Professional Documents
Culture Documents
Aubrey 1991
Aubrey 1991
To cite this article: Rachel Aubrey C.S.W. (1991) International students on campus: A challenge for counselors, medical
providers, and clinicians, Smith College Studies in Social Work, 62:1, 20-33, DOI: 10.1080/00377319109516697
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INTERNATIONAL STUDENTS ON CAMPUS: A
CHALLENGE FOR COUNSELORS, MEDICAL
PROVIDERS, AND CLINICIANS
RACHEL AUBREY, C.S.W.*
ABSTRACT
INTRODUCTION
Many campuses across the United States host large numbers of inter-
national students. In 1988-89 some 366,000 were enrolled in over
2,500 accredited institutions of higher learning. Increasingly they are
graduate students; international students from Asia currently account
for 63% of the nation's graduate student population (Institute for Inter-
national Education, 1989). In the Fall of 1990 Columbia University
enrolled 3,077 international students, constituting 13.7% of the total
student body. They represented 102 countries, the leading five being
the People's Republic of China (PRC), Japan, Korea, Taiwan, and
India. Nationally the most significant growth in the last five years has
been in students from China; at Columbia the PRC continues to baffle
the experts by showing an increase of 42 students in 1990 in spite of the
aftermath of the 1989 Tienamen Square massacre. Twice as many
international men as women enrolled, but the gender gap in lessening;
Fall 1990 saw a one-year increase of 10% in international women at
Columbia {Columbia University, 1990).
*Rachel Aubrey, C.S.W., is Senior Staff Therapist, Mental Health Division, Columbia
University Health Service; Consultant on Cross-Cultural Issues, International Student
Office, and in private practice. She has done cross-cultural work in England, Sweden,
Turkey, and continental Europe.
INTERNATIONAL STUDENTS 21
SOURCES OF STRESS
Academic Stress
Stress, a Western folk model that has been "scientified" (Jacobson,
1987), may have academic and non-academic causes. Most foreign
students focus on academic issues. A typical American classroom dif-
fers greatly from those in all but a few Western countries. In the United
States, active class participation is expected, especially at the graduate
level. American teachers tend to question their effectiveness unless
students are visibly involved and final grades often reflect classroom
discussion. This situation can be very confusing for Asian, Middle-
Eastern, and African students. They have been taught to sit in class
silently, taking verbatim notes that will be studied, memorized, and
then reproduced on exam or paper. They may feel at a real disadvan-
tage compared to other students. For example, Tomoko, a 32-year-old
Japanese graduate student, spoke bitterly about her English language
class, stating:
22 RACHEL AUBREY
Before I am quite sure of the right answer all the non-Asian
students have their hands up, ready with an answer that is often
wrong, yet they get credit for class discussion. I usually have
the right answer but I never speak in class; in Japan this is
considered very rude.
Discussing such concerns with the teacher is rarely a viable option; it
might suggest lack of respect or imply fear of failure. Issues of self-
esteem are ever present. Many international students belong to the
intellectual elite of their country and have been considered special at
home. Chinese students, often individual children in the family as a
result of China's one-child policy, may not be accustomed to the com-
petitive interactions typical of larger families or of Western education.
Receiving a bad grade not only adds to a foreign student's fear of
failure but is likely to accentuate feelings of isolation from American
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Non-Academic Stress
Unfamiliar living arrangements can be very stressful. At Columbia,
many graduate students must live off-campus. While American stu-
dents may welcome this, foreign students often find life in a single
room or small apartment very lonely. Many have never lived away
from home, or only in large dormitories. Having a room of one's own is
rare outside the United States. Sharing with a roommate may raise
specific cross-cultural problems. Tsen, a 28-year-old male Chinese stu-
dent, reported great joy at meeting his American roommate who, he
was sure, would now become his best friend. He was shattered when
the roommate asked him to leave for a few hours each day so that he
could have his privacy. Tsen finally posted his class schedule and
INTERNATIONAL STUDENTS 23
chorage, loss of status, disruption of basic social skills and ties with
loved ones (Klein, Miller, & Alexander, 1981). Foreign student advi-
sors identify three stages of adjustment to the host culture. First, there
is a honeymoon stage: The newly arrived student, happy to be here,
finds everything and everyone great and exciting. Then comes a period
of increasing disillusionment and irritability; nothing feels right and the
host culture is increasingly belittled. Perceptions of Americans become
more negative; they are now seen as rude, self-centered and unavail-
able. The burden of making friends seems entirely on the newcomer
who tends to withdraw and/or seek out fellow nationals. The third stage
is one of partial adjustment to the new culture; some things are ac-
cepted, others rejected. There may be a double dip in stage two, (disil-
lusionment), the second dip deeper than the first, especially when ear-
lier angry feelings have not been worked through. This sequence closely
parallels the usual stages of recovery from loss. The international stu-
dent is coping with loss of family, country and native language (Aubrey,
1988). The losses can be very painful when a student prepared for
many years to come here or, as a political refugee, cannot return home.
Yet to admit one is unhappy in a country long idealized may imply loss
of face, a situation very threatening to Asian, African and Middle-
Eastern students taught not to express negative emotions overtly. When
such feelings are denied or repressed stress often results.
Somatization of Stress
American students tend to experience stress as anxiety and/or de-
pression; non-Western students nearly always develop physical com-
plaints and a coping pattern of seeking medical help. In many socie-
ties, including some rural, ethnic and lower class groups in the West,
stress is expressed primarily by physical symptoms. In China even
24 RACHEL AUBREY
Medical providers in the Student Health Service are often the first
and only professionals to notice symptoms of stress in foreign students.
They are thus in a unique position to do preventive work. Unfortunately
they often do not have time to fully engage these students and may opt
for quick referral. Efforts to refer to mental health clinicians often meet
resistance, since mental problems are severely stigmatized in all but a
few Western countries. "Talking therapy" is virtually unknown and the
concept difficult to explain. Students present with specific symptoms
for which they expect concrete advice or medication. Yet medication is
often not indicated or may already have been used; self-medication
with antibiotic or psychoactive drugs, readily available in many coun-
tries, is not infrequent. Nevertheless, many international students are
eventually seen in a mental health service. How do we best engage and
work with them? Are our usual clinical interventions effective with
non-Westem students and others who are therapeutically naive? Per-
sonal experience, discussion with colleagues, and a still scant literature
suggest that considerable flexibility in therapeutic technique is indicated.
CLINICAL INTERVENTIONS
calmed down visibly and soon insisted on going home, rejecting any
exploration of his stress. The ambulance man, a former Peace Corps
volunteer in Africa, then explained to the puzzled staff that Philippe, as
a proud member of the Wolof tribe, felt deeply ashamed and his man-
hood threatened by his symptoms. Having to lose vital blood to a
white-coated stranger, then to be told again he is not ill, was more than
Philippe could tolerate. Fear and panic turned into aggression and
paranoid-like behavior. Speaking with a fellow student in a familiar
language calmed Philippe, as did the suggestion that red juice would
help replace his lost blood. He endowed the ambulance man with some
of the powers of a marabout or native healer.
In parts of Africa and Asia Western-trained physicians work side-by-
side with indigenous healers to help integrate a biomedical approach
with local illness-related beliefs. Collignon (1978) describes this ap-
proach as highly successful in the Senegalese psychiatric teaching-
hospital, Fann-Dakar. American physicians may profit from consulta-
tion with native healers, found in many large cities, in treating students
from developing nations.
In Rethinking Psychiatry, Kleinman (1988) proposes an international
vision of mental illness and mental health which challenges some basic
tenets of American psychiatric training and practice. He points out that
the reification of one cultures's diagnostic categories and their projec-
tion on to patients in another culture, where their validity has not been
established, is a category fallacy.
Treatment Modalities
Crisis intervention and/or brief therapy focused on the presenting
problem appear to be the treatments of choice for a majority of foreign
students. In selecting among various modalities the therapist must often
28 RACHEL AUBREY
their body but will talk about sadness or stressful events only upon
careful inquiry. Presenting symptoms commonly seen among foreign
students include epigastric pain, colds, headaches, dizziness, fatigue,
insomnia, skin disorders, and a generalized feeling of body weakness
or "neurasthenia." While no longer diagnosed in North America and
Western Europe, neurasthenia is still a common diagnosis in Eastern
Europe, China, Hong Kong, Taiwan, and several South-East Asian
societies (Kleinman, 1988). Internists and urologists who see young
Chinese males may also encounter the shen-k'uei (kidney weakness)
syndrome. Wen and Wang (1981) describe this as a culture-specific
psychosexual neurosis, involving various symptoms, often including
specific complaints of sexual dysfunction. In the popular view shen-
k'uei is always attributed to masturbation, with the resulting loss of
vital energy leading to neurasthenia. Kleinman (1990) reports several
cases of shen-k'uei among Asian students at Harvard.
Communication
Communication, the basis of any clinical relationship, can be a major
problem. Students' command of English is often limited, especially
when under stress. Use of an interpreter, though sometimes unavoid-
able, can lead to complications. When a student does not speak English
well, non-verbal affect and body language take on added meaning.
Here again we must bear in mind cultural norms. Avoidance of eye
contact may signify politeness rather than distrust; moving very close
or pulling away may also be rooted in cultural tradition. A rich source
of communication can be found in dreams, considered of great impor-
tance in many societies, and often freely shared with family and friends.
Interest in dreams can be used diagnostically in brief therapy, or help
30 RACHEL AUBREY
Cultural Learning
Cultural learning is vitally important for all clinicians. It can also be
very stimulating. Our best teachers are the very students we are here to
help. By enlisting international students as active interpreters of their
culture we accomplish several things: We help them overcome their
passive deference to us, the perceived experts on life in America; we
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academic one. This is a safe topic which allows the student to teach you
as rapport develops. Then focus on milestones in the life cycle, starting
with the student's current stage of development, usually young adult-
hood. Invite him or her to compare experiences here with normative
behavior at home. When appropriate, move into other relevant areas,
such as family relationships, including important members of extended
family or clan, and friendships. Listen for issues of loss and distinguish
between normative and catastrophic crises. Inquire about the impact of
forced uprooting due to political upheaval, as in China's Cultural Revo-
lution and Tienamen Square Massacre, or of war, famine and disease,
as in parts of Africa and the Middle East. Pay close attention to the
student's affect before proceeding to the more sensitive topics of lone-
liness, relationships, belief systems, fate, marriage, and sex.
In conclusion I believe that an interdisciplinary and cross-cultural
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