Journal of International Students | 306 Research in Brief ISSN: 2162-3104 Print/ ISSN: 2166-3750 Online Volume 5, Issue 3 (2015), pp. 306-312 © Journal of International Students http://jistudents.org Psychological Symptoms and Concerns Experienced by International Students: Outreach Implications for Counseling Centers Senel Poyrazli, PhD The Pennsylvania State University, Harrisburg (USA) ______________________________________________________________________________ Abstract This study examines psychological symptoms and concerns experienced by international students. Participants identified with a variety of psychological symptoms and concerns. The top three were related to academics (71%), career (60%), and stress (43%). In addition, 34% of the participants indicated being concerned about depression and/or anxiety. For married students, the top three concern areas were related to academics, career, and stress, but 27% of participants also indicated experiencing couple and marital problems. Implications for outreach activities for counseling centers are discussed in light of these findings. Keywords: psychological symptoms, psychological concerns, outreach, international students ____________________________________________________________________________ International students have been studied to a considerable extent in the United States, largely because of their economic and cultural contributions and because they face a unique set of challenges in comparison to other students (Pedersen, 1991; Tung, 2012). Researchers have studied this group to find ways to help them achieve their academic goals and to acclimatize to their new surroundings (see, e.g., Coppi, 2007; Poyrazli & Lopez, 2007; Reynolds & Constantine, 2007; Zhang & Goodson, 2011). While a large amount of literature on international students has focused on psychosocial and academic adjustment, few studies have examined the symptoms that may necessitate psychological help (Yakushko, Davidson, & Sanford-Martens, 2008) or that bring international students to counseling centers. One of these few studies was conducted by Yi, Lin, and Kishimoto (2003), with results revealing that concerns most commonly presented by international students seeking help at counseling centers were “academics/grades, anxiety, and depression” for undergraduates, and “depression, time management, and relationship with romantic partner” for the graduate students (p. 333). In another study, Mitchell, Greenwood, and Guglielmi (2007) explored reasons for seeking counseling among those international students who sought counseling over a two-year period. Anxiety and depression were the top self- reported concerns. In addition, 38% of the students presented with academic problems. The researchers also found that compared to the U.S. students, international students were less likely to seek non-crisis help, but were more likely to seek crisis help. The authors of the study concluded that international students might be “more likely to seek services when their distress is July/August 2015 http://jistudents.org Volume 5(cid:1)Issue 3 307 | Journal of International Students intolerable and impairment is more significant” (Mitchell, Greenwood, & Guglielmi, 2007, p. 127). A limited amount of research has looked into what types of concerns international students experience outside of the clientele that the counseling centers receive. For example, Parr, Bradley, and Bingi (1991, 1992) surveyed both international students and the directors of the international student offices of the campuses these students attended in order to identify the usual concerns the students experienced. Directors indicated that students were mostly concerned about their education, family back home, and the cultural differences they were facing. The researchers also identified that the students felt lonely. In another study, Hyun et al. (2007) explored the mental health needs of graduate international students, but they focused on a limited number of psychological symptoms which were feelings of hopelessness, exhaustion, sadness, depression, and being overwhelmed. Other research (e.g., Bradley, et al., 1995; Hyun, Quinn, Madon, & Lustig, 2007; Mori, 2000) has looked into the number of international students seeking psychological help based on the observation that few seemed to be utilizing counseling center services. Yakushko et al. (2008), for example, found that during a 5-year period, only 1.8% of the total international students at a particular college campus sought help at the counseling center. The most common presenting concerns for those who did present were relationship issues (22%), followed by depression (15%), isolation and loneliness (7%), and anxiety (7%). In another study, Nillson, Berkel, Flores, and Lucas (2004) identified that only 2% of the international students in their research sought help from the counseling center over a particular academic year. The top presenting concerns for which the students sought help were feelings related to depression and anxiety, assertiveness issues, and difficulty selecting a major. Besides revealing the low rates of utilization of counseling centers among international students, the literature also identified what these students are more likely to do when experiencing psychological symptoms. It seems that they tend to first go to their professors, advisors, a medical professional, or a friend, rather than going to their counseling center for psychological help (Aubrey, 1991; Bradley et al., 1995). In addition, international students from non-Western cultures tend to somaticize their psychological experiences (e.g., stress, homesickness), which increases the likelihood of seeking medical instead of psychological help (Aubrey, 1991; Hyun, Quinn, Madon, & Lustig, 2007). In light of outdated and/or very limited research related to all international students’ psychological symptoms and concerns, this present study aims to explore prevalence rates of psychological symptoms and concerns among all international students enrolled at a university so that information about the prevalence rate of these students’ psychological symptoms and concerns is determined in order to compare the rate of international students indicating psychological need in the current study to the known rate of international students seeking help at counseling centers and to discuss likely outreach implications based on the findings. Method Participants The data were collected from 198 international students who were studying at the Pennsylvania State University. Of these students, 58% were men and 42% were women. The age of the students ranged from 18 to 46 years of age (M = 26.10, SD = 4.78). The majority of the students were enrolled in graduate school, 16% were undergraduates. About 23% of the students indicated that they were married. In terms of race-ethnicity, the majority of students were Asian- Journal of International Students | 308 Pacific Islander (65%). 19% were European, 5% were Latina/o, 4% were Middle Eastern, 3% were African, and 4% indicated they belonged to the “Other” category. Table 1. Psychological Symptoms and Concerns Psychological symptoms/concerns % of students who indicated experiencing related to: the psychological symptom/concern Academics 71 Career 60 Stress 43 Loneliness 28 Family 23 Eating 22 Sleep 21 Interpersonal Relationships 20 Depression 18 Anxiety 16 Couple and Marital Problems 15 Roommate 10 Sexual Orientation 6 Grief 3 Alcohol and Drugs .5 N = 198 Procedures Instructors of a group of randomly chosen undergraduate and graduate courses were contacted and permission was requested to distribute a packet of questionnaires to the international students enrolled in their courses. Presidents of international student clubs were also asked to hand out the surveys randomly with their members. International students were instructed not to take a survey package, if they had already completed one through a class. Students were given a self-addressed stamped envelope to send their completed survey back to the researcher. A total of 360 surveys were distributed. 198 surveys were returned, yielding a 55% return rate. Instruments Demographic Information. A demographics questionnaire was developed by the researcher to gather information about students’ gender, age, race/ethnicity, marital status, and whether they were a graduate or undergraduate student. Psychological Symptoms and Concerns. A checklist was used to determine students’ psychological symptoms and concerns. Checklists are often used by the counseling centers to gather preliminary information from the clients about what symptoms or concerns they may be experiencing (cf. Zalaquett & McManus, 1996). Reviewing intake forms at counseling centers of three separate universities, a checklist was created and used in the current study. The checklist asked participants to place a checkmark next to the concern areas that they were currently experiencing with the areas listed being: academics, alcohol-drugs, anxiety, career, roommate problems, couples/marital, family, depression, stress, eating, grief, loneliness, interpersonal July/August 2015 http://jistudents.org Volume 5(cid:1)Issue 3 309 | Journal of International Students relationships, sleep, and sexual orientation. The participants could check as many items that applied to their situation. Results Descriptive statistics were conducted to determine the prevalence rates for psychological symptoms and concerns the international student experienced. Table 1 shows the frequency of each psychological symptom and concerns that the participants reported. The results showed that the students indicated experiencing a variety of psychological symptoms and concerns. The top three concerns were (1) academics (71%), (2) career (60%), and (3) stress (43%). An examination of married students indicated that their top three psychological symptoms and concern areas were similar: first, academics (78%); second, career (53%), and third, stress (36%). Results also indicated that 27% of these students reported experiencing couple and marital problems. Discussion This study is important insofar that it sampled international students attending a university— regardless of whether or not they sought help at the counseling center—to determine prevalence of psychological symptoms and concerns. Previous research has largely focused on identifying psychological symptoms among students who had visited counseling centers. The current study yields findings that provide empirical evidence that the percentage of international students seeking psychological services is not proportionate to the percentage of students that acknowledge that they are experiencing psychological symptoms and concerns. Results revealed that international students mostly experienced psychological symptoms and concerns related to academics, career, and stress. These findings are in line with previous research (e.g., Yi et al., 2003). Since the main goal of international students presumably is to successfully finish their academic studies, it is understandable that they would concentrate mostly on their academics and career-related issues, and have concerns related to making sure that they attain their educational goals. Their concerns related to stress may be as a result of trying to achieve their educational goals or trying to learn to function in new cultural settings. It is, however, important to cope with stress successfully, so that progress towards accomplishing educational plans and career aspirations is not hindered. Other findings of this study lend support to the observation that alcohol and drug use tend not to be a major issue among international students. Similar to Parr, Bradley, and Bingi (1992), this study revealed that very few students experienced concerns in this regard. It is important to draw attention to the experience of depression. About one out of every 5 students indicated experiencing concern related to depression. This is an alarming result and requires some intervention. In addition, 16% of the students indicated being concerned about anxiety, a phenomenon that may interfere with academic and psychological functioning. This study targeted a general population, not one involving students who had sought services at a counseling center. As a result, students’ concern about depression and anxiety being quite high is particularly worrisome. An additional finding in this study was that over a quarter of married international students reported experiencing couple and marital problems. The top three concern areas for this group were the same as for the entire group; i.e., academics, career, and stress. The married Journal of International Students | 310 students’ role, as a student, may be conflicting with their role as a spouse, resulting in a higher level of couple and marital problems. Findings in this study lend further evidence to the observation that international students tend to underutilize counseling services (e.g., Nillson et al., 2004; Pedersen, 1991; Yakushko et al., 2008). While a large percentage of students in the study reported psychological symptoms and concerns, the literature indicates that only about 2% of international students actually seek out psychological services. Some students may be content and feel that such services are not necessary. However, other students may not be utilizing counseling center services due to not having enough knowledge about the services a counseling center provides or as a result of having a negative stigma attached to seeking help of this kind. Recommendations The findings in this research study lend several recommendations related to outreach provided by counseling centers. Developing a brochure directed to international students in particular, as opposed to a general brochure about a counseling center, may be beneficial. In such a brochure, a list of common psychological symptoms and concerns typically experienced by international students may be listed and a summary of what types of services were sought in the previous academic years by international students could be outlined. In addition, the confidential nature of counseling services could be emphasized. Yahushko et al. (2008) identified that students learned about counseling centers mostly through their friends, a health care professional at the college’s health center, their academic advisers, or a brochure about the counseling center. Therefore, there would seem to be value in making available a brochure specifically developed for international students to inform them about different services and to normalize the act of seeking help. Moreover, the literature indicates that international students tend to underutilize counseling services because of the cultural stigma associated with having mental health needs, instead somaticizing problems and seeking help for physical symptoms (Hyun, Quinn, Madon, & Lustig, 2007). Therefore, such brochures should especially be made available at college health centers. In addition to developing and distributing an international-student-specific brochure, the findings of this study suggest other implications. Outreach efforts should especially target students who may be in need of initial guidance or who may be in need of psychological support services for the concerns they experience related to their role as a student. Married students should be another particular group to target. In addition, the high level of depression- and anxiety-related concerns students reported require additional programming to specifically target international students (e.g., depression screening days offered especially in settings where international students tend to visit, such as international student offices or relevant international student clubs). The results of this study underscore the importance of the collaboration between counseling center staff and other key individuals on campus, namely advisors and instructors, and staff at the international student offices. Evidence in the literature shows that international students prefer to seek advice from their professors or advisers, rather than going to counseling centers first (e.g., Aubrey, 1991; Bradley et al., 1995). In addition, literature also shows that compared to local U.S. students, international students are twice as likely to be referred to the counseling center by either their professors or other personnel on campus (Mitchell et al., 2007). As a result, periodically informing campus staff and professors about services available at the July/August 2015 http://jistudents.org Volume 5(cid:1)Issue 3 311 | Journal of International Students counseling center, how to access these services (walk-in intakes versus scheduled intakes), number of sessions available to a student, type of services available (psychological counseling, therapy, career counseling, psycho-educational workshops such as academic skills training, etc.) may help counseling centers in reaching out to international students through these campus personnel. Counseling staff could provide training to faculty and advisers about psychological symptoms and concerns international students tend to experience and how to recognize them. Faculty and advisers could also be trained to provide initial help to the students by normalizing their experiences and, if needed, to provide referral to the counseling center. Literature also shows that international students prefer to go to friends initially for psychological help, before going to professors or advisers (Bradley et al., 1995). Reaching out to international students through orientation programs or student listservs, teaching these students ways of helping a fellow friend who is experiencing a psychological concern, enlightening them about how the counseling center could help with these concerns, and encouraging them to approach such settings to seek help and further information about how to help friends are a few methods to consider. The fact that students prefer first to go to friends, professors, or advisers for psychological help may be related to the students having more easy and regular access to these groups. As a result, counseling center staff could make themselves more readily accessible to the international student community by having a clear presence at international student gatherings and by visiting different international student club meetings to present basic information about the counseling center. In addition, staff could regularly attend international student orientation programs where they can outline typical psychological experiences of international students, normalize these experiences, and make themselves available for questions. These methods will likely help counseling center staff be more easily and regularly accessible to international students and thereby increase the prospect of utilization rates of services provided. Limitations and Suggestions for Future Research While this study has important findings, the results should be considered in light of its limitations. The return rate in this study was relatively high (55%); however, the sample might not be representative of the intended population. The students who chose not to participate may be experiencing a different set of psychological concerns than the ones who participated in this study. The study did not determine the severity or the extent of the psychological symptoms and concerns the students were experiencing, and whether or not the students sought psychological help. Future studies could explore these aspects. Moreover, future researchers could give the same checklist to domestic students so that differences between the two groups can be identified. REFERENCES Aubrey, R. (1991). International students on campus: A challenge for counselors, medical providers, and clinicians. Smith College Students in Social Work, 62, 20-33. Bradley, L., Parr, G., Lan, W. Y., Bingi, R., & Gould, L. J. (1995). Counseling expectations of international students. International Journal for the Advancement of Counseling, 18, 21- 31. Journal of International Students | 312 Coppi, C. (2007). The changing landscape of international student advisement: Balancing bureaucracy with student advocacy. In: H. D. Singaravelu & M. Pope (ed.). A handbook for counseling international students in the United States. (p. 3-11). Alexandria, VA: American Counseling Association. Hyun, J., Quinn, B., Madon, T., & Lustig, S. (2007). Mental health need, awareness, and use of counseling services among international graduate students. Journal of American College Health, 56, 109-118. Mitchell, S. L., Greenwood, A. K., & Guglielmi, M. C. (2007). Utilization of counseling services: Comparing international and U.S. college students. Journal of College Counseling, 10, 117-129. Mori, S. (2000). Addressing the mental health concerns of international students. Journal of Counseling and Development, 78, 137-144. Nillson, J. E., Berkel, L. A., Flores, L. Y., & Lucas, M. S. (2004). Utilization rate and presenting concerns of international students at a university counseling center: Implications for outreach programming. Journal of College Student Psychotherapy, 19, 49-59. Parr, G., Bradley, L., & Bingi, R. (1991). Director’s perceptions of the concerns and feelings of international students. College Student Journal, 25, 370-376. Parr, G., Bradley, L., & Bingi, R. (1992). Concerns and feelings of international students. Journal of College Student Development, 33, 20-25. Pedersen, P. B. (1991). Counseling international students. Counseling Psychologist, 19, 10-58. Poyrazli, S., & Lopez, M. D. (2007). An exploratory study on perceived discrimination and homesickness: A comparison of international students to the U.S. students. The Journal of Psychology, 141, 263-280. Reynolds, A. L., & Constantine, M. G. (2007). Cultural adjustment difficulties and career development of international college students. Journal of Career Assessment, 15, 338- 350. Tung, W-C. (2011). Acculturative stress and help-seeking behaviors among international students. Home Health Care Management & Practice, 23, 383-385. Yakushko, O., Davidson, M. M., & Sanford-Martens, T. C. (2008). Seeking help in a foreign land: International students’ use patterns for a U.S. university counseling center. Journal of College Counseling, 11, 6-18. Yi, J. K., Lin, J. G., & Kishimoto, Y. (2003). Utilization of counseling services by international students. Journal of Instructional Psychology, 30, 333-342. Zalaquett, C. P., & McManus, P. W. (1996). A university counseling center problem checklist: A factor analysis. Journal of College Student Development, 37, 692-697. Zhang, J., & Goodson, P. (2011). Acculturation and psychological adjustment of Chinese international students: Examining mediation and moderation effects. International Journal of Intercultural Relations, 35, 614-627. __________________________________________________________________________ About the Author: SENEL POYRAZLI is professor of counseling psychology at the Pennsylvania State University Harrisburg. She received her Ph.D. in counseling psychology from University of Houston. Dr. Poyrazli is a fellow of the American Psychological Association (APA). She serves as the vice- president of Pennsylvania Immigrant and Refugee Women's Network (PAIRWN). E-mail: [email protected] July/August 2015 http://jistudents.org Volume 5(cid:1)Issue 3