Mental Health: At Home and Abroad

When Cheryl Woehr launched the international program at Truckee Meadows Community College in 1990, there were just over two dozen students, all from Japan, and they knew exactly where to go when they were struggling—whether it was academically, socially, or psychosocially.

“I was the counselor, I was the adviser, and I also taught a freshman orientation class,” says Woehr, who still serves as a counselor and full-time faculty member at the Nevada community college. “I got to wear all the hats, so when students had problems, they came to me.”

Nearly 3 decades later, the steady growth of international programs, combined with the well-documented rise in mental health issues among college students, has changed the equation. Depending on the study and the terminology, anywhere between one in three to more than half of all college students have faced some kind of mental health challenge. What has been described in some circles as a “mental health crisis” has impacted all areas of campus life, and study abroad programs are no exception.

“We were finding that some of our faculty were on site with students having a variety of very serious mental health concerns and were feeling at a loss,” says Kim Priebe, director of study abroad in North Carolina State University’s Office of Global Engagement. At many other institutions, study abroad officials have grappled with what to do when students are in crisis, including the need for emergency evacuation when mental health resources are not readily available locally.

“While the increase in mental health symptoms among college-aged students may be under the microscope in Western countries, it has become a worldwide phenomenon.”

Further shifting that equation is the growing recognition that international students face many of the same challenges, argues Gary Robinson, director of counseling services at Hartwick College in New York, and a licensed mental health coordinator.

“The mental health epidemic has gone from primarily an American student studying abroad scenario to international students from around the world coming here,” says Robinson, who also is cofounder of P3 Mental Health Advisors. “While the increase in mental health symptoms among college-aged students may be under the microscope in Western countries, it has become a worldwide phenomenon.”

For international programs in recent years, “the biggest thing has been the increased emphasis and awareness,” says Jason Hope, director of international health, safety, and security at the University of Kentucky and co-chair of NAFSA’s Health and Safety Subcommittee. “Mental health is being treated in a more proactive way, and there’s a real hunger for more information in the field.”

Yet the international educators interviewed for this article acknowledge that on many campuses, more needs to be done to evaluate programming, train staff, and provide information to both inbound and outbound students.

“International programs are looking at mental health differently than they used to,” says Woehr, “but many need to do a lot more to serve their students better.”

An Ongoing Shift

To be sure, international educators have always been aware that the very things about international education that foster emotional and intellectual growth can also present challenges as students strive to adjust to new cultures and customs. Being pushed outside of their comfort zone can cause some students to develop new mental health issues, or it can exacerbate issues that are normally under control at home. But as awareness of mental health issues has increased, international programs have become much more intentional in aligning their efforts with the growing numbers of campus wellness initiatives.

In many places, self-care strategies for addressing stress and anxiety and pinpointing the warning signs of more serious mental health challenges have become integrated with an overall focus on well-being, supported through courses and programming offered to all students.

“[Campuses] are looking at mental health more holistically—how you stay physically healthy and emotionally healthy,” says Barbara Lindeman, director of student international health, safety and security at the University of Missouri-Columbia International Center. “We’re carrying that over into the orientation and training we provide to students before they go abroad.”

The more holistic focus on wellness has helped destigmatize mental health issues, at least among U.S. students. 

“You don’t have to do any sales job when it comes to self-care,” Robinson says.

International staff have also focused on breaking down silos between their programs and campus counseling services, which may often struggle to address the intercultural dimensions of mental health and acculturation issues on their own. At the same time, many counseling services are overwhelmed by the sheer volume of students’ needs.

“Five to 10 years ago, counseling staff did not have the waiting lists they have today,” Robinson says. “Now they have more staff, but more students.” An added challenge for community colleges, says Woehr, is that many of the smaller campuses and systems typically don’t have psychologists and psychiatrists on staff.

However, none of the educators interviewed for this article think that the growing awareness of mental health issues is keeping students from pursuing international opportunities. In fact, international education may actually be more beneficial than in the past, according to Robinson.

“International education is going to be for this generation, even more so than others, like a booster shot for development,” he says. “It’s going to help with things their generation isn’t particularly good at—delayed gratification, social skills, the ability to handle ambiguity. International education is going to help them answer the call. But we need to go into it with our eyes open and be intentional. If you don’t, things can take you by surprise.”

Improvements to Planning and Review

As their institutions increasingly take a more holistic approach to mental health issues, international offices must consider how to address them across the entire scope of their programming, for both inbound and outbound students. Often, strategies for improvement start in the planning stages.

“You start looking at mental health when you’re planning programs,” says Lindeman, and a critical first step is incorporating mental health into protocols for developing new education abroad programs and reviewing existing ones. One crucial component of these protocols involves confirming the availability of mental health resources abroad, including English-speaking counselors or remote Skype or phone counseling options wherever counselors are not readily available.

Support for Inbound Students

While cultural differences can often make it more challenging to explicitly discuss mental health issues with incoming international students, videos and other orientation materials can help to prepare students for acclimating to campus life. Among the information to consider for online or orientation programming:

• General information about navigating the campus (such as virtual tours) and expectations of faculty;
• Examples of common adjustment challenges for international students, such as communication style and language anxiety, illustrated with videos of international students describing their challenges and successes;
• Opportunities to initiate direct one-to-one connections with current international students, such as online pen pal programs via Facebook or Skype; and
• Introductions of international and other student support staff, including counselors, with descriptions of their roles and the differences between counselors, advisers, and other international staff.

Throughout discussions of the mental health services available on campus and in the community, it must be reiterated that participation is confidential, unless a serious threat emerges, says Cheryl Woehr, a counselor and full-time faculty member at Truckee Meadows Community College.

Students have the right to disclose (or not disclose) their personal medical information as they so choose. “A lot of students come from countries where they don’t trust the system,” she says.

For students participating in education abroad programs operated by third-party organizations or direct enrollment agreements, it is also important to communicate expectations with providers, including when international offices on the home campus need to be alerted to issues, according to Hope. 

“There are cultural differences that can create barriers to communication,” he says, noting that some international institutions may be unclear about their expected role in addressing mental health issues. “The conversations we have with partners are about when they need to be in touch with us about issue X, Y, or Z.”

For the larger study abroad programs, there’s another, albeit costly, option: sending a counselor abroad as part of the in-country staff, something only a handful of institutions have done, according to Robinson. Despite the cost, “it’s something universities should be thinking about if they have large programs in one location,” he says. “If they’ve got 150 students somewhere where there’s not a lot of local support, it makes sense.”

Training for Faculty and Staff Abroad and at Home

Field staff, including educators involved in faculty-led study abroad programs, should be trained in what Robinson calls “emotional first aid”—the ability to assess a student’s emotional health, provide appropriate support, and know when to refer the student to professionals, either in-country or on the home campus.

“We’re not trying to make everybody a therapist or counselor,” Robinson says. “What we are trying to do is help people understand that, like physical first aid, you ought to be able to assess the risk and provide low-level, nonprofessional support until you can hand them off to higher-level support.”

Staff from campus counseling centers often walk faculty through potential mental health scenarios and discuss indicators of distress, including suicide warning signs. It is critical to ensure that staff know where to seek help, according to Lindeman. “We make certain they understand they never have to go through that with students alone,” she says.

Faculty tend to be receptive to the training, says Hope. “This is one of the trainings faculty members engage with most,” he says. “They’re worried they’re not going to have the tools to properly assess what’s happening with students or know how to liaise with us.”

Such training strategies often leverage resources from campuswide mental health and referral initiatives, such as the University of California’s See Something, Say Something, Do Something and the University of Kentucky’s Community of Concern. These initiatives enable faculty and staff to proactively identify concerning behaviors in students and take appropriate action.

Homebound international office staff should also receive training because international students—particularly those from countries where therapy is considered taboo—may feel more comfortable coming to them with issues.

“If the student doesn’t feel comfortable going to a counselor but does feel comfortable with an adviser in the international office, how do they [the advisers] respond when a student comes to them with a mental health issue?” Robinson asks.

While cultural taboos involving mental health are often well understood by international staff, training should explain some of the nuances that can come into play in conversations with students and provide strategies to bridge the cultural gaps. At Truckee Meadows, for example, Woehr had counseled a Mexican-American student who had been diagnosed as clinically depressed but resisted medication because the problem was seen as a family issue.

Many students from Asia may also be leery of medication for both cultural reasons—including the perception of the United States as an overmedicated country—and for more specific ones, such as prescription dosages not taking into account their size and weight, Woehr says. Knowledge and awareness of these cultural customs and taboos can help faculty and staff in communicating with international students and finding the right approach forward.

Another group that would benefit from training includes nontraveling faculty in departments with high percentages of international students, Robinson says. “Sometimes it’s faculty members who the international students are comfortable talking with,” he says.

Predeparture Preparations

Predeparture training and planning should encompass both the students who disclose mental health issues and the broader study abroad population.

Most universities have health information disclosure policies that allow students to decide whether they wish to share that they are receiving counseling or mental health treatment. Study abroad students who choose to disclose their mental health issues often discuss and develop plans for ongoing support with international office staff or counselors, including understanding specific triggers and planning out their responses, such as arranging virtual sessions with campus counseling staff or their own mental health practitioners.

Such plans can also help to stave off more drastic interventions once students are abroad. For example, Woehr helped a struggling student in Morocco create a self-care contract, including weekly counseling sessions and specific steps he pledged to take when not feeling safe, which helped avert an emergency evacuation, she says.

Managing medication, in particular, can be challenging for students with existing mental health issues. Some students may be so engrossed in exploring a new environment that they may stop taking their medication; others who take certain prescription drugs, such as those used to treat ADHD, may not be able to do so in certain countries where the medication is illegal.

Not all students who receive mental health treatment choose to disclose their condition, however. To address this issue, staff members in the University of Kentucky International Center send the counseling center a roster of all participating students so that counselors can have conversations as they deem appropriate. 

Counselors also focus on what Hope calls “mindful preparation”—encouraging study abroad students to think through their needs, including medication, and “giving students the tools to advocate for themselves, along with identifying ways to connect with the counseling center” and other supports, Hope adds.

While most study abroad health insurance plans address mental health issues, it is important to regularly review policies and services, including those offered by external assistance providers, to make sure that students can easily access resources abroad. Policies should be assessed to ensure that they adequately cover various emergency situations, such as medical evacuation with a psychiatric nurse in serious cases of potential self-harm.

Proactive Programming

These kinds of mindful preparation strategies can benefit students who are acclimating to a new culture. As part of the predeparture programming, colleges and universities often share information about self-care practices with outbound students and encourage them to develop their own strategies for dealing with stressful situations. These discussions often accompany—or, in some cases, replace—broader conversations about student behavior, including long-standing programming focusing on alcohol and drug use while abroad.

“We’ve shifted away from a focus on alcohol concerns and toward mental health, because that’s what we’re seeing,” says NC State’s Priebe. “We’re helping students understand what goes beyond culture shock and what crosses the line into a more serious concern….we’re asking students to do a little self-care and think about the concerns they may have, who their support networks are, and what they will do.” 

Another area of focus is encouraging students to look out for each other and become comfortable discussing issues with their peers.

“We’re asking students to do a little self-care and think about the concerns they may have, who their support networks are, and what they will do.” 

Materials such as mental health checklists and tips for creating self-care plans—for example, identifying who students will reach out to if they feel anxious or depressed while abroad—are often presented as handouts or in large group sessions. However, according to Robinson, they are generally more effective when discussed one-on-one.

“It’s hard when you’re sending a thousand students abroad each year, but the more that colleges can meet face-to- face with students who are studying abroad to talk about self-care, the better,” he says. “From anecdotal evidence, it’s not happening as often as it should.”

International Student Orientations

Helping prepare inbound international students for their experience on U.S. campuses can often present a greater challenge. Some coordinating programs and organizations provide orientations before international students enroll, but institutions must be mindful of cultural barriers surrounding counseling and communicating about health issues in their own outreach to incoming students, Robinson says.

“These students are coming from another cultural context, and to get materials sent to them about self-care may or may not make sense—or [could] be culturally offensive,” he says.

Institutions can help orient inbound students through the lens of helping prepare them for U.S. campus culture. Colleges and universities can also provide services such as peer counseling once the students arrive or encourage participation in broader, campuswide orientation and wellness initiatives, such as the University of Southern California’s Thrive: Foundations of Well-Being, an elective course that focuses on self-care and resilience.

Coordination Across Departments

While collaboration between international offices and counseling departments is now more common, a small number of institutions are embedding counselors within the international program, according to Robinson.

“It’s a best practice, but it’s tricky because you have funding issues,” he says.

A more feasible option for many campuses, Robinson adds, is dedicating a point person on the counseling staff to serve as a liaison who coordinates incoming referrals from international programs and provides context to other counselors.

Since inbound international students often must navigate a wide range of services and systems, just as their U.S. peers, it is also essential for the international office to make connections with other departments beyond counseling, including admissions and records, academic advising, disability resource centers, housing, and departments offering academic support such as writing centers or tutoring. Intercultural training can help staff in many departments better serve international students, according to Woehr.

Emergency Planning

International programs must develop emergency response plans and protocols for campus and abroad to address suicidal students and other life-threatening situations, as well as other serious mental health issues such as eating disorders or debilitating depression. Scenarios involving evacuation “are rare, but when they happen, you have to be ready to respond,” Robinson says. When students return to the United States after experiencing a crisis abroad, protocols should exist to follow up and connect them with resources on campus.

It is also critical to develop contingencies to ensure emergency mental health supports for students who may be indirectly affected by a traumatic event, such as the injury or death of a peer, Lindeman says.

Above all, international educators must model the kinds of behaviors that can help students to help themselves by being transparent and open about mental health issues, Robinson says.

“One foundational teaching about mental health is if you ignore it, it tends to get worse, not better,” he says. “Mental health issues often exist because there’s an elephant in the room. The more you can get those issues out and train people, the better off it’s going to be.”

A Peer-Powered Solution for International Students

Once on campus, less than 3 percent of international students seek help for mental health concerns. Of those who do, 38 percent drop out after an initial intake session, according to research compiled by Peitao Zhu, a doctoral student in Syracuse University’s Department of Counseling and Human Services and author of a chapter of NAFSA’s forthcoming publication, Addressing Mental Health Challenges Affecting International Students.

Peer mentoring for international students offers one viable avenue for increasing access to mental health support. It represents a promising opportunity to address their emotional and psychological well-being, as well as other challenges related to academics, cultural transitions, campus and community connectedness, and career development, Zhu argues.

Given the difficulty of creating one-to-one mentorship matches on campuses with large numbers of international students, Zhu suggests creating programs in which peer mentors are assigned about 10 to 15 international mentees in a structured program for which the mentors are financially compensated.