Like many, my mental wellness declined during the pandemic. I fell into some mild depression and anxiety, but relationships, hobbies, and exercise helped me stay grounded (usually). I'm thankful for that. Despite some new lows, I grew a lot, and 2022 began optimistically. So for this assignment, I planned to interview a mental health professional and spread the good word about how to cope.

Then everything fell apart.

A week before the interview, a close family member had a medical crisis and required immediate surgery. It was risky – they might not make it. Should I fly home the next day? How do you even get back into China? Plans changed every hour and that had me vexed and ready to rage. If anyone said something well-intentioned about how I couldn't go back home for CNY this year, but that I was safer here anyway, I was going to snap. And the construction upstairs at 8:30 am daily definitely didn't help.

So by the time I sat down with Chen Zhang, a mental health counsellor from SinoUnited Health, I was in the worst mental shape since the pandemic started. Almost all the symptoms she described to me were exactly how I felt. No doubt many, many readers have met similar challenges in recent years.

These are excerpts from a long conversation we had about mental health in the COVID era. The pandemic has been hard for everyone, and while this article focuses on some of the unique challenges faced by those who live away from their home country and traditional support network, many of the concepts apply to everyone.

SmSh: What are some of the more common mental health issues you see with expats in Shanghai?

Chen, SinoUnited Health: The first one is the symptom of anxiety. To give some examples, feeling anxious, feeling on edge, having trouble relaxing, and not being able to stop worrying. Also, becoming easily annoyed or irritable. Not necessarily to the point of aggressive or violent behavior, but they notice that their level of patience changes a lot.

The second one is symptoms related to depression. Sometimes it's hard to fall asleep, sometimes it's hard to maintain sleep. Also we notice some changes in interests or pleasure. In the past they had passions and hobbies, but now it's changed a lot. Also, feeling down, feeling hopeless, or having trouble concentrating. When I ask them to describe the feeling, they say, "I feel nothing." Not in a good way, like being calm. It's flat.

Those are some common issues related to depressive symptoms. Not necessarily to be diagnosed with depression, but people can have those common symptoms.

And the third part is mixed symptoms, depression and anxiety. But it's not only issues. Crises can bring about opportunity as well.

SmSh: What are the best ways to deal with these issues?

Chen: There are no "best" ways, since everyone has his or her own definition of best. That said, there are some common effective ways:

Increasing self-awareness is always the first huge step. Understand the triangle of thought/feeling/action and how they connect to each other.

Remind yourself about your underlying needs and strengths. Redevelop healthy lifestyles and take care of your health. Eat well, get enough sleep, exercise regularly, and expand your social support. Schedule meaningful, enjoyable activities, and avoid being hard on yourself. Know your strengths, not just your barriers. Identify your real underlying needs.

SmSh: We all face low points and struggle from time to time. But how do we know when it's time to get some help from a professional?

Chen: So this will be the time. When you start to think about talking to a professional, that's a good time.

That's the sign. You start to think, or you already accept that's one of the resources you can use. That's a good thing. I would encourage you to take the big step. Just try it. And if you try one therapist after a few sessions and you think "it doesn't fit me", I would encourage people to try different therapists. Finding the right one for you is a process.

SmSh: What about some other signs that it's time to get help?

Chen: Physical signs can be rapid heartbeat, shortness of breath, sweating, sweaty palms, and headache. That's another big thing. Headaches are usually related to stress. People go to the general practitioner and figure out why they started having headaches, and then when they figure out everything is fine, then they come here. That's a good step – check with a physical doctor first, and if everything is alright, you can start to think about if it's related to mental health.

As for emotional signs, mood swings are a big one. Becoming irritable, like even smaller things bother you – your level of impatience changes a lot, no matter if you become easily agitated at work or at home. Also, concentration, level of energy, feeling exhausted even after a long sleep – that's telling us something. Worrying too much about small things. And fear, or easily thinking about worst-case scenarios. Like you can't stop thinking about the worst scenarios one by one.

Be aware of your body, be mindful. We are the experts actually.

SmSh: What should we NOT do? Which habits or behaviors will exacerbate our mental health issues?

Chen: Using drugs and alcohol is not something we recommend, no matter how you want to use them: to solve any problems, or to reward yourself – that's not a healthy way. Also, don't shut yourself off from people and activities you enjoy or avoid day-to-day responsibilities. [That's] not something we encourage you to do.

SmSh: Right, don't be a turtle...

Chen: And the next one is eating in an unhealthy or excessive way. Eating is a big part. And finally, don't harm yourself.

SmSh: What about expats living in smaller cities where it might be harder to find support in English? What can they do?

Chen:There are mental health service hotlines in many cities across the country [Ed's Note: Mostly Chinese-language, though LifeLine is English]. Take action to seek help. Look for it. Check with people around you. You might be surprised to find a professional who speaks English even in smaller cities, as there are many people like me who have returned from studying or living abroad.

SmSh: What are some misconceptions about mental health? Maybe we can use this space to clear them up.

Chen: The first one, the differences between psychiatrists and psychotherapists. Many people may say, "Oh I don't want to take medication, could you please not give me medication?" That's a misconception [ed's note: psychotherapists can't prescribe meds].

Some people may understand therapists as just "talking". It's not just talking. We can do many different things. We have drama therapy, art therapy, and music therapy and so on. And not necessarily for young kids. Some adult clients want to use different ways to express themselves easily.

So, it's not just talk. And don't be scared that people are going to prescribe medication.

Different therapists have different roles, different approaches, and different theories. My approach is very integrated. Recovery is a process. It's not something like "Oh I finished!" It's a journey, it's something we work together on. I also tell my clients that they can see me as their GPS. We set up a goal together, and we just try different ways.

Also, seeing a therapist doesn't mean you're sick. People still have some stereotypes about seeking help. In the US, more people normalize that it's one of the resources.

SmSh: It's a normal thing. It's like going to the bathhouse.

Chen: Right. But not here, and also with some expats from different countries. They still tell me, it's hard to come here, or they say, "my family members told me, ‘you don't have to go. What's wrong with you?'" They don't want to share that experience with other people.

SmSh: What about expat kids? It's never been easy, but what has changed since COVID? What can kids and their parents do to thrive?

Chen: I can only say, from my experiences with my clients, those kids seem to be having an easier life than their parents. It's easier for them to adjust themselves, with all new friends, or new activities that their parents prepare for them. They seem happier than the parents.

SmSh: Even in the pandemic?

Chen: Right, even in the pandemic. They may find more excitement. They also get support from their parents. But for parents, it's hard to get support from the kids.

But, be mindful about those soft skills. People need to develop skills though interpersonal relationships, like empathy, independence, and conflict resolution. I heard from international teachers that right now part of their job is focusing on soft skills. They noticed some change during the pandemic.

SmSh: I know there's a lot of people who are thinking, "I'm missing opportunities elsewhere in the world... My family is getting older... It doesn't look like things are going to open up again soon... should I move back?"

Chen: Right. That's a complicated question to answer actually. For me, at the time when I made the decision to come back to Shanghai, it also wasn't that easy.

Are you familiar with the Decision-Making Model? We consider four different things: Staying in Shanghai (the good things about this), Staying in Shanghai (the bad things about this), and then Leaving Shanghai (the good things about this), and Leaving Shanghai (the bad things about this).

This will help you have space to organize your thoughts together. Otherwise, it's so easy to only think about the good parts today, and then tomorrow you only focus on another part. You want to put everything on one piece of paper and have a vivid comparison.

The second part is to prioritize those things. Prioritize the top three. Circle them. I hope you will have a clearer mind.

*****

Even though we did more of an interview than a session, just talking to someone about mental health and how I felt made me feel way better. Mental wellness is indeed, for lack of a better word, a journey. Sometimes we wander off course and someone to help us on the journey, just like we might need to consult a strategy guide when we get stuck in a game. Nothing wrong with that. It's hard out there for everyone. Talking to someone – whether that's a therapist, a friend, or a diary – can really help.

(For this article, SinoUnited Health was kind enough to sponsor a full medical check for me as well, and after not having one for nearly three years, the [mostly] clean bill of physical health did a lot for how I'm feeling mentally.)

SinoUnited Health (SUH) is a unique medical institution run by doctors. Their philosophy is simple: patients first. They have five clinics in Shanghai and one in Hangzhou.