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Article 20

Mental Health Concerns of Mainland Chinese International Students in the United States

A Literature Review

Kaifang Zheng & Cirecie A. West-Olatunji

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With a significant increase in enrollment of mainland Chinese international students (MCIS) in the United States over the past 10 years, mental health concerns for this population have increasingly drawn the attention of educators, counselors, and psychologists (Cheung, 2011; Goff & Carolan, 2013; Tsai & Wong, 2012; Wei, Heppner, Mallen, Ku, Liao, & Wu, 2007; Yan & Berliner, 2009). Research has shown that this population experiences a high rate of mental health concerns, such as depression and anxiety, yet underutilizes professional counseling services (Cheung, 2011; Han, Han, Luo, Jacobs, & Jean-Baptiste, 2013; Wei et al., 2007).

Three major areas of mental health concerns for MCIS have been discussed. The first area presents research on issues related to transcultural adjustment of MCIS (Berry, 1998; Mori, 2000; Qin, 2009; Roysircar, 2004; Sandhu, 1994; Wang & Mallinckrodt, 2006; Yeh & Inose, 2003). The second area describes MCIS’ relationship issues and relational-cultural factors that impact their well-being (Goff & Carolan, 2013; Ye, 2006; Ying, Lee, & Tsai, 2007; Zhang, Smith, Swisher, Fu, & Fogarty, 2011). The third area provides a review of the literature on stressors of MCIS and how these students cope as well as their help-seeking preferences (Cheung, 2011; Tsai & Wong, 2012; Yan & Berliner, 2009, 2011a, 2011b, 2013). It has been suggested that counselor educators and practitioners have insufficient knowledge about this population’s unique needs to provide effective interventions and services (Tsai & Wong, 2012; Yakushko, Davidson, & Sanford-Martens, 2008). Thus, this paper serves to increase knowledge in this area to foster dialogue and augment awareness about MCIS’ needs.

Review of the Literature

While there are international students representing a host of countries from around the globe, Chinese students represent the largest body of international students in the United States, followed by India and South Korea (Institute of International Education, 2013; Yan & Berliner, 2011b). According to the Institute of International Education (2013), the number of international students enrolled in U.S. institutions of higher education increased by 7% to 819,644 students in the 2012–13 academic year, while Chinese student enrollment increased by 21% to almost 235,000 students, representing 28.7% of international students. Multicultural scholars have noted that studying in a foreign land comes with its challenges, such as navigating language, social customs, and institutional rules and expectations (Roysircar, 2004; Sandhu, 1994). How MCIS cope with these transitions is a focus of this paper.

Despite the fact that international students encounter substantial acculturative challenges and present frequent concerns of depression and anxiety, a considerable number of studies have demonstrated that these students underutilize counseling services compared to other students within the United States (Nilsson, Berkel, Flores, & Lucas, 2004; Yakushko et al., 2008; Yi, Lin, & Kishimoto, 2003; Yoon & Jepsen, 2008; Yoon & Portman, 2004). Studies have also revealed a high rate of early termination of treatment after the initial session, suggesting an apparent dissatisfaction with counseling services (Nilsson et al., 2004; Yakushko et al., 2008). More specifically, research on Asian international students found that they experienced higher levels of acculturative stress (Cross, 1995; Yeh & Inose, 2003) and attended fewer counseling sessions as compared to European international students (Mitchell, Greenwood, & Guglielmi, 2007). Asian international students, including MCIS, also have been shown to experience less exposure to counseling in the United States and report greater discomfort and shame associated with counseling compared to U.S. students (Yoon & Jepsen, 2008).

For MCIS in particular, several studies found that these students have high levels of depression and anxiety symptoms but disproportionately low utilization rates for professional counseling services (Cheung, 2011; Han et al., 2013; Wei et al., 2007). A report on a mental health survey of 130 MCIS at Yale University showed that 45% of participants reported symptoms of depression, and 29% reported symptoms of anxiety (Han et al., 2013), but only 4% of participants reported utilization of on campus mental health counseling services. Compared to U.S. university students in general, 12.8% and 13% of U.S. university students reported having been diagnosed with depression and anxiety in 2009 (American College Health Association, 2010), and 11% of U.S. students sought on campus counseling services during 2014 (Gallagher, 2014). Cheung’s (2011) study of 203 Chinese international students (144 from mainland China) found prevalence rates of 47.5% for depression symptoms and 48% for anxiety symptoms. Again, the majority of these Chinese international students did not report seeking professional mental health services (Cheung, 2011). Another study with a sample of 189 Chinese international students (135 from mainland China) found a 32% prevalence rate for depression symptoms (Wei et al., 2007). Although the differences may partially be due to the use of varied instruments, the results from these multiple studies suggest that Chinese students may face a varied but high rate of mental health problems.

Transcultural Adjustment

One primary area that contemporary scholars have explored in relation to MCIS is transcultural adjustment. This term refers to the process of entering into a new culture and trying to develop new coping strategies within the new context. Two salient features of transcultural adjustment are noteworthy: acculturation and identity development. Because of the challenges presented when transitioning from one culture to another, acculturation is one of the most significant features of transcultural adjustment for MCIS (Berry, 1998; Mori, 2000; Roysircar, 2004; Sandhu, 1994; Wang & Mallinckrodt, 2006; Yeh & Inose, 2003). Studies have shown that identity development intersects with acculturation in the process of transcultural adjustment (Qin, 2009).

Acculturation and acculturative stress. The concepts of acculturation and acculturative stress in the comprehensive acculturation model developed by Berry and colleagues (1998) provide a framework for understanding the processes and outcomes of transcultural adjustment (Berry, 1998; Berry, Kim, Minde, & Mok, 1987; Roysircar, 2004; Wang & Mallinckrodt, 2006). Acculturation, from Berry’s perspective, refers to the two dimensional processes of cultural and psychological transformations that are evident from persistent contact between two or more cultural groups and their individual members. Acculturative stress connotes the stress generated from the experience of acculturation with the ineffectiveness of prior coping patterns and the lack of availability of new ones within the new cultural environment (Berry, 1998; Berry et al., 1987). Contemporary counseling scholars have identified several sources of acculturative challenges that are correlative to international students’ adjustment difficulties. These include: (a) a profound sense of loss and homesickness, (b) loneliness and social isolation, (c) identity and value confusion, (d) discrimination and prejudice, (e) culture shock, and (f) stress due to changes (Constantine, Kindaichi, & Okazaki, 2005; Constantine, Okazaki, & Utsey, 2004; Hayes & Lin, 1994; Mori, 2000; Sandhu, 1994; Yeh & Inose, 2003).

While specific studies on acculturation for Chinese international students are limited, scholars have investigated the relationship among acculturation or acculturative stress, Chinese international students’ (with MCIS as the primary group) mental health, and their psychosocial adjustment, using mediating factors per Berry’s framework (Davis & Melanie, 1999; Lowinger, He, Lin, & Chang, 2014; Wang, Heppner, Fu, Zhao, Li, & Chuang, 2012; Wang & Mallinckrodt, 2006; Wei et al., 2007). In particular, Wang and Mallinckrodt (2006) found that high attachment anxiety among Chinese international students was associated with lower acculturation levels and more acculturative stress. Both high attachment anxiety and high avoidance were significant predictors for both sociocultural adjustment difficulty and psychological distress. A more recent study by Wang et al. (2012) took a longitudinal and person-centered approach to profile types of Chinese international student acculturative adjustment stages before and during the initial transition. Four stages emerged: constantly distressed, relieved, culture-shocked, and well adjusted. Factors that predicted a better acculturative adjustment pattern included high self-esteem, positive problem-solving skills, and lower maladaptive perfectionism.

The impact of acculturation level or acculturative stress on depression, eating disorder issues, and procrastination behaviors among Chinese international students have also been investigated. The study by Wei et al. (2007) found that acculturative stress and maladaptive perfectionism (defined as the discrepancy between one’s expectations and actual performance) have significant main effects on depression. Additionally, the variables of acculturative stress, maladaptive perfectionism, and length of time in the United States interact to predict depression (Wei et al., 2007). A study investigating the correlation between acculturation level, perfectionism, and eating disorder problems of Chinese international students found that highly acculturated female students reported higher body dissatisfaction and a greater sense of ineffectiveness (Davis & Melanie, 1999). These scholars also discovered significant correlations between female Chinese international student academic procrastination with their academic self-efficacy, English language ability, and culture shock and stress, while male student academic procrastination was significantly associated with discrimination and homesickness.

In all of the studies presented on acculturation of Chinese international students, mainland Chinese students were the majority group, with a prevalence ranging from 50% to 71.4%. These studies have all primarily focused on graduate students, except the Davis and Melanie study (1999).

Identity development. Multicultural counseling scholars have long asserted the need to explore identity development as a foundation for conceptualizing culturally diverse clients’ needs (Han, West-Olatunji, & Thomas, 2010; West-Olatunji et al., 2007). Identity models in counseling describe the ways in which culturally and socially marginalized individuals cope with social bias and oppression. For international students, this is also an area of concern.

Qin (2009) examined Chinese female graduate students’ psychological and socio- cultural experiences in the United States from the perspectives of feminist theory, relational-cultural theory, symbolic interaction, and sociocultural theories while considering the social-cultural contexts and power dynamics. This study demonstrated the identity development process of female Chinese international students before and after they came to the United States. Before and after becoming a student in the United States, they experienced three similar stages of weaving self in socio-cultural contexts, fragmenting self by deconstructing ways of being in cultural contexts, and reweaving multiple selves through critical cultural elements. Identity development theory offers a comprehensive lens to more effectively conceptualize MCIS’ emotional, psychological, and relational issues.

Relationship Issues

The second area of investigation related to MCIS is relationship issues. Though only a few studies have been conducted in this area, marital issues of mainland Chinese international couples, social support, and relational-cultural context of mainland Chinese students have been revealed and explored (Goff & Carolan, 2013; Ye, 2006; Ying et al., 2007; Zhang et al., 2011).

Gender role and marital issues. A study on Chinese international student couples’ marital issues revealed a few dominant themes, including traditional versus flexible gender ideology, the sacrificial wife, relationship expectations, the influences of Western culture and communism, problem-solving communication, and spousal support (Goff & Carolan, 2013). The term “sacrificial wife” was used in this study to emphasize the giving nature of these wives and the priority they placed on their families over individual goals (Goff & Carolan, 2013). This study also indicated female graduate international students’ gender role conflict due to the cultural expectation of a subordinate and sacrificial wife role and the choice of spending more time on graduate study (Goff & Carolan, 2013). Another study also found that wives of Chinese international students experienced gender role disruptions, and this disruption negatively impacted their marital satisfaction (Zhang et al., 2011). In Goff and Carolan’s study (2013), they found that the flexibility of gender role was essential in the couple’s adjustment and success that served as a form of relational resilience. Other relational resilience found in their study included utilization of support systems, inner resources, and spouse support to adjust to their new academic environment and maintain healthy relationships.

Attachment and social support. Social support is a relational resilience of MCIS (Goff & Carolan, 2013; Ye, 2006). A study conducted by Ye (2006) in the communication field confirmed that social support, including both interpersonal support networks and online ethnic social support groups, decreased Chinese international students’ acculturative stress and facilitated their attitudinal and emotional changes during the acculturative adjustment process. Another study on Chinese American college students found that the parent relationship was a protective factor against depression for the late Chinese immigrants who arrived the United States after the age of 12, and that both positive parent and peer attachment contribute to these late Chinese immigrants’ sense of coherence (Ying et al., 2007). Other factors, such as relational-cultural influences, have also been shown as correlative to MCIS’ coping.

Relational-cultural factors. Historically, the Chinese government implemented the “one-child-per-family policy” in 1979 to control the country's burgeoning population (Potts, 2006). This generation of only-child students has grown up in an economically and technologically rapid changing society (Edwards et al., 2005). Scholars have been concerned about this new generation of “only-child” Chinese student development. There are inconsistent and contradictory findings regarding the differences of physical, psychological, emotional, and social development between the only-child students and the sibling-students (Chen et al., 2002; Edwards et al., 2005). One study found that sibling-students have more positive perceptions on their psychological health and interactions related to both their physical and home environments than only-child students. Though only children reported higher rate of their perceptions of independence than did sibling students, authors suggested that only children were more likely than sibling students to refuse assistance (Edwards et al., 2005). A study on the impact of sibling status on Chinese college students’ quality of life provided some relational and social-cultural contexts of students who are transitioning from mainland China to the United States (Edwards et al., 2005).

Stressors and Coping/Help Seeking

The third area that scholars have explored relative to MCIS is stressors and these students’ ways of coping and help-seeking preferences (Tsai & Wong, 2012; Yakushko et al., 2008; Yan & Berliner, 2009, 2011a, 2013). A few counselor educators who conducted research on international students have described a need to target research on students from unique countries (Yoon & Portman, 2004).

Stressors. Over the past 5 years, two scholars from the higher education field have conducted a series of studies to examine MCIS’ stressors at academic, personal and social, and individual levels by using Berry’s stress-coping framework (Yan & Berliner, 2009, 2011a, 2011b, 2013). These scholars also summarized the demographic trends, motivations, acculturation features, adjustment challenges, and coping process of MCIS in the United States based on their previous studies. One of their significant findings was that academic stress is extremely high for most MCIS (Yan & Berliner, 2009). Most participants reported that their high academic stress was generated by their internally high motivations to achieve. Other external sources of academic stress were identified as well, such as cultural and educational disparities between China and the United States, language difficulties, lack of effective interactions with U.S. faculty members, and differences in learning styles (teachers’ direct guidance in China and self-directedness in the United States). Personal stressors, job opportunities, visa problems, and immigration concerns were identified as the top concerns for MCIS. Dating and marriage relationships were identified as their concerns as well. In terms of social-cultural stress, it has been shown that MCIS experience high levels of culture shock and adjustment stress (Yan & Berliner, 2009).

Coping strategies. In a qualitative study, MCIS in U.S. graduate programs reported use of strategies, such as endurance, to cope with emotions and seek support from various social support networks, including friends, family, church, and even professional counseling (Yan & Berliner, 2011a). Another study on Chinese and Taiwanese international college students explored their participation in social organizations, such as professional, religious, and informal students groups, and suggested that involvement in social organizations facilitated their problem-solving (Tsai & Wong, 2012). Thus, MCIS may be seeking help using alternative resources other than conventional counseling services.

Help-seeking attitudes and behaviors. Two studies examined the help-seeking attitudes and behaviors of Chinese students. One focused on mainland Chinese students in China (Goh et al., 2007), while another focused on Chinese international students in the United States (Cheung, 2011). The first study showed that mainland Chinese students generally reported positive attitudes toward help seeking (Goh et al., 2007). In particular, female students with higher educational level and students with prior knowledge of counseling or prior counseling contact indicated positive help-seeking attitudes (Goh et al., 2007). In Cheung’s study (2011), though positive help-seeking attitudes were reported, he found that the majority of the Chinese international students studied (including MCIS) chose not to use professional services to deal with emotional and personal distress. Instead, they tended to resolve issues on their own and within their families, or seek support from friends or religious leaders. The results of this study also indicated that students who believed that they could resolve their emotional problems by themselves were more likely to have depressive symptoms and less likely to seek professional help. It was also found that there was a discrepancy between the mainland Chinese students’ positive attitude and their reluctance in seeking professional help.

Research on Asian international students revealed lower utilization of counseling services by Asian international students than other ethno-cultural groups in the United States. Other studies on Chinese international students found evidence of underutilized counseling services despite high rates of depression and anxiety (Cheung, 2011; Han et al., 2013; Wei et al, 2007).

Discussion

The underutilization of mental health resources among international students studying in the United States, particularly among MCIS, is of concern among counselor educators and professional counselors alike. By focusing on international students, the counselor profession as a whole would be afforded the opportunity to expand our application of the Multicultural Counseling Competencies (MCCs) beyond diverse cultural groups within the United States to employ a global understanding of multiculturalism in counseling. Scholars have long asserted that much of what we teach about multicultural counseling is founded upon the unique experiences of culturally marginalized groups within the United States (Han et al., 2010; West-Olatunji et al., 2007). Thus, much of what is known is situated within U.S. socio-political and historical realities. By internationalizing the MCCs, counseling professionals can enhance their ability to serve diverse client populations and create a research trajectory that would mandate collaborative research with scholars outside of the United States, thereby opening a dialogue about multicultural competence that includes lived experiences very different from our own.

Additionally, this focus on international students provides an avenue of clinical service provision and training that is much needed. As the counseling profession continues to develop, new areas of application are constantly being identified. Given the globalization of counseling in various regions of the world, it would be forward thinking for U.S. counselor educators and professional counselors to begin thinking about how to internationalize their curricula and service provision across the various settings.

Recommendations

Based upon the review of the literature on the help-seeking behaviors among MCIS, we recommend three approaches to increasing their propensity to engage in counseling services. They include intentional outreach, peer-to-peer counseling, and support groups.

Intentional outreach activities to the MCIS population could focus on four primary activities: (a) seize opportunities during the adjustment period upon arrival on campus, (b) creation of bilingual handouts, (c) use of culture-centered intentional interactions, and (d) recruitment of other MCIS as volunteers to serve as liaison to the counseling service staff and services. By reaching out to MCIS as they arrive on campus, college counseling staff can provide early monitoring services, educate students about available services, and establish counseling as an integral part of the college experience. In order to offer informational materials to new MCIS, it would be helpful to develop bilingual handouts that help students to feel welcome to the campus and to clarify the nature and structure of counseling services to avoid misunderstandings or misrepresentation. In addition to the use of bilingual written materials, it would be important to ensure that all interactions and communications are culture-centered and responsive to the needs of MCIS. Thus, multicultural counseling training for the college counseling staff is recommended. Finally, use of current MCIS as volunteers to serve as liaisons to new students would be beneficial in developing trust and rapport. Current students can help in the transition, educate students about existing counseling services, validate the benefits of counseling services, and assist with cultural exchanges between university faculty, staff, and students (Han & Pong, 2015; Jacob & Greggo, 2001; Yi et al., 2003).

Peer-to-peer counseling can serve as a two-fold intervention. First, peer-to-peer counseling can empower current MCIS to become involved in campus activities and help others in the process. For new MCIS, peer-to-peer counseling can ease the transition from home to the U.S. campus and help to develop relationships in the new environment (Zhan, Liu, Wang, & Shang, 2014). Additionally, peers can better serve as helpers in navigating the new culture. Entry level counseling issues, such as homesickness, acculturative stress, and academic concerns are of paramount concern for this student population (Hayes & Lin, 1994; Yan & Berliner, 2009, 2011b; Ye, 2006).

Finally, support groups led by current MCIS can help college counseling staff to partner with student organizations. By collaborating with Chinese student organizations, various on-campus and online support groups can be formulated for MCIS to meet their academic and emotional needs. University faculty and staff can employ advocacy efforts to assist student groups to develop workshops and seminars to assist students in helping themselves. Examples of theme-based seminars and support groups include Emotion Expressiveness, Behavior Labeling, Healthy Coping Strategies, and Growth Groups (Chien, Thompson, & Norman, 2008; Kwok & Ho, 2011; Lo, 2010).

Future Research

Particularly, for the fast growing MCIS in the United States, more research needs to be conducted to better understand the strengths and coping skills of MCIS. Additionally, research exploring their patterned use of counseling services from an ecosystemic perspective is needed in order to provide effective and culturally competent counseling services to meet their needs. Specifically, research can be conducted to explore the relationship among acculturative stress, attachment style, and coping style of MCIS.

In sum, current literature on MCIS provides groundbreaking knowledge about acculturation issues, identity development, relationship issues, sources of stress, coping strategies, and help-seeking preferences. Most of the studies focused primarily on graduate students. Only three studies in this literature review on Chinese international studies were focused primarily on undergraduate students. This literature review found insufficient research on mainland Chinese international undergraduate students and particularly the experiences of male students. An inspirational finding is that counselor educators have been conducting fruitful research on general international counseling in the past 30 years (Yoon & Portman, 2004; Yakushko et al., 2008). They have provided sufficient examples and suggestions to conduct research on students from unique countries (Yakushko et al., 2008; Yoon & Jepsen, 2008; Yoon & Portman, 2004; Zhang & Dixon, 2003).