When Justine de Jesus began her freshman year at the University of Pennsylvania in 2017, she often wished that she had someone to talk to about the unique challenges of being an international student: homesickness, cultural differences, and such remarks from other students as “Where are you from?,” “I’ve never heard of that place,” “Wow, your English is so good.”

“My friends at the time were also mainly international students, so we were just all echoing each other,” said de Jesus, who is originally from the Philippines but grew up in Singapore. “We were not really finding solutions.”

On top of those challenges, mental health wasn’t widely discussed in the Philippines or Singapore, de Jesus said. She said that when she chose to go to Penn’s Counseling and Psychological Services (CAPS) for the first time in her sophomore year because of stress from schoolwork, being able to admit that she needed help was a significant moment.

“The hardest part was not necessarily that there was an extreme lack of resources, but the fear of talking about mental health,” de Jesus said.

International students often struggle with adjustment on all levels, from language barriers to harder classes to homesickness. Tasks such as going to the bank or scheduling a doctor’s appointment can be extremely stressful, which can lead to self-doubt and lower self-esteem, making students more susceptible to anxiety and depression.

Global news events taking place in their home countries can add to their stress, such as the recent coronavirus outbreak in China. Racist reactions, as have been reported in the U.S., only pile on the pressure.

Seeking out help can be challenging — like other students, international students say they often wait too long for appointments. But they also struggle with opening up due to cultural stigma, and then face mental-health professionals who have too little understanding of their cultures to be truly helpful.

‘Demand is way beyond supply’

In 2019, nearly 52,000 international students were enrolled at universities in Pennsylvania, giving the commonwealth the sixth-highest international student population in the country. More than 40% of students were from China, followed by India at 15.4%.

In fall 2018, Temple University had 3,171 international students, who made up 7.9% of the student body. The University of Pennsylvania had 5,333 international students enrolled in its 2019 undergraduate- and graduate-level programs, while international students made up 10.1% of Drexel University’s most recent incoming class.

“There’s a lot of variation among international students’ needs,” said Suzanne Chong, a staff psychologist at Ursinus College in Collegeville and a therapist based in Center City who offers sessions in Cantonese, Malay, and Mandarin. “Some colleges are more willing to acknowledge limits, which means hiring people who can work with them. Other colleges take on a lot of students, but then they get overwhelmed, and that’s where you have issues.”

Suzanne Chong, a staff psychologist at Ursinus College, at her office in Center City.
HEATHER KHALIFA / Staff Photographer
Suzanne Chong, a staff psychologist at Ursinus College, at her office in Center City.

A 2010 study published in the Journal of American College Health found that although international graduate students were as likely as domestic graduate students to report a mental-health issue that “significantly affected their well-being or academic performance within the past year,” they were less likely to be aware of available counseling services. The study found that only 33% of international students had considered using mental-health services, versus 56% of domestic students.

Chong, who is originally from Malaysia, said that Asian students can often feel too ashamed to ask for help.

“When it comes to East Asian cultures, you only see a psychologist or psychiatrist when you’re really, really struggling,” Chong said. “People think Asian Americans have better mental health because they present fewer symptoms. But when Asian Americans present with symptoms, there’s more impairment, more dysfunction.”

A recent study published in the Journal of International Students last year by University of Delaware researchers found that out of 490 international students, 45.3% met the clinically significant screening cut-off for depression, and 24.7% screened positive for moderate to severe anxiety symptoms. Undergraduate students tended to report higher rates for both.

Zheya “Jenny” Yu, a clinical assistant professor of psychiatry at Penn’s Perelman School of Medicine, said that an international student who struggles with adjustment experiences a lot of anxiety and depression. She said that, when most international students arrive, they go through a “honeymoon stage” of culture shock, when things are exciting and emotions are pleasant. But then some people may start feeling frustrated from experiencing communication difficulties or cultural gaps.

“A combination of those things can culminate in thoughts like, ‘You don’t belong here,’ or ‘You don’t want to be here,’” Yu said. “I’ve seen some teenagers who are studying here, who are not assimilating. They’re not communicating with their peers here and often choose to communicate in Chinese on social media with kids back in China. Their worlds are not here, but their bodies are here.”

Inclusivity is key

In February 2014, Jack Park, then a junior at Penn, wrote a Tumblr post about his failed suicide attempt during his freshman year. It got wide circulation because he wrote it for Active Minds, the university’s chapter of the nonprofit organization raising mental-health awareness among college students. At the bottom of the post, Park, who grew up in Seoul, South Korea, listed his email so students who were struggling after the 2014 suicides of Madison Holleran and Elvis Hatcher, who died just a few weeks apart, could reach out. He ended up speaking with more than 100 students, both offline and online.

Park, now 26, said it wasn’t until after he arrived at Penn that he began to experience depressive episodes.

University of Pennsylvania student Jack Park was an outspoken advocate for campus mental health during his time in college. Park now works as a mental-health counselor in South Korea.
Courtesy of Jack Park
University of Pennsylvania student Jack Park was an outspoken advocate for campus mental health during his time in college. Park now works as a mental-health counselor in South Korea.

He scheduled an appointment with CAPS, but the staff there categorized him as a mild case at intake and made him wait weeks while more serious cases were handled. Park, who was eventually diagnosed with bipolar disorder, said his depression rapidly worsened and he became suicidal while waiting. Being away from home added to his feeling of isolation.

“I had a great close-knit community of Korean students at Penn,” Park said in an email. “I just thought I had nobody, with my depression taking over my mind and fogging up my perceptions.”

Park, who is now interning in a counseling center in South Korea after graduating with a master’s of theology degree from Yonsei University, said that in a perfect world, college counseling centers should offer international specialists from many major cultural backgrounds. But he acknowledged their limited resources, and instead suggested the expansion of heritage centers where students can build informal, supportive relationships on campus.

“Korean students, and many other students, don’t share their hardships easily,” he said. “Getting to know the students personally can help heritage center faculty become a better support network with common immigrant backgrounds.”

Hider Shaaban, a doctoral extern in psychology at Temple’s Tuttleman Counseling Services, said that most college counseling centers care about multicultural competence. Shaaban, who grew up in Iraq and came to the United States as a refugee with his family in 2009, said that he’s been seeing more training and seminars about cultural sensitivity within therapy.

“People from many other countries don’t have access to this sort of health care,” Shaaban said. “Sometimes I have to start with very basic psychoeducation, like what thoughts and feelings are and what their functions are.”

Hider Shaaban is a doctoral extern in psychology at Temple’s Tuttleman Counseling Services.
STEVEN M. FALK / Staff Photographer
Hider Shaaban is a doctoral extern in psychology at Temple’s Tuttleman Counseling Services.

Focusing on resilience

Saad Haye, who co-owns Live Better Therapeutic Services in West Philadelphia and offers services in Urdu and Hindi, said that international students often internalize their mental-health struggles because those issues are seen as weaknesses.

“All you’re getting from people around you are examples of people who have made it,” said Haye, who is from Pakistan. “And first-generation parents are often in a mode where they’re trying to fix things. Parents will say, ‘It’s because you’re not exercising, it’s not like this is an actual problem, so let’s try to fix it.’ It’s much harder for them to actually understand it.”

Leilei Duan, a Mandarin-speaking therapist based in Center City, said that in her sessions with students, she focuses on their personal strengths to draw out the resilience that brought them here in the first place. She also said that she sets reasonable goals, such as making more of an effort to make friends after normalizing the anxieties that the students face.

“We practice socializing with peers and professors,” Duan said. “And I encourage them to join some social groups. I make sure they know that it’s going to take some time to adjust and adapt to life here. But if you shut yourself off from the outside, then you have no opportunity to practice taking the steps that lead to that.”

De Jesus, now a 20-year-old junior studying cognitive neuroscience and visual studies at Penn, eventually found her footing. She recently became the president of the Assembly of International Students, which helps organize international student orientation. The assembly is currently trying out a program to work with CAPS to train students on how to have conversations about mental health so that students can better reach their peers who are uncomfortable going directly to CAPS.

“I see my friends who come from countries where there’s such a huge stigma surrounding these kinds of topics mostly go to their friends,” de Jesus said. “Reaching out to people from home can be an added barrier. But CAPS does offer services in an incredible amount of languages, and if more students knew that, I think they would feel more comfortable approaching CAPS. So we’re making more of an active effort to demystify what goes on at CAPS.”