White Paper: Improving Mental Health Care for International Students Studying at American Universities

Improving Mental Health Care for International Students Studying at American Universities

The American post-secondary system of colleges and universities strives to educate students and prepare them to be citizens in the diverse, multi-cultural landscape of today’s society. An integral part in this process is the instruction of international students who come to the United States seeking an education and bring with them myriad cultures, languages, and belief systems. In fact, American college campuses have experienced an increasing presence of international students each year. These students have many unique needs that American schools are meeting with varying levels of success. With a traditional focus on academic support, financial assistance, and protection from discrimination, most campuses miss an essential aspect of student life when they fail to meet the mental health needs of international students. International students studying at colleges in the United States face a distinctive set of stressors that combine to create unique mental health concerns, many of which are not adequately being met. American universities need to be proactive in reaching out to the international student body, work to reduce shame and stigma from mental health concerns, and offer services informed with multicultural and international understanding.

1. Scope of the International Student Population

According to UNESCO, international students are those students who are not citizens of their host country and do not have permanent residency in that host country. Additionally, they have not completed the education that they moved to the host country to seek (Fritz, Chin, and DeMarinis 245). Information from the Institute of International Education indicates that in 2013 there were 819,644 international students in the American higher education system. This represented a 7.2% increase from the previous year. Three nations accounted for 49% of these students: China with 235,597, India with 96,754, and South Korea with 70,627. The nations with the highest growth rates included China, Saudi Arabia, Brazil, Iran, and Kuwait. In the United States, 69% of the international student population is hosted by only 5% of the educational institutions. Further, international students make up only 3.9% of the total enrollment in the American higher education system (Institute 5-6, 8-10, 13).

2. Stressors in Higher Education

Matriculating to and studying at an American college or university is a process of great change, often bringing feelings of stress and anxiety. For many students, both international and domestic, the first time being away from home, family, and friends can bring feelings of isolation and loneliness.  The pressure to succeed in an academic setting that is often more rigorous or competitive than high school brings additional challenges. These difficulties can cause emotional and psychological distress that manifests in ways that affect the students’ mental health. In 2002, the American College Health Association surveyed 29,230 college students, many of whom reported common indicators of compromised mental health; 29.3% reported levels of stress that interfered with their academic performance while 21.3% indicated sleep difficulties that negatively affected course work. The students indicated that 44.7% felt so depressed that it was difficult to function at least once in the last year, 64.7% reported strong feelings of hopelessness, and 72.3% had felt emotionally exhausted (Kadison and DiGeronimo 38, 240).

            While these mental health concerns are present for the student-body at large, international students represent a distinctive subset of that group, and, as such, have unique needs, circumstances, and stressors.  In fact, many of the primary stressor for international student are concerns that are rarely, if at all, present in the lives of domestic students. These problems can include language barriers that affect academic performance and daily living, adjusting to a new educational system, the complexities of establishing social relationships in a new culture, and adjusting to different social norms (Lee, Koeske, and Sales 401). All of these are complicating factors on top of the all-encompassing issues of developing and establishing a personal sense of identity and coping with financial concerns

2.1 Acculturation

The primary stressors for international students involve areas related to the process of acculturation and include educational, sociocultural, and language-related concerns.  Acculturation is “the dual process of cultural and psychological change that takes place as a result of contact between two or more cultural groups and their individual members” (Barry qtd. in Fritz, Chin, and DeMarinis 245).  As this process develops for international students, the primary area of concern involves language barriers. Language is central to a person’s identity, and as difficulties arise in transitioning to a second-language based culture, language difficulties can create deep anxiety for students. Additionally, this anxiety can have a lasting effect on a student’s self-concept, self-esteem, and cognitive and behavioral development (Chen 51). Moreover, it can make adjusting to a host culture more difficult. In fact, perceived language competency is essential to developing effective work habits and study skills.

2.2 Second Language Difficulties

For international students, these language difficulties can create unique stressors related to educational performance.  Language difficulties have a direct negative impact on academic performance. A student’s insufficient language skills can interfere with the ability to comprehend lectures, take notes, and understand reading assignments. Also, they can affect writing assignments and examinations (Mori 138). These difficulties are made more complicated by the fact that students may not feel able to ask questions adequately, either in class or privately. This level of academic stress is problematic because research indicates that academic stress can be a significant predictor of life stress (Smith and Khawaja 702).

2.3 Academic Stressors

The unique pressures on international students can serve to exacerbate academic stressors.  Many international students are from the best-educated sectors of their home societies.  As such, they often feel the pressures of their families, extended families, communities, and sponsoring groups and may feel driven to attain academically high achievements that are unrealistic. With this pressure comes a fear of academic failure and anxiety over meeting expectations (Mori 138). When academic performance suffers—even from factors outside of the student’s control including acculturative difficulties—students often experience a decreased sense of academic self-confidence (Smith and Khawaja 703).  However, it is important to note that when researchers compare the stress levels of international students with those of domestic students, American students expressed higher levels of academic stress, possibly due to the cultural emphasis on competition for American students (Hyun et al. 110). Therefore, academic anxiety is not unique to international students, but its sources are quite different from those of domestic students.

One distinct aspect of academic stress for international students can be the adjustment to a new academic system and the accompanying teaching styles. The lack of familiarity with the educational system in the United States can cause a range of results from a generalized feeling of anxiety or distress to a lack of ability to adjust.  For students from many cultures outside of the American/Western European educational model, college classes can require a complete shift in method relating to both preparation and participation. Students from Asian, Middle Eastern, and African countries are often used to sitting quietly in lecture style classes and being expected to take notes verbatim, memorize them, and prepare for a once or twice-yearly examination. For these students, the American educational system is both new and unpredictable, containing such elements as independent research, creative essays, frequent and unannounced quizzes, and the expectation of active participation in class discussions (Mori 138).

2.4 Sociocultural Stressors

Outside of the academic setting, international students typically face unique sociocultural stressors that serve to complicate an already complicated situation. These stressors include both difficulties in establishing social connections and the complexities of dealing with culture shock. For students living in a host nation, creating a social support network can be difficult, especially when this requires forming cross-cultural relationships. Studies have shown that international students desire social interactions with domestic students, and those cross-cultural friendships bring with them psychological, social, and academic benefits (Williams and Johnson 41). In fact, when international students limit their social interactions with domestic students, research has shown an increase in levels of feelings of anxiety, depression, and alienation (Williams and Johnson 42).

The difficulties of culture shock affect many international students, despite the efforts to prevent or minimize it. Virtually all American colleges and universities have taken strides to reduce the culture shock international students experience. In spite of such efforts, many students are not psychologically and emotionally prepared for cross-cultural adjustment and the difficulties it provides. Such culture shock can affect students’ emotional well-being, mood and behavior patterns, and identity development while bringing with it predictable increases in levels of stress (Prince 4). Culture shock can have an especially profound effect in terms of developing those sociocultural connections that are essential to student success. American culture emphasizes a highly mobile, individualistic society with ideas of friendship that are less enduring than those with which most international students are familiar. Moreover, there can be misunderstandings caused by Americans’ tendencies toward friendly social interactions that might be perceived as offers of serious friendships or romantic relationships. Casual phrases like “Come on over sometime” and “I’ll call you” can carry more perceived seriousness than intended, leading to feelings of disappointment and heartbreak (Mori 138).

One additional complication for international students can be that of being on the receiving end of a cultural backlash. After September 11, 2001, international students have reported facing unwelcoming atmospheres at some American universities. Additionally, they may be subjected to increased surveillance due to regulations in the USA PATRIOT Act and increased difficulty with securing student visas (Hyun et al. 109). Certain cultural, religious, and ethnic groups have reported higher levels of suspicion and racism. These unwonted and undeserved attentions and negative reactions can make a student studying abroad feel less secure, more self-conscious, and more anxious.  

3. Mental Health in the Collegiate Setting

For a student in the 18-24 age range, which includes the majority of students in higher education, both domestic and international, college represents a time of great emotional and psychological change and development. Many college students for the first time will experience mental health concerns and need to seek treatment at counseling and mental health care centers. The added stressors on international students, combined with the distance from supportive family members and communities, can cause cracks in an already strained level of mental health.

            Beginning to study in higher education happens for most students at a difficult age, and can have a significant impact on future levels of mental health. Most lifetime cases of mental health conditions begin, though are not necessarily diagnosed, by the age of 24. For college students as a whole, the primary areas of mental health concern are depression, sleep disorders, substance abuse, anxiety disorders, eating disorders, self-harm, and thoughts of suicide (Kadison and DiGeronimo 90). Due to several factors including increased antidepressant use and efforts to reduce stigma, college students are more likely to seek help for mental health concerns than they have been in the past (Baker).

However, these positive trends of seeking help from mental health services apply to the student body as a whole and often do not apply to the subset of international students.  Research has shown that international students are less likely to use counseling services than domestic students are. One possible reason is the lack of awareness of the need for mental health services. Instead of seeking help for depression or anxiety issues, international students tend to seek treatment for the physical manifestations of the emotional problems (Hyun et al. 110). For example, if depression is causing a student to have difficulties eating or sleeping, the student might seek help for the resulting fatigue, rather than the depression that is the true antecedent. Instead of consulting a college mental health or counseling clinic, international students tend to seek treatment from primary care providers.

3.1 Mental Health Behaviors

Additionally, international students tend not to make use of the services available to them. Studies indicate that international students are disinclined to use campus mental health services. Moreover, such students often delay seeking help and have higher rates of “no shows” at the counseling centers after an intake session (Yoon, Awe, and Portman 34). International student may seek alternative forms of mental health care such as from a tribal elder, healer, clergy member, academic advisor, or international student services staff member (JED 25). In addition, many international students seek no help at all. Even though the college campus might have a counseling center available to provide treatment as most do, some students come from a culture that either does not understand or does not acknowledge mental illness. Also, if the student is from a culture that discourages revelations of personal problems, that student is unlikely to seek mental health care.

The problem with failing to seek help for mental health concerns is neither new nor limited to the international student population.  Most American adults with mental health disorders do not receive mental health care. This is in spite of the availability of evidence–based treatment. Moreover, those receiving services have often delayed seeking help, and they typically do not follow through on recommended treatment plans. These trends are consistent across all age groups (Eisenberg et al. 1), and are likely due to the long-standing and pervasive effects of social stigma regarding mental health care.

3.2 Stigma

Stigma, as a factor in mental health care, has been researched at length, and its effect on treatment-seeking behavior and follow-through is well documented.  Numerous studies have detailed the high levels of public stigma related to mental health. As such, stigma is often a barrier to seeking treatment and following through on a treatment plan. Complicating the issue is the fact that there are two types of stigma, public and personal, and both can interfere with a person seeking needed treatment. Public stigma can include the perceived potential for criticism or discrimination, while personal stigma includes one’s own acknowledgment of a mental health problems and the personal negative attitudes that acknowledgement brings with it (Eisenberg et al. 3).

3.3 Colleges Providing Access to Care

American colleges and universities have struggled with adequately meeting the needs of the rising numbers of international students who are experiencing increased rates of anxiety and stress amidst both a general and often culture specific atmosphere of stigma regarding the treatment of mental health concerns. College mental health and counseling centers are typically underfunded and understaffed, causing wait times for service and limits on hours of availability. The National Alliance on Mental Illness’s “College Students Speak” report on mental health indicated that of student seeking care, 39% had to wait more than five days, while 20% had to wait two to four days (Gruttadaro and Crudo 15). The Association for University and College Counseling Center Directors’ Annual Survey further indicated such trends. 31.5% of centers had a waitlist during the year, 50.5% impose session limits, and only 30% reported an increase in staffing levels (Mistler et al. 7-8). These restrictions are in spite of increasing levels of treatment-seeking and the fact that only between 6 and 12 % of students as a whole seek treatment, even though rates of mental health concern are significantly higher.

4. Recommendations

These challenges to meeting the mental health needs of students apply to the campus as a whole. International students represent a unique subset of the university population with specific needs and complicating factors. A combination of proactive and focused communication, social support, clinical support, and outreach will be required to meet the mental health needs of this oftentimes vulnerable population.

4.1 Increased Communication

Any campus-wide effort to meet the mental health needs of the international student population must begin with a focused effort to increase communication. For college students in general, when asked about mental health awareness, a majority of students indicated the importance of mental health awareness training. This includes activities for both faculty and staff, and is often seen by students as the most important awareness step universities can take (Gruttadaro and Crudo 10). Such efforts can allow schools to train all students, staff, and faculty concerning the early warning signs of mental health crises (Gruttadaro and Crudo 18). Further, it can provide them with information on steps to take and resources available. 

 In order to utilize mental health services, students must first know about them. One study surveyed students regarding their knowledge of their universities’ mental health services. Those who were aware of them typically located that information on the school’s website; however, a majority of students did not even know if the website offered information about mental health services at all. Thus, it is crucial for colleges and universities to develop websites with comprehensive and current mental health information (Gruttadaro and Crudo 10-11). Moreover, there needs to be a strategic effort at communicating the information to the student body, including informing students that the information is available on the website and making that information clear and easy to obtain.

However, for incoming international students, many of whom face language or communication barriers, simply maintaining a comprehensive website is not enough. Communication efforts need to be focused and proactive.  Some researchers have suggested a specific drive, beginning with the intake process, that consistently communicates the message of mental health care as a university priority. This could include separating groups based on cultural regions to allow discussions involving the distinct perceptions each cultural group might present. Information could be provided, as needed, in a native language to eliminate any second-language barriers. This could also include both an individual and group component, periodically assessing the progression of the acculturation processes for each student and cultural group (Fritz, Chin, and DeMarinis 251). Additionally, schools must consider orientation times as opportunities to not only provide standard information on academic assistance but also to communicate about stressors, support, and resources available. All incoming international students must be communicated with clearly concerning resources to help resolve issues of adjustment, coping, and stress (Misra, Crist, and Burant 154).

4.2 Strengthening Social Support Systems

The cornerstone of any mental health drive for international students must be a system of encouraging social support. Research consistently shows that international students who feel included in and connected to a social network within a host country are less likely to experience indications of acculturative stress. Social connections are consistently shown to lead to effective adjustment. In fact, studies have shown that frequent contact between individuals of different cultures can lead to “decreased intergroup anxiety and increased positive intercultural attitudes” (Williams and Johnson 42).

For most international students, however, it is essential to maintain strong connections with other international students, often those from the same culture group. Students feel a sense of social support when they are able to establish a network of friends in the host country. This network then provides an essential web of encouragement and support, reinforcing the student’s self-confidence (Wan et al. 609). They may rely heavily on their peers for both social support and information on mental health care and resources, and “institutional and social support is positively related to emotional well-being” (Hyun et al. 110).

 While many international students build social support systems quickly, not all do. Thus, it is crucial that universities step in to help students develop these essential networks. This can include offering programs that enhance social support systems such as arranging informal discussion groups among students and encouraging students to discuss their feelings and experiences with others who have experienced culture shock (Prince 6). Such an effort would create safe settings for students to both experience social support and have a network of students and staff that can help to bridge the cultural gap. Research suggests that programs that support intercultural contact help the acculturation process of international students. Further, maintaining contact with both individuals and groups can be used by the counseling staff periodically to assess connections with the students’ home cultures, knowledge of the host culture, and the degree to which the students are adjusting (Fritz, Chin, and DeMarinis 251-252).

4.3 Efforts to Reduce Stigma

Though students might have a network of social support, many will still need to make use of campus mental health services. Even if effective communication was offered and the student knew about the availability, the services would not be utilized unless there was a focused effort at outreach and the reduction of stigma. Stigma, in fact, is consistently reported as the number one barrier to students seeking mental health services (Gruttadaro and Crudo 15). Additionally, even when students do seek help, stigma often prevents that help from being effective; “studies with clinical samples have found that higher perceived stigma is associated with lower treatment adherence and premature termination” (Eisenberg et al.  3).

Universities are uniquely positioned to have a positive effect on the issue of stigma for students, both domestic and international. As most college students are young adults, they are in the process of establishing a separate identity from parents and family. This can cause their attitudes about mental disorders to evolve rapidly (Eisenberg et al. 17). Thus, it is the ideal time for universities to spearhead efforts to reduce stigma and develop new understandings of mental health. This will not only allow students to have positive mental health care experiences in college but also to develop lifelong attitudes reducing shame and stigma.  

4.4 Facilitating Access to Clinical Support

For some international students, creating a network of social support and reduced stigma will be enough to reduce the stress and anxiety of acculturation and lead to positive mental health. However, some international students will still need to seek clinical care. This can only happen if such care is available and in such a way that meets the students’ needs and matches their schedules. Schools need to establish easy protocols for getting help. This may include such steps as limiting the amount of paperwork required and having help available during the week, weeknights, and on weekends (Gruttadaro and Crudo 18). This is difficult to do when clinics are already understaffed and underfunded.

Often, when budget difficulties arise, access to mental health resources are reduced, but this only creates an educational environment where students are set up to fail (Baker). International students are a more vulnerable population, and it is difficult to justify cutting mental health services due to funding shortfalls while international students consistently pay the highest tuition rates of any students in a school.  One step that schools can take is to require students to have health care coverage that guarantees access to mental health care. Recent studies have shown that having health coverage reduced the rates of depression by 30 percent for patients, even without an increase in the use of antidepressants. The alleviation of concern over potential costly medical emergency may help reduce rates of depression (Rampell). For international students facing complex concerns without the support of family, worries over health care and potential financial difficulties can cause or worsen mental health concerns. Additionally, if students do have health care coverage, they can make use of off-campus services that are more likely to be able to meet their unique scheduling needs and might be a more appropriate cultural match.

Off-campus services notwithstanding, college and university counseling centers will often be the primary mental health care provider for international students with mild mental health concerns. As such, informed counseling grounded in an understanding of diverse cultures is essential to successful treatment. For example, it is important to understand the students’ cultural background and value system concerning academic success. Many international students come from cultural value systems that connect academic success and family honor, creating a unique facet to the student’s sense of self (McSwiney, Gabb, and Piu 255).  Such an understanding is vital to effectively counseling any student dealing with mental health concerns while being deeply involved in an academic pursuit. Additionally, it can be complicated to assist student who may have differing baselines for defining personal mental health. Traditional counseling theories are often based on assumptions about universal definitions of what constitutes normal behavior (Olivas and Li 217). These assumptions may or may not be accurate.

4.5 Culturally Informed Counseling Services

It will be necessary to have counseling and mental health services that are uniquely crafted to meet the needs of international students. One problem arises when international students are treated as one homogeneous group. While they may experience similar problems to other international students, such as language barriers and culture shock, there are important cultural differences even between the subsets of the international student population. Combining culturally diverse groups into one large category overlooks culture-specific needs, socialization patterns, and adjustment strategies (Fritz, Chin, and DeMarinis 251).

            Research has consistently shown that it is essential to provide people with culturally relevant and informed counseling. However, this is not taking place for many international students on American campuses.  The fact remains that there is little training to prepare counselors to work with international students. Counseling textbooks address multicultural issues but do not customize those for international students. Theories and skills that are used for American minorities are generalized, though this application brings with it many limitations. International students and American minorities do share some aspects of cultural heritage and minority status, yet these groups are still very different, as are the needs of the group members (Yoon, Awe, and Portman 34). For example, for international students, often the two most promising interventions are strengthening English –language skills and social support networks (Wan et al. 619). However, it is likely that an American minority student might not have any English-language difficulties, so this strategy might not even be considered.

4.6 Increased Research

This lack of training in competencies to provide care for international students reveals a core area of concern: the lack of research in the area of international student mental health care. Much of the research conducted on “public attitudes toward mental illness refer mostly to Western societies” (Ng 382).  In fact, the universality of mental illness across cultures is well documented. However, public perceptions and understandings of mental health are influenced by culture:

in terms of the conception, perception, experience of symptoms, recognition and labeling, classification, treatment, and course of mental illness. These issues are the concern of cross-cultural psychiatry where one is mindful of western ethno-centric bias in diagnostic classifications of psychiatric disorders. Such are usually based on concepts of normality and deviance which are not culture free, and are derived from clinical populations selected via social processes for Western treatment (Ng 383).

Since there is empirical validation of differences in causes of, experiences with, and reactions to stress for American and international students, more research needs to be conducted to gain a better understanding of potential prevention and treatment programs for international students (Misra and Castillo 146). In this area, American universities are uniquely positioned to have a lasting positive impact through a commitment to encouraging and funding research on this important topic. Such efforts would show the higher education system’s commitment to international students’ mental health, both now and in the future.

International students in the American higher education system face a unique set of stressors that create distinctive mental health concerns; American universities need to be proactive in reaching out to the international student body, working to reduce shame and stigma from mental health concerns, and offering services informed with multicultural and international understanding. By committing to this area through pledges of funding and facilitation of improved research, universities can ensure the improved care of students, both currently and in the future. International students represent a vital segment of the American higher education population. They bring diverse backgrounds, cultures, and languages and deserve the high quality mental health care necessary to protect them as they pursue their education.

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