In Higher Ed’s Mental-Health Crisis, an Overlooked Population: International Students

It’s like a garden, Muyi Li remembers thinking when she first walked on Emory University’s campus, in 2016. Among the tall trees and stark, white buildings, she says she felt hope for her first day of classes, her first time living alone — for her future.

Ms. Li grew up in Beijing among tall, crowded buildings and busy rivers of people. Coming to Emory was like taking a trip to the country. The campus was warm and sun-soaked, and she loved it.

She packed only two suitcases for her first semester: one for clothes and one for everything else. She didn’t do much decorating in the little, yellow dorm room she affectionately calls cozy. She hung a single strand of flamingo lights beneath her lofted bed, and placed on her nightstand a photo of her and friends in costume at a high-school production of Beauty and the Beast.

The photo is one of her very few mementos from Beijing, but it was something she would turn to often in the coming months when she missed home.

As the homework assignments and projects piled on, Ms. Li began to feel stressed. She describes it as an immobilizing need to do everything at once. She felt guilty at not having finished projects even as she worked on them. As her anxiety mounted, she began to feel trapped.

“I felt this incessant strand of guilt and anger about myself, like I was failing myself if I kept feeling this way,” Ms. Li says. “I was not doing well in class, I wasn’t talking to anyone, and I felt that there was no way out — that it was really hopeless.”

In the coming months she would begin to feel dizzy, and she says a heaviness weighed on her. Though she is fluent in English, she would watch her professors speaking in class without comprehending what they said, as though it were a dream. Worse, she says, was her memory loss.

“What scared me the most were my memories,” Ms. Li says. “I couldn’t remember the thing that happened one day before when I woke up in the morning. I was like a new person every day, but that was horrifying.”

Later that year Ms. Li found that those experiences were symptoms of clinical anxiety and depression, with which she was diagnosed. Stories like hers are not uncommon among international students.

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Though it’s now more widely accepted in the United States that college students are at a high risk of experiencing chronic mental illness, some students are more at risk than others. Nonwhite students, data show, are more likely to suffer depression than are their peers, and are often less likely to seek help, according to the Healthy Minds Network, a web of researchers, primarily at the University of Michigan at Ann Arbor, who study mental health in adolescents and young adults.

For international students, a newfound minority status can combine with the isolation of a new culture, expectations from home, and a mandatory full course load — all in what is often a second language — to produce mental illness.

American colleges and universities have safety nets for students with mental illnesses. Advisers, professors, counselors, and administrators all play roles in ensuring students find the help they need.

But for students from cultures that see mental illness as a fiction or a sign of weakness, asking for help can mean inviting their culture’s stigma. The job of those holding the safety net can become, in cases of international students, not only to identify the symptoms of mental illness, but also to help a student understand that the illness is real — and treatable.

Seeing Signs of Distress

The first line of defense Ms. Li encountered was Frank Gaertner, associate director of academic advising at Emory. Before students arrived last year, Ms. Li was added to a group-messaging app that Mr. Gaertner uses to answer students’ questions.

Mr. Gaertner would send stickers with funny faces in the chat, and learned all of the students’ names before they set foot on the campus. He was not, Ms. Li says, what she thought an academic adviser would be.

Mr. Gaertner, who has worked at the university for 25 years, says he wants students to feel as if they already have someone at Emory who wants to know them. He became interested in Korean culture during work on his doctoral thesis, on identity development in Korean-Americans.

He says that when he began learning about the intricacies in spoken and unspoken Korean traditions, he “fell in love.” Since then, he’s sought out ways to use his knowledge of Korean culture to make international students feel welcome.

When they arrive on the Georgia campus, Mr. Gaertner sets up regular meetings with his students to make sure they’re settling in and to keep an eye on them.

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Advisers are some of the first people to notice signs of stress among their students, and Mr. Gaertner says he sees them often. “It’s much more than I ever would have guessed,” he says.

For students who do not suffer from mental illness, the stress of college is problematic. But for those suffering from conditions like depression or anxiety, the stakes can be higher.

The National Institute of Mental Health has identified 10 primary risk factors for suicide, including depression and chronic pain. The institute says around 90 percent of people who die by suicide have experienced at least one of those risk factors.

Paul T.P. Wong, founding director of the graduate program in counseling psychology at Trinity Western University, in Canada, wrote in a 2013 article that the stressors of being an international student act as risk factors, too. Those risk factors, he wrote, can exacerbate the symptoms of people with depression or anxiety. Students like Ms. Li.

The signs of a student in distress are subtle, but Mr. Gaertner watches for them. Sometimes it’s something out of character about their physical appearance — unkempt hair or sweatpants, for example, on students who pride themselves on looking professional. But often, he says, their eyes give it away.

“When I talk to them and look at their face, there’s a sadness I can see that’s hard to describe,” Mr. Gaertner says. “That, to me, is usually the sign.”

Before referring them to the counseling center, he asks a few questions to see if they are willing to talk. Some students don’t need counseling, he says; they just need someone to listen.

A ‘Vicious Circle’

Though no two students’ stories are the same, similarities crop up in international-student counseling, according to many of the advisers and therapists who spoke to The Chronicle.

The first is the language barrier. Many international students have never faced situations in which everyone speaks native English, making classes and social life difficult for even the most proficient English speakers. “It’s not just about words, about sentences and grammar and stuff,” Ms. Li says. “It’s about what kind of persona you display through your language.”

If students seek refuge from their second language among other international students from home, they don’t practice English, which can lead them to fall behind in their studies.

Slipping grades are another source of distress. International students often have been preparing for college for years. Ms. Li and her parents made the decision to apply to American colleges when she was 13. Failing would mean the death of a long-held dream.

Marie Whalen, associate director of international admissions and recruitment at Whitworth University, in Washington, says those expectations come from families, too. “Sometimes the problems students encounter are because they have extremely unrealistic expectations of themselves or from their families,” she says. “Maybe they were the star student in their school, and they were supposed to come out with straight A’s, and it doesn’t happen.”

Mr. Gaertner says many students are afraid to tell their parents when they feel overwhelmed, afraid to disappoint or worry them. Those expectations, he says, form a “vicious circle” of compounding pressures. Advisers like Mr. Gaertner and Ms. Whalen can sometimes help relieve that stressor. Ms. Whalen says some students are in a major that doesn’t suit their talents, or are taking too many hard courses in one semester. In those cases, advisers can guide the student to a more manageable course load.

But students suffering from mental illness don’t need to speak to advisers; they need counselors. All too often, however, international students feel they can’t go.

Ms. Li says having a mental illness in her culture means that “you almost must have a kind of flaw in your personality — if a person is depressed, then this person must be weak.”

Mr. Gaertner says sometimes he can’t persuade students who know they need help to come to his office because they fear other international students will see them and tell friends or family members back home.

He walks a thin line. If he becomes known as more counselor than adviser, students may be reluctant to visit him. The solution, he says, is to befriend as many students as he can, to speak to everyone and, hopefully, maintain the trust he has built with students who need him most.

James Dorsett, director of the Office for International Students and Scholars at Michigan State University, faces a similar situation.

“If they’re not going to anybody else, but they’re talking to us, we try to get them back and check in on them as often as we can,” Mr. Dorsett says.

When students do agree to counseling, Mr. Dorsett, like the advisers at Emory, helps them make appointments so he knows they will go to counseling. Often he refers students to Grace Hung.

The Language of Self-Care

Sometimes, says Ms. Hung, a psychologist specializing in international students at Michigan State’s Counseling Center, her biggest achievement with students is simply helping them understand their condition is real.

When Ms. Li was in high school, she took an AP Psychology course. A section focused on abnormal psychology. “I remember reciting the terms and their definitions, and thinking those things were really remote from me,” Ms. Li says. “I was experiencing a few of them not even a year later.”

Ms. Hung says she often explains what the body does under duress. Physical symptoms are easier to believe in than mental ones, sometimes. “I just let them know what their brain is doing in times of stress,” Ms. Hung says. “What does that mean for their body? Or their focus? For their sleep and their appetite? Giving them education on what this all means tends to help.”

Once they understand, she says, it becomes much easier for them to open up about what they feel. Another successful tactic is framing counseling as an American custom, she says.

“Sometimes I say to them, ‘You know, you’re in the U.S., this is what people do to figure out problems. Why not, as a cultural experience, try the American way to do it?’” she says.

Ms. Hung focuses on international students, in part, because she was once one herself. To some students that is a deterrent; she says they fear she will judge them as might their friends and family members back home.

But for a majority of Chinese students, being able to speak about their feelings in Mandarin helps them better connect to the root of their problems. “We know language shapes how we think and the emotions that we experience, or how we talk about emotions, so I think this is a big piece of it,” Ms. Hung says. “I’ve had students tell me before, ‘I’ve seen English-speaking therapists, but it just doesn’t feel real when I talk about it in English, so I wanted to talk about it in Mandarin.’”

Emory lacks a Mandarin-speaking therapist, but Ms. Li says the feeling is familiar. “It wasn’t hard for me to put my thoughts into English, but I felt a little dissociated from myself,” she says. “It’s like the person who was speaking English was not really me, and the person who was speaking English was not really the person who was feeling all my feelings.”

This summer, when she returned to Beijing, she was able to speak with a therapist in Mandarin, and says she could talk about herself and hear what the counselor recommended without dissociation. For the first time, she says, she felt as though the treatment was getting through to her.

Jane Yang, associate director of outreach programs at Emory’s counseling and psychological services, who is Korean-American, says she sees something similar in her students. “When Korean international students hear they can meet with a provider who can speak Korean, it’s something that is very powerful,” she says.

But few colleges and universities can afford to offer a counselor in every language. In fact, many institutions can barely accommodate students’ demand for mental health care. The Center for Collegiate Mental Health’s 2015 annual report said that over the previous five years the number of students seeking such services had increased by 29.6 percent, on average, whereas overall enrollment had increased by only 5.6 percent.

Funding for campus mental-health care has also not matched the growth in need. The demand means many students wait weeks to see therapists — Ms. Li waited two weeks for an appointment at Emory — but it also means that colleges struggle just to provide care to students, much less the specialized or multilingual care that can help international students.

There sometimes isn’t a Ms. Hung or Ms. Yang. Often there isn’t a Mr. Gaertner. But there is almost always a Ms. Li.

At Fort Hays State University, in Kansas, there are no multilingual therapists, but Gina Smith, director of the counseling center, the Kelly Center, says international students and their mental health are still a priority.

“What we’ve tried to do is make ourselves visual outside of the center,” Ms. Smith says, speaking of the orientations and group outings in which counselors participate.

The center also provides “multicultural training” for counselors and hosts events for international students. The Kelly Center often invites graduate students to help counsel undergrads.

Fort Hays doesn’t have the budget of larger colleges, but it also doesn’t have the wait times. “We’re doing the best we can,” Ms. Smith says.

Demystifying Counseling

Some students perceive therapists as emergency-care workers — seen only in dire circumstances. Counselors participate in orientations and student-group activities, she says, to show students that counselors are there as guides too.

Back at Emory, Mr. Gaertner also is learning about the cultures of his students in order to more easily relate to them.

Last year he took an introductory course in Korean, and began using a few of the words in his meetings with Korean students. One, he says, had clinical depression, but every time Mr. Gaertner would use a Korean word, the student’s face would light up.

Minho Cho, a finance major from Seoul, South Korea, says Mr. Gaertner is now the “go-to person when things are going wrong,” in part because he has taken such an interest in their lives and cultures.

“However they can be demystified about counseling will help all students, but particularly international students,” Mr. Gaertner says. “It’s everyone’s responsibility to some degree. I don’t mean everyone needs to be a counselor. But I mean faculty and staff and other international students and domestic students need to be willing to ask questions, to reach out if they see a student in distress, and then help connect students to resources.”

It’s simple, he says; you just need to care.

As for Ms. Li, things are now better. Packing for her sophomore year at Emory, she says, was almost like going to college for the first time again. This time, however, she knows what’s coming.

“I did feel hope at the very beginning, but I almost didn’t feel that again over the past year,” she says. “I think hope is coming back, actually, which is very strange, but happy for me.”