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WASHINGTON -- International students may be more reluctant than other students to seek mental health counseling for a wide variety of reasons, including stigmatization of mental illness in their home countries and common (incorrect) myths that seeking treatment could result in a notation on their transcript or the revocation of their visa, panelists told attendees Thursday at a session focused on international student mental health at the annual NAFSA: Association of International Educators conference.

A study published in the Journal of American College Health in 2010 found that while international graduate students were about as likely as domestic graduate students to report “an emotional or stress-related problem that significantly affected their well-being or academic performance within the past year,” the international students were less likely than their American peers to be aware of available counseling services. Just 61 percent of international graduate students surveyed were aware of the availability of services, versus 78.6 percent of domestic graduate students. They were also less likely to have considered using mental health services (33 percent for international versus 56 percent for domestic), and were less likely to have actually used them (17 percent versus 36 percent)

Justin Chen, the co-founder of Massachusetts General Hospital’s Center for Cross-Cultural Student Emotional Wellness and an assistant professor of psychiatry at Harvard University, described a number of barriers for treatment for Chinese students specifically, a group that accounts for about a third of all international students in the U.S. Another study published in the Journal of American College Health, in 2013, found that 45 percent of Yale University students from China reported symptoms of depression, and 29 percent reported symptoms of anxiety. Chen said that a similar, more recent, study at the University of Delaware found almost identical rates.

Chen cited a number of barriers to Chinese students seeking treatment, including the belief that depression and anxiety are personal weaknesses rather than illnesses, a cultural tendency toward emotional inhibition rather than expression, a low awareness of services, and language/cultural barriers. “I think there’s a real lack of linguistic diversity in many university counseling systems,” Chen said.

Chen also cited as a barrier the stigmatization of mental illness in many Asian cultures, including China’s, and what he described as the “insidious” role of the model-minority myth and the pressures it puts on students to live up to expectations that Asians are a model group who uniformly perform well in America.

Chen also discussed common stressors for international students, including stresses related to academics, communication styles and use of a second language. One firsthand account from a Chinese former graduate student who experienced anxiety attacks describes academic and linguistic stresses, as well as stresses associated with being away from a support network: "Over time, the isolation of graduate school, the heavy reading load in a second language and the strain that distance put on relationships with people in Beijing all began to add up," the former student, Helen Gao, wrote in an op-ed published in The New York Times in December 2017 titled "Chinese, Studying in America and Struggling."

Xuhua Qin, a psychologist and multicultural specialist in counseling and mental health services at Tufts University, listed a range of signs advisers for international student can look for in determining whether to refer students to the counseling center, including deterioration in personal hygiene or dress, dramatic weight loss or gain, noticeable changes in mood, excessive absences, academic problems, social isolation, unusual behaviors, drug and alcohol abuse, or threat of harm to themselves or others.

Qin said that in referring students to counseling, international student advisers may have to bust a lot of myths. She suggested that advisers emphasize that seeking counseling is a sign of strength, that they explain confidentiality -- that a visit to the counseling center will not appear on a student's university record or transcript, that their friends, family or sponsors won’t know, and that it won’t impact their visa status -- and that they discuss with students how counselors are trained to be open and culturally competent.

“Sometimes students would like to maybe work with someone who came from a similar cultural background or who has other language skills,” Qin said. At the same time, she stressed, “Please do not make assumptions that international students always want to work with a counselor who has a similar cultural background. Instead of making assumptions, you can always ask directly about their preference.” Qin also recommended that advisers be prepared to either make the call to the counseling center together with the student or to walk him or her to the counseling center.

Qin said some students she sees in counseling told her that that when they first started struggling, they feared no one cared. They would tell her, “I really wished someone would just say, 'How are you doing?' and ask me about difficulties that I’m having.”

"Keep in mind sometimes acknowledging and asking makes a difference," Qin said. "Please do not let the worry of being obtrusive or being offensive get in the way of this very important first intervention.”

Patricia Burak, the former longtime director of the Slutzker Center for International Services at Syracuse University and the editor of a new book published by NAFSA, Addressing Mental Health Issues Affecting International Students, discussed steps international student offices can take. She suggested inviting representatives from the counseling center or other mental health professionals to orientation -- if counselors speak another language, let them do so, she urged -- and addressing challenges related to cultural adjustment. She recommended training peer mentors on these issues and tapping in to their knowledge and expertise. Burak mentioned a number of programs that can help, including peer mentor and buddy programs, discussion groups, workshops on topics like culture shock, drop-in hours, friendship family programs, holiday programs, and discussion and support groups. She talked about reducing stigma and collecting and publicizing testimonials from current students.

Burak also stressed common courtesy -- things like not talking about students in the hallway outside one's office and learning how to pronounce students' names correctly (that last suggestion garnered applause among the international educators here at NAFSA).

"You have to show in the international student office an atmosphere of care," Burak said.

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