almost ran out of ideas, my husband blurted out, "Remote Access Mental Health!" Then my son chimed in, "Counseling Within Reach!" Thus was born my company name and tagline. From the start, the birth of this company was a team effort.

Through Remote Access Mental Health, I apply the same evidence-based therapeutic approaches that I use with clients in my in-person practice. However, I tailor my approach to the unique needs of those who travel or live internationally, with the hope that globally mobile people can thrive no matter where they are. Video conferencing is a viable alternative given the hectic travel schedules and lack of local services that many expats experience. 

I tailor my approach to the unique needs of those who travel or live internationally, with the hope that globally mobile people can thrive no matter where they are.

I have been surprised by how well video conferencing works. I can hear their story just as clearly as if they were physically there. I am able to assist clients in formulating goals, uncovering trauma, challenging unhealthy thinking patterns, discovering strengths, demonstrating relaxation exercises, practicing emotional regulation skills, and developing wellness plans for long-term self-care. I send homework — worksheets, reading material, reflection questions, and therapeutic exercises — that they can work on in between sessions. 

And I've been surprised at how much my clients have expressed that they prefer engaging in counseling remotely. In fact, many of my clients find comfort in the space between us as it allows for a safe boundary. They appreciate that I've had international experience, yet have no connection to their specific work or location. 

Apparently, emotional connection, not physical presence, is more strongly conducive to helping my clients open up to me. This has confirmed my conviction that distance and geographic isolation do not have to be insurmountable obstacles in our God-given quest for connection and understanding.

Remote Access Mental Health provides globally mobile people access to professional evidence-based therapy from a licensed mental health therapist via video conferencing. The counseling sessions create a safe, confidential, non-judgmental space to process and address issues such as trauma, panic attacks, anxiety, depression, grief and loss, and stress due to culture shock and re-entry (reverse culture shock) adjustment.

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