Supporting International Students

The number of international students enrolled in postsecondary education in the United States continues to increase (Institute of International Education [IIE], 2018) as higher education embraces the notion of a diverse campus with global impact. Research supports this trend as the diversity international students bring to college campuses enhances the learning experience (McMurtrie, 2011) and provides opportunities to help faculty and students develop their cultural sensitivity and awareness. Additionally, an international presence on college campuses potentially promotes developing the academic curriculum for diverse populations, establishing networks for future recruitment, and developing global diplomatic relationships (Arthur & Flynn, 2011). It is also important for colleges to attract international students to remain competitive, adapt to global challenges (IIE, 2016), and create a pipeline to recruit highly skilled workers (Alberts, 2007). Furthermore, international students’ financial contribution through their tuition fees and living expenses benefits the U.S. economy. Approximately 67% of international students receive financial assistance from outside the United States, and it is estimated that international students contributed $36.9 billion to the U.S. economy in 2016 (National Association of Foreign Student Advisers, 2017).

Despite their contributions to the U.S. economy and higher education, international students face unique challenges in adjusting to their new circumstances. The struggles include, but are not limited to, language barrier, unfamiliar living conditions, cultural differences pertaining to academics, and different systems of customs and values (Hotta & Ting‐Toomey, 2013). Notably, international students report higher levels of distress than their U.S.‐born counterparts (Hechanova‐Alampay, Beehr, Christiansen, & Van Horn, 2002). Moreover, international students in the United States have been affected by changes in the political climate, particularly after the terrorist attacks on September 11, 2001 (Starobin, 2006), when an additional security system, the Student and Exchange Visitor Information System, was implemented to scrutinize international students and visiting scholars, resulting in the first decrease (by 2.4%) in enrollment of international students since 1949 (Chin & Gallup‐Black, 2004). Even years after 9/11, international students reported experiencing challenges based on the atmosphere of distrust toward individuals from different countries (Sümer, Poyrazli, & Grahame, 2008), which marginalizes this population with additive stressors.

Nonetheless, international students use mental health services less than domestic students in the United States (Russell, Thomson, & Rosenthal, 2008). Yakushko, Davidson, and Sanford‐Martens (2008) found that only 1.8% of enrolled international students used college counseling services during a 5‐year period. Similarly, Hwang, Bennett, and Beauchemin (2014) examined the 5‐year utilization rate of counseling services by international students and found significant underutilization in all but 1 year. Even when international students sought professional help, they reported higher levels of premature dropout than their U.S. counterparts (Yakushko et al., 2008), and approximately 33% to 70% of international students terminated their treatment after the initial sessions (Yakushko et al., 2008). Research also indicates that international students’ underutilization of mental health services may be ascribed to various cultural‐related factors, including the tendency to seek help from informal sources (e.g., family and friends; Tsega, 2014), stigma related to utilization of mental health services (Mendoza, Masuda, & Swartout, 2015), and lack of language proficiency (Sentell, Shumway, & Snowden, 2007).

Despite distinctive challenges and unique mental health needs, there is a dearth of literature regarding effective approaches to support international students (Spooner‐Lane, Tangen, & Campbell, 2009). Intervention on both an individual and a systemic scale is imperative to support international students who are marginalized and underserved. Therefore, this article aims to explore effective ways to support international students by increasing college counselors’ multicultural and social justice competence to address this issue. Specifically, this article (a) describes international students’ difficulties in the United States, (b) informs college counselors about how to provide appropriate services for international students, and (c) presents guidelines to enhance international students’ psychological health. An overriding goal is to enhance international students’ overall well‐being and facilitate a trustworthy counseling environment wherein students are afforded culturally responsive mental health services.

International Students’ Challenges in the United States

The United Nations Educational, Scientific and Cultural Organization (n.d.) defines international students as “students who have crossed a national or territorial border for the purpose of education and are now enrolled outside their country of origin.” As international students integrate their cultural identity into the dominant U.S. culture, they experience unique challenges that contribute to their marginalization and threaten their overall well‐being. Examples of the challenges they face include language barrier (Constantine, Kindaichi, Okazaki, Gainor, & Baden, 2005), lack of social support (Zhang & Goodson, 2011), psychological difficulties (Sümer et al., 2008), acculturative stress (Hamamura & Laird, 2014), and overwhelming pressure for academic achievement (Zhang & Goodson, 2011). The majority of international students experience homesickness and financial concerns that lead to adjustment difficulties (Spooner‐Lane et al., 2009). In addition, cultural differences and lack of social support are found to be associated with international students’ psychological well‐being. For example, international students with limited social support showed higher levels of depression and anxiety compared with their peers with more social support (Misra, Crist, & Burant, 2003).

International students identify insufficient language proficiency (Constantine et al., 2005) and social/cultural factors (Zhang & Goodson, 2011) as some of their primary difficulties in academic adjustment. A study examining Chinese female students’ academic success identified language barrier as a significant predictor of academic failure (Lowinger, He, Lin, & Chang, 2014). Additionally, international students with low levels of English proficiency exhibited higher levels of depression and anxiety and lower levels of self‐efficacy (Sato & Hodge, 2009; Sümer et al., 2008). Furthermore, several social and cultural factors contribute to the struggles that international students experience. An absence of social support (Zhang & Goodson, 2011) and differences in values between their cultures of origin and U.S. culture (Lee & Carrasquillo, 2006) may negatively affect international students struggling to adapt to the cultural norms of the academic environment. For example, Ng, Haslam, Haslam, and Cruwys (2018) explored international students’ social identity change in adjusting to the United States and found that cultural differences were a significant barrier to the students forming meaningful friendships and social connections. One international student participant explained, “For my new friends here, because we don't know each other deep, you do not know how they think, how is the way they ask each other. Just, for me, I just always scared that I'll say something wrong” (Ng et al., 2018, p. 178). Although international students may have acquaintances, meaningful social connections are far less common. Collectively, the aforementioned findings suggest that English proficiency and social support could be critical factors in international students’ adjustment to their education in the United States.

Numerous studies have reported distinctive challenges that international students experience. Despite the unique mental health needs and marginalization of international students, a paucity of literature exists regarding how to effectively support the students (Spooner‐Lane et al., 2009). Therefore, customized programs and support services for international students are of critical importance to create an environment in which they have a fair chance of succeeding (Gribble, 2014). To better serve this population, the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts, Singh, Nassar‐McMillan, Butler, & McCullough, 2015) framework provides essential information.

The MSJCC

The MSJCC (Ratts et al., 2015) underscore the facilitation of individual‐ and systemic‐level changes to maximize the well‐being of clients. Incorporating individual counseling with advocacy work is the cornerstone of addressing the problems that marginalized or underserved clients (e.g., international students) bring to counseling (Ratts et al., 2015). Specifically, the MSJCC emphasize the ability of counselors to develop four competencies for working effectively with clients: (a) attitudes and beliefs (self‐awareness), (b) knowledge, (c) skills, and (d) action (Ratts et al., 2015).

Counselors should critically examine their attitudes and beliefs about their own culture by continuously reflecting on their cultural values, heritage, and privileges. Continuous self‐reflection allows counselors to be aware of not only the values and privileges they possess as a cultural being, but also how a variety of sociocultural factors influence individuals’ psychological experience and behaviors. In addition, counselors must develop cultural knowledge of the experiences and worldviews of clients from different backgrounds. Specifically, counselors need to increase their awareness of how various sociocultural factors influence clients’ life experience and well‐being, as well as understand the way these factors shape clients’ help‐seeking behaviors (Ratts, Singh, Nassar‐McMillan, Butler, & McCullough, 2016). Particularly, understanding cultural differences in help‐seeking behaviors and the expectation for mental health services can improve the quality of culturally responsive services for diverse clients (Abdullah & Brown, 2011).

Counselors should be equipped with relevant skills to engage clients in discussion of cultural factors and their potential impact on psychological well‐being. Mental health professionals with sufficient cultural competency are able to guide clients in reflecting on the impact of cultural factors and identify interventions that help clients develop healthier self‐image and/or behaviors in a way that aligns with their culture (Ratts et al., 2015). Furthermore, multiculturally competent counselors are able to take action for systemic‐level changes that maximize clients’ well‐being. Advocacy works to address systemic issues (e.g., health disparities, access to resources, cultural stigma of mental health service) in the community by enhancing clients’ help‐seeking behaviors and allowing for more safe and affirmative counseling environments for all clients. In sum, mental health professionals need to improve the four competencies (i.e., attitudes and beliefs, knowledge, skills, and action) together to better serve diverse needs of their clients. In this article, therefore, we discuss these four competencies as a framework for college counselors working with international students. In the following sections, we offer information on (a) how to build affirmative attitudes and beliefs (Competency 1), (b) multicultural knowledge that is vital to counseling effectiveness with international student clients (Competency 2), (c) skills relevant to addressing unique needs of international students throughout the counseling process (Competency 3), and (d) specific recommendations for college counselors and actions that can be taken at a systemic level to maximize international students’ well‐being (Competency 4).

Competency 1: Attitudes and Beliefs

Developing a reflective attitude toward one's own culture is the cornerstone of the MSJCC, shaping counselors’ perception of the therapeutic relationship with clients (Wong‐Wylie, 2007). The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) Standard 2B states that counselors should be able to “reflect current knowledge and projected needs concerning counseling practice in a multicultural and pluralistic society” (p. 10). Thus, having intentional opportunities to reflect on their cultural attitudes and beliefs and cultivate multiculturally competent attitudes is of particular importance.

One way to reflect on self, clients’ worldview, and cultural difference is using the cultural auditing process (Collins, Arthur, & Wong‐Wylie, 2010), a reflective‐focused practice that applies different questions depending on the stage of counseling sessions. At the initial stages, example questions include “What are my initial reactions to this client, and what do these tell me about my own beliefs, values, and assumptions?” and “How might my prior history of working with clients from a similar cultural group affect my working with this client?” (Collins et al., 2010, p. 343). At the working stages, example questions counselors can use are “What are the potential cultural influences on how I view desirable change made by clients?” and “What are the important indicators in the client's cultural context that demonstrate how counseling has made a difference in her or his life?” (Collins et al., 2010, p. 343). On the basis of these questions, counselors may keep journals in which they reflect on their own attitudes and beliefs and how their perception affects their relationship with clients.

Competency 2: Multicultural Knowledge for Working With International Students

Multicultural and socially conscious counselors should possess relevant knowledge regarding the impact of multiple cultural factors on clients’ worldviews, life experience, and behaviors. With the recognition of unique challenges faced by international students, counselors need to develop knowledge of how cultural factors shape these students’ help‐seeking behaviors toward counseling services. Even though the mental health needs of international students are increasingly recognized, these students are less willing to use mental health services compared with domestic students (Hyun, Quinn, Madon, & Lustig, 2007; Russell et al., 2008). Soorkia, Snelgar, and Swami (2011) noted that cultural factors might play a role in international students’ decision‐making related to utilization of mental health services. Therefore, the following sections present information regarding how cultural factors influence international students’ help‐seeking behaviors and advise college counselors and institutions on ways to reduce the discrepancy between mental health distress and help‐seeking behaviors in international students.

Ethnocultural Influence on Help‐Seeking Attitudes

International students perceive their cultural values as a factor that hinders them from seeking mental health services. Studies indicate that when international students identify strongly with their ethnic‐based culture, they are less willing to use mental health services (Soorkia et al., 2011). Specifically, greater identification with their tribal culture is negatively related to attitudes toward using counseling services (Li, Marbley, Bradley, & Lan, 2016). Instead, international students show preference for asking help from family members or friends rather than mental health professionals (Kahn & Williams, 2003). Additionally, international students from a culture in which traditional health beliefs are prevalent are less likely to use counseling services that are based on Western medical models of mental health care (Rothstein & Rajapaksa, 2003). For example, individuals from Indian and Chinese cultures consider family and friends to be critical sources of health‐related knowledge (Rothstein & Rajapaksa, 2003), which influences their attitudes toward seeking professional psychological help. Therefore, taking these different factors into consideration when promoting international students’ help‐seeking attitudes is warranted.

Stigma Related to Mental Health Services

Negative perceptions of mental health services prevent international students from seeking professional help (Mendoza et al., 2015). For example, Mendoza et al. (2015) conducted a study on Latina/o college students in the United States and found that their overall help‐seeking attitudes were predicted by the presence of mental health stigma. In addition, international students display limited awareness of their need for mental health services compared with their U.S.‐born counterparts, and this lack of awareness can govern their initiative to seek professional help. Furthermore, research indicates a negative relationship between mental health stigma and the recognition of personal need for professional psychological services (Mendoza et al., 2015). Overall, researchers have identified mental health stigma as a fundamental obstacle to accessing mental health services for international students (Hyun et al., 2007).

Insufficient Language Proficiency

English language proficiency is considered a major barrier to mental health services for many international students (Li et al., 2016; Sentell et al., 2007). For example, Sentell et al. (2007) reported that limited English proficiency discourages international students from seeking counseling services because of the anticipated challenges communicating with counselors. Although use of interpreters in counseling may be beneficial for international students, concerns about confidentiality may contribute to their hesitation to seek counseling services (Tung, 2011).

Lack of Knowledge About Mental Health Services

Another cultural factor affecting international students’ help‐seeking behaviors is insufficient knowledge about mental health services (Russell et al., 2008). Roberts and Dunworth (2012) indicated that international students have difficulty accessing information regarding the availability of mental health services offered by universities or colleges, which highlights the importance of informing international students about the availability of support services on college campuses. In Russell et al.'s (2008) study on international students’ utilization of college counseling services in Australia, participants reported that they did not use counseling services because of insufficient understanding of their problems, lack of information about services, and doubts and discomfort about using the services. Increasing awareness of mental health services will expose international students to information they can take advantage of, such as going to college counseling centers when they need the services. These findings underscore the necessity to take these factors into consideration when developing an approach for international students to seek help.

Competency 3: Multicultural Skills and Interventions in Session (Individual Level)

Simply possessing cultural self‐awareness and knowledge would be insufficient for working with diverse clients unless transferred to demonstrable skills and interventions in practice (Ratts et al., 2015). Counselors must operationalize self‐awareness and knowledge by addressing cultural factors in the counseling processes (e.g., initiating meaningful dialogues with clients about their cultural challenges, engaging clients in reflecting how the culture or system influences their well‐being).

One effective technique to addressing cultural factors in the counseling process is broaching, defined as “a consistent and ongoing attitude of openness with a genuine commitment by the counselor to continually invite the client to explore issues of diversity” (Day‐Vines et al., 2007, p. 402). Although broaching is important in all counselor–client relationships, addressing diversity is imperative when working with international students because culture permeates nearly all of their lived experiences. Broaching requires warmth, empathy, positive regard, openness, and genuineness on the part of the counselor. Discussing differences in culture between counselors and clients is an important step in the counseling process. However, broaching also involves exploring issues of bias and discrimination openly and without resistance. For example, an international student facing racial profiling in the classroom may be reluctant to speak with a college counselor employed by the same institution. A college counselor who immediately tries to reframe the situation will risk invalidating the student's perspective and damaging the therapeutic alliance. Therefore, counselors should seek to explore the issue and subsequent feelings experienced by the student before developing empowerment strategies (Day‐Vines et al., 2007).

Given that international students commonly experience similar stages of adjustment, counselors might want to deliver their skills and interventions in line with the stage of the students’ adjustment. One of the initial models explaining the adjustment stages of international students is the U‐curve model of adjustment (Gullahorn & Gullahorn, 1963; Lysgaand, 1955). Although several researchers have proposed revised versions of the model (e.g., Adler, 1975; Oberg, 1960), the basic components of the model describe the level of adjustment in the following stages: (a) honeymoon period, (b) culture shock, (c) adjustment, and (d) mastery. In the first stage, the honeymoon period, individuals feel initially excited about the new environment and find the new culture fascinating. The second stage, culture shock, is when individuals notice negative aspects of the new culture and display a range of negative feelings, including frustration, sadness, depression, and anxiety. The third stage, adjustment, is characterized by individuals finding ways to follow the norms of the host culture. The fourth and final stage is mastery, in which individuals function effectively in the new environment. Although the model has been criticized for failing to explain the underlying causes of challenges in adjustment, to distinguish different populations such as students and immigrants, and to describe the adjustment process in depth (Thomas & Harrell, 1994), it provides a distinct guideline of the processes student sojourners commonly experience.

To better serve international students, college counselors can follow the suggested curriculum based on the students’ stage of adjustment. In the honeymoon stage, counselors can assist international students by providing psychoeducation regarding common adjustment experiences. Normalizing experiences like homesickness and the academic demands of college can instill hope that adjustment is a process that will get easier with time. In addition, developing coping strategies that are conducive to the students’ new environment is crucial. For instance, international students might not have adequate social support when faced with difficult situations in the United States. Example questions counselors could ask include “What are the things that you like and dislike about studying here?” and “What are the coping strategies you use?” Counselors can help students develop a plan to explore different social groups (e.g., sports teams, student government) to determine the environment that best suits their interests and help students connect with their peers.

In the culture shock stage, counselors can provide international students with opportunities to explore the differences between their home country and the United States to enhance their awareness of the difficulties and brainstorm strategies to address problems. During the counseling session, counselors should validate the students’ experiences and encourage them to learn ways to handle negative emotions (e.g., relaxation skills). Example questions include “What is the most difficult things for you here?” and “What works for you and what does not in addressing your difficulties?”

Even during the adjustment stage, international students may still struggle with certain situations. Establishing coping strategies, including journal keeping and book reading, may further promote well‐being (e.g., see Cohen, 2005; Lipson, 2008). To explore the challenges students face and help them navigate the situation, counselors may ask “When do you feel stressed?” and “What coping strategies have worked and what have not?” Finally, in the mastery stage, making a wellness plan, which includes physical, mental, and social wellness, would provide a chance for the students to balance their lives in the long run. Example questions at this stage include “What are the things that may cause you difficulties?” and “How do you maintain your wellness? Which area would you like to work on more?” Overall, utilizing different approaches based on the client's needs is essential.

Competency 4: Actions for Systemic‐Level Change

Culturally competent counselors are called to address their clients’ psychological well‐being inside and outside of the counseling session. Therefore, college counselors are called to advocate for systemic‐level change both at the university level and at the college counseling center level and provide outreach specifically tailored to international students. In this section, we discuss common challenges international students face and subsequent supports to promote their mental health.

Institutional Level

Difficulties international students commonly experience in the United States include language barriers (Constantine et al., 2005), social isolation (Kaczmarek, Matlock, Merta, Ames, & Ross, 1994), academic adjustment (Constantine et al., 2005), psychological difficulties (Sümer et al., 2008), and cultural stigma associated with mental illness (Hyun et al., 2007). Therefore, it is imperative for university counseling centers to consider ways to support international students at the institutional level. For example, contacting other university organizations (e.g., Office of International Scholars and Students, Office of New Student Orientation) to find ways to help international students, such as helping them navigate financial aid and partnering with the international student center, would maximize the counselor's role to advocate for the students. Furthermore, counselors need to ask administrators, policy makers, and faculty to prompt the following changes to address international students’ difficulties.

Language barriers. Although demonstrated English‐language proficiency is a common prerequisite for university admission, fluency requires years to develop. Thus, additional supports are essential for both international students and faculty who work with multilingual students. Academic writing centers with tutors specifically trained to work with multilingual students can help students feel more confident and supported as they find their academic writing voice. Additionally, workshops for faculty through university centers can help increase support for and understanding of the unique stressors international students face in the classroom. Benz, Kinyon, Leake, and Schonberg (2014) provide specific resources and guidelines for instructors to respond to the writings of international students. Tips include considering cultural differences in rhetorical construction, allowing students more time when necessary for writing assignments, beginning feedback with larger issues as opposed to minor grammatical problems, and identifying grammatical patterns as opposed to all errors in a paper.

Social isolation. Mentoring programs can assist international students as they transition to American culture. U.S.‐born students who are interested in learning about other cultures can volunteer as cultural mentors and support international students as they navigate through campus resources and the surrounding university environment. For example, universities can create a mentoring program in which mentors (i.e., domestic students) and mentees (i.e., international students) can participate in one‐to‐one mentorship meetings every other week or in social activities. Regular mentorship communication can promote social connection and protect against loneliness and homesickness. Additionally, social events in which international students are invited to share their culture through food and tradition (e.g., international food festival) can provide opportunities for peer connection between international and domestic students.

Academic adjustment. Regular appointments with academic advisers provide international students with an opportunity to discuss challenges they may be facing, allow for further contact with faculty, and present an avenue for identifying academic resources the students may not yet be familiar with. Orientation workshops are essential in preparing international students for the expectations of the academic curriculum in the United States. Inviting a panel of international students who are further along in their academic studies to share their perspectives on how to succeed in the academic setting can help newer international students identify potential difficulties and strategies to work through them. In addition, institutions could benefit from providing international students with English‐language support courses that focus on academic contents related to their field of study.

Psychological difficulties and mental health stigma. International students have varying perceptions of mental health and stigmatizing beliefs about mental health services. Mental health literacy (Jorm et al., 1997) provides a useful framework in orienting international students to mental health. An online workshop designed to increase knowledge of common mental health concerns and available mental health services and to decrease mental health stigma can encourage international students to seek professional help if they face a mental health crisis or need additional support during their time in the United States. Counselors can contact administrators or policy makers and ask for inclusion of the workshop in a web‐based educational platform (e.g., Blackboard or Canvas) to enhance its availability to more students. Additionally, mental health outreach initiatives can increase visibility of mental health services. For example, an event (e.g., Let's Talk About Depression Day) can promote students’ awareness of depression, suicide, and related services. College counselors can host a yearly event (e.g., International Students Well‐Being Day) to screen international students for causes of mental health difficulties. In these events, counselors can provide a battery of brief assessments that focus on symptoms of mental illness (e.g., depression, anxiety). To encourage students to participate, counselors can collaborate with instructors to promote the event, such as by offering extra credits to students who attend the event.

College Counseling Center Level

Despite the unique mental health needs of international students, a limited number of students seek helping resources (Constantine et al., 2005; Russell et al., 2008). To increase utilization, college counselors must engage in advocacy for systemic changes.

Language barriers. One of the stressors international students experience is language proficiency (Constantine et al., 2005). This can also affect their willingness to use counseling services because the difficulty to express their emotions is exacerbated by speaking in a second language. Hiring bilingual/multilingual counselors may encourage international students to seek professional help when needed and convey the message that college counseling centers are inclusive centers of support. In addition, college counselors can employ professionals from different counseling centers part time, or have them rotate in different counseling centers to meet the needs of international students at multiple universities.

Social isolation. To create more opportunities for international students to socialize in the United States, college counselors can present practical information and promote volunteer programs. For example, volunteer programs with different purposes, such as visiting nursing homes or helping homeless communities, may satisfy the needs of both international and domestic students to help people while making friends with each other. Counselors can serve as facilitators who promote the building of support systems among students and encourage self‐exploration as cultural beings. Additionally, counselors can introduce an array of topics for discussion among the students, including cultural barriers, language concerns, and religious diversity.

Psychological difficulties and mental health stigma. College counseling centers can promote international students’ well‐being by addressing their psychological difficulties and reducing stigma related to mental health. Mental health centers can offer different types of psychological testing that are not directly related to mental health issues to expose international students to the services in the counseling centers, such as personality tests, interest tests, and career aptitude tests. Offering these other services may encourage international students to start utilizing the services in the centers and learn what other resources they can use in the future. Furthermore, presenting a range of group counseling programs based on different languages and specific fields may be helpful. For example, starting a counseling group particularly for international students or a group in Spanish or another language would be beneficial to international students. Finally, college counselors and course instructors can collaborate to increase international students’ awareness of challenges and mental health needs in classrooms. Counselors can visit as a guest lecturer to conduct a workshop for students about the unique and diverse views on mental health and enhance the students’ understanding about the nature and benefit of mental health services.

Conclusion

International students face myriad challenges adjusting to the academic and cultural environment in the United States. They experience distinctive stressors because of cultural differences, concerns about the stigma of mental health, and limited language proficiency. These stressors may work as obstacles to seeking necessary help from mental health professionals. Thus, it is important for universities and counselors to promote international students’ help seeking and increase their willingness to use counseling services by taking several factors into consideration and implementing actions based on students’ needs, which would eventually improve their mental health. To achieve this goal, college counselors must enhance their multicultural counseling competency to effectively serve this population, and universities need to implement proper approaches for strengthening international students’ willingness to use available mental health services. Achieving this goal can lead international students to improve their sense of psychological well‐being, which may result in a better academic outcome and social life for all students.