Higher Education Institutions

and International Students’

Mental Health
The following publication is produced by the YoungMinds Stressed Out and Struggling (SOS) Project,
which is funded by the Big Lottery Fund. The project aims to highlight the mental health needs of 16-25
year-olds, and campaigns to improve access to and acceptability of mental health services for this age
group. YoungMinds believes that this group requires particular consideration because of the stresses and
strains they face in making the transition from adolescence to adulthood, which can compound problems
already faced by young people who are vulnerable to mental ill health.

YoungMinds is the leading children’s mental health charity, working within the Every Child Matters five
outcomes framework to improve the mental health of all children and young people. If you would like to find
out more about YoungMinds, please visit www.youngminds.org.uk

Other publications produced by the SOS Project include:

• Perspectives on the Causes of Mental Health Problems in Children and Adolescents, in which leading
figures from the fields of psychiatry, nutrition, foetal development, psychotherapy, attachment theory and
evolutionary psychology give their views about the causes of mental health problems.

• Information for Higher Education Institutions on Helping Students with Personality Disorder or
Personality Difficulties.

• The Stressed Out and Struggling Mentoring Guidelines – of interest to those involved in the running and
funding of mentoring schemes.

• A briefing paper which summarises recent findings from the field of neuroscience into adolescent and
young adult brain development.

• The interim findings from the YoungMinds Stressed Out and Struggling Service-mapping Exercise is
an invaluable resource for all those interested in how services are meeting the needs of this age group.

• The Stressed Out and Struggling Commissioning Guidelines challenge planners to step back from
commissioning in the usual age-banded format, and to give greater consideration to the particular needs
of 16-25 year-olds, not just when considering the development of new services, but also existing services.

• The Stressed Out and Struggling Focus Group Report – the SOS team met with a range of ordinary young
people in England and Northern Ireland to discuss what the transition from adolescence to adulthood felt
like, what was difficult and what was easy, and the report draws conclusions for policymakers about the
stresses and strains young people face today.

For further information about the project or to download these publications, please visit
www.youngminds.org.uk/sos
Purpose of this paper
This paper is intended to draw attention to and help Higher
Education Institutions (HEIs) support the mental health of their
international students. HEIs already make considerable efforts to
ensure that international students have a positive experience; this
paper considers how attention to the psychological aspects of
studying abroad might enhance that experience. It suggests a variety
of ways – from relatively low-level strategies through to referral to
specialist mental health services – in which HEIs can help this to
happen. It is aimed at all staff groups, whether they are involved in
teaching or in support services.

The challenge
Institutions are under enormous pressure to recruit international students. UK Higher Education
is fiercely marketed – against the USA, Australia, Canada, and institutions within the UK
compete against each other. Students, and often their parents, commit considerable sums
towards an overseas education, with the expectation of success and prestige. When a mismatch
occurs between expectation and reality, between the dream of success and the pressure of
assignments, both individual and institution are at risk of disappointment and failure.1

International students face not only the same life events and stressors as other students –
events and stressors which can have an impact upon their mental health – but they also face
additional pressures, all without the usual support structures of family, friends and home. They
may experience a sense of loss, in the wider sense – of native language, customs, security, of
the sense of self even – due to being in a foreign culture. Students will respond to the difficulties
of transition in a variety of ways: some, for example, may manifest their distress physically
(through sleep difficulties, headaches, stomach problems etc.); others may become depressed
and/or anxious, or develop a panic disorder or an eating disorder. Those students who are less
resilient to adversity, change and loss prior to leaving their home countries will tend to
experience greater difficulty in adjusting to life and study abroad.

The transition from one academic system to another can be unexpectedly confusing and can
lead to high levels of anxiety, as well as to overwork and isolation. Students may be reluctant
to discuss such difficulties with academic staff, for fear of appearing weak. Study skills and
language support providers may be the first to identify students who are experiencing difficulty.

Many international students (over 70 per cent) are self financing or are dependent on their
families.2 Their awareness of the high financial commitment can increase the pressure to
succeed, as well as encourage a reluctance to admit to underachievement or failure. Financial
pressure can lead international students, just like UK students, to work part time. However, this
can create added pressure, as studying in a different language and in a different academic
tradition can be more time-consuming than for a UK student. Financial hardship can also

STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health 1
 lead students to take the cheapest accommodation, or economise on food, both to
detrimental effect.

It is reported that international students, because of their reluctance to admit to psychological

difficulties, may be more willing to present distress in the form of somatised complaints, for
example headaches, digestive disorders, backaches and sleep difficulties. ‘In some cases, in
response to a strong need to evade stigma and to retain family honor, some international
students develop a tendency to ‘somatise’ their psychological problems and express them
through physiological disorders’.3 There is, however, a danger of assuming that students who
do not come from Western industrialised countries may be less psychologically minded, with a
tendency to place more emphasis on physical health.4 This may in fact be evidence of a more
holistic approach to health (as opposed to the traditional Western mind-body split) or simply
that students are less aware of services that may be available within higher education and of
how to gain access to them.

Many international students (and domestic students also) will be unfamiliar with the
definitions of the various disciplines associated with mental health (for example, people are
often not well-informed about the differences between counselling and advice). Even where
mental health support is relatively widely available, the distinction between psychiatrist,
psychologist, psychotherapist, counsellor and student adviser may be far from clear. In
some systems, including within Europe, a psychotherapist or counsellor will, of necessity,
have already qualified as a psychologist or psychiatrist. This can have two effects: a university
counsellor who is not a psychologist or psychiatrist may be seen as less ‘professional’.
Alternatively, students may assume that a university counsellor is a psychologist or a
psychiatrist, and this can inhibit a student from making contact because of the perceived
association with mental illness or ‘madness’.

Factors to consider in relation to the mental health

of international students
One group or many?
The widely-used term ‘international students’ is a convenient shorthand but it encompasses a
vast range of individuals, varied in age, class, ethnicity and religion. Moreover, many international
students’ own communities may be culturally diverse and the students themselves may have
developed bi-cultural, tri-cultural or even more complex mixed identities. When considering
mental health in the context of international student welfare, an awareness of this diversity is
essential: the designation ‘international student’ will include US students already familiar with
mental health diagnoses and intervention (perhaps expecting ready access to provision) to
students from Africa, Asia and the Middle East, where provision will be much less easily
available and where mental health difficulty frequently carries a stigma, not only for the individual
but for the whole family. (To give but one example, it is reported that in China working with the
mentally ill carries such a stigma that few medical graduates consider it to be an option.5)

Culture shock
‘Culture shock’ is a term often used to describe a reaction to the process of transition from one
cultural environment to another; it is referred to in this way by, amongst others, Adler,6 and
Ward, Bochner & Furnham.7 Winkelman8 describes culture shock in these terms: ‘Experiences
that violate their basic sense of morals, values, logic, and beliefs about normality and civility
may contribute to their cultural confusion and disorientation’. Evidence suggests that the

2 STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health
 greater the cultural difference between the familiar and the new, the greater the culture shock.
Lack of access to familiar foodstuffs, change in climate and light levels can prove unexpectedly
disturbing. However, students will respond to this ‘shock’ in an individual manner, according to
their own particular disposition. It is also the case that students from apparently similar cultures
to the new one can be profoundly disoriented by unanticipated changes – a possibility that
should not be overlooked when organising support for students.9

Culture shock of some sort cannot be avoided, but students’ understanding and navigation
through the process can be aided and facilitated by the provision of information and support.

For information about culture shock, see the Information and resources section at the end of
this publication.

Social life and peer relationships

In terms of relationships with their peers, Furnham and Alibhai10 have described how
international students develop friendships, being most likely to associate with fellow nationals,
next with other international students, and then least likely to associate with local students.
Research by Berry11 describes four types of identity in response to a majority culture:

• Assimilated (becoming as much like the majority culture as possible).

• Integrated (adjusting to the majority culture and adopting some aspects of the new culture,
while retaining attitudes and behaviours from the culture of origin).

• Traditional (becoming more associated with original, traditional culture, and rejecting the new).

• Marginalised (retreating from others, rejecting both original and new cultures).

Berry suggests that the mental health outlook is more positive for students who adopt a
strategy of integration or tradition than for those who attempt to assimilate or those who isolate
themselves. The latter appear to be more at risk than the former.

International students are often criticised for forming ‘cliques’ and not mixing. This is to
understate the stress associated with engaging in new social structures, which may appear
difficult to penetrate, or even unwelcoming; therefore association with other ‘incomers’ may
be a sound strategy for creating support networks.

Reducing the risk of mental health difficulties amongst

international students
Information
Many universities provide extensive pre-arrival information and an orientation event on arrival
that may last up to a week. Students report the helpfulness of this information and of these
events,2 which are designed to prepare them for the experience of the new environment. These
preparatory strategies, though thorough, tend to focus on the practical aspects of the
experience: study skills, immigration and finance, shopping, sightseeing, “who’s who” in the
institution. They are less likely to focus on the psychological or emotional process, perhaps so
as not to cause alarm or appear negative. This may leave students unprepared for the other
aspects of change, affecting mood, sleep patterns, social confidence etc. It is also true that
these programmes focus heavily on the initial week or weeks of the first term. Consideration
should be given to ongoing programmes of support,12 including self-access materials, taking
advantage of new technologies, as well as, not instead of, access to experienced personnel.
It may also be worthwhile to devote more time later on in the students’ first term, so that these
important issues can be dealt with again/in more detail.

STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health 3
 Language proficiency
Despite the inevitable assurances to the contrary, anecdotes persist about the recruitment of
students who are ill-equipped academically or linguistically to tackle the demands of an
undergraduate or postgraduate degree in English in a different cultural environment. Even when
additional language tuition is provided at the beginning of the academic year to students with
an International English Language Testing System score of below 6.5, HEIs need to be aware of
the potential pitfalls, in terms of the well-being of international students, of their limitations in
this area. For example, evidence points – not surprisingly – to there being a strong association
between a lack of proficiency in English language skills and homesickness, and also between
English language proficiency and mixing with UK students.13 ‘The language barrier has direct
negative implications for the academic performance of students. The students’ inadequate
language skills often diminish their ability to understand lectures, to take notes, to complete
reading and writing assignments and examinations, and to express orally their opinions and ask
questions in classes.’14 Such difficulties may well have a negative impact on the self-esteem of
international students, and help foster feelings of shame and failure. Over and above this,
however, HEIs should consider assessing language proficiency in terms not just of academic
ability (ie. the ability of the student to fulfil the criteria of the course) but also the student’s
capacity to participate in the cultural and social life of the place of study. In Canada, Australia
and the UK, programmes have been developed to assist international students to feel more
proficient in social and academic interaction. Research shows that these programmes add to
students’ confidence and academic progress.15

Other academic matters

It is also important that HEIs address the widespread lack of knowledge amongst international
students about what is expected of them regarding the style and standard of academic
submissions. The disappointment and frustration which can arise when coursework is deemed
to fall below requisite standards should not be underestimated. HEIs should make the provision
of guidelines on this subject a priority. These could include, for example, information about the
circumstances under which the standard of English in submitted work will affect the overall
mark awarded, examples of coursework highlighting different styles of academic writing, and
information about essay structure and construction of argument.

A piece of written work submitted and marked at an early stage can provide useful indications
of possible difficulties as well as helpful feedback to students uncertain of the standard or style
required. This is as true at PhD or Masters level as at undergraduate level.

Many international students will be unfamiliar with the teaching methods used in UK
universities. To some extent, HEIs have a responsibility to familiarise themselves with the kinds
of teaching employed in the home countries of the international students they recruit from, not
least since the strangeness of UK methods can cause or contribute to international students’
distress. The personal tutor system within HEIs should ideally include the capacity for tutors to
receive training in this issue, so that difficulties and stresses can be aired and discussed. Simply
expecting international students to adjust to UK teaching styles, rather than acknowledge the
difficulties involved, will only increase the potential for international students to feel marginalised
and alienated.

4 STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health
Holidays
While university support systems are available during weekday working hours, provision may
be more patchy during evenings, weekends and vacation times. The Christmas vacation period
can be particularly stressful for students. It may be a time when deadlines for exams or
coursework are pressing; many UK students will have disappeared to join family or friends;
most normal services are closed and the days are dark, short and cold. In some institutions,
students may have to vacate their accommodation for the holiday period, causing unsettling
disruption (in such cases, HEIs could consider helping students find alternative places to stay
for these periods).

It is good practice for institutions, and particularly for student support services, to ensure that
information is available on voicemail, web-pages and in student residences to enable students
to gain access to basic facilities, social company and emergency services during such periods.
It is also helpful to work closely with those personnel in student residences who may be the first
to identify students at risk.

The role of faith/religious networks

In a predominantly Western, secular environment the importance of a faith community to
international students may be overlooked. Numbers of international students will be
accustomed to religious observance as a significant part of their daily life. The private nature of
religious affiliation and the absence of religious practice from daily life may contribute to a sense
of alienation. Many universities have chaplaincies, but these may consist predominantly of
Christian chaplains. Many universities, however, will provide a prayer room or space for Muslim
students, which will offer a valuable place for association.

Research conducted by the National Institute for Mental Health in England16 shows that religious
and spiritual belief can protect people from mental health problems. For instance those with
strong spiritual belief show lower instances of depression and lower suicide rates.17

It is also true that those experiencing mental distress can be vulnerable to exploitation by
certain religious movements or cults.17 International students who become isolated may be
particularly at risk if they do not have ready access to other support networks.

Returning home
It should be remembered that HEIs can help international students prepare for their return
home. Although international students may not appear to be very interested in thinking about
the potential difficulties involved in returning home after a period of study abroad, information or
seminars to help them reflect upon issues of separation/loss (some women, for example, may
have anxieties about the loss of newly found privacy/independence) may be helpful for
international students when dealing with the emotional aspects of going home.

Early warning systems

Staff need to be fully aware of the indicators that suggest a student is in distress. Some will be
more evident to academic staff, others to staff in residences or to peers. Indicators may include
erratic attendance or unexplained absence, disinterest in personal appearance, avoidance of
participation in class, or withdrawal from social contact. Changes in academic performance
need to be noted, for instance an unexpected fluctuation in the quality of work or delays in
handing in assignments. Other behaviours which arouse concern can include drug abuse or
problematic drinking; or health complaints, such as headaches, memory lapses, poor
concentration and tiredness.

STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health 5
 Several institutions have developed robust systems of peer counselling or buddy support. Any
member of staff in regular contact with students needs sufficient levels of awareness to identify
students at risk. This includes less obvious staff groups, such as security staff in halls of
residence, who may have significant interaction with students on a daily basis. Specifically,
training in cultural awareness, including mental health awareness, needs to be made available
to all staff who are in regular contact with international students.18

The GP as a link between student mental health services and the NHS
Accessing NHS mental health services is greatly facilitated by international students being
registered with a GP; encouraging international students to do this, and giving them information
about how to do it, should form part of any orientation or induction event at the beginning of the
academic intake. It is useful for students to have information about the wide range of NHS services
and how these are accessed via the GP, as well as information about dentists, opticians, family
planning, sexual health and well-woman clinics, which can be accessed directly.

Other services
HEIs should bear in mind that there is a tendency to make assumptions about international
students’ attitudes: for example, the blanket assumption that students from particular cultures
will not be interested in counselling. However, it is also unwise for HEI staff to assume that all
international students share a Western view of psychological health. If a student is accustomed
to thinking about mental health in terms of, for example, an organic disturbance in the body,
then the concept of using counselling services may be quite alien. A short information leaflet
giving explanations of concepts such as psychiatry, psychotherapy, psychology and counselling
would be useful. Such a leaflet could be distributed to all international students on arrival.
Alternatively, institutions could direct international students to web-based information on the
topic, for example the MIND website (see the Information and resources section below).

Similarly, staff will need to be sensitive to the importance some students attach to religion
(see section above), and be aware of the spiritual context in which psychological distress may
be regarded.

For those international students, however, who may be more receptive to the concept of
counselling as a way to alleviate psychological distress, one study has found that ‘the physical
location of counselling services seems to be closely related to international students’ utilization
rate’.19 The study which contains these findings recommends that ‘mental health facilities be
situated within or near such non-psychological services as legal, financial, linguistic,
educational, social, and medical assistance.’ If there is a stigma attached to mental health
problems in an international student’s home culture, then this may deter the student from
seeking help from an obviously medically-orientated service. However ‘sufficient representation
of cultural diversity on the counselling centre staff can strengthen the belief of international
students that their unique issues will be understood’.20

Whatever the location of services, good liaison can make a significant difference in ensuring
rapid and effective referral. This is particularly true of the following services (where provided):
academics/personal tutors, counselling services, health services, financial and welfare services,
chaplaincy, international student advisers, Students’ Union advisers, learning support staff,
disability advisers, mental health advisers and careers advisers.

6 STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health
 Disabled students
The Disability Discrimination Act (part 4) covers all students, including international students; its
remit extends to mental illnesses, as well as physical disabilities. Under the Act, institutions
have a duty not to treat disabled people less favourably for a reason related to their disability,
and a duty to make reasonable adjustments (which might include providing adapted equipment,
note-takers or assistants) for disabled students. The only difference between international and
home disabled students is that their study is not funded in the same way, and international
students are not eligible for publicly funded support.

Information and resources

MIND
http://www.mind.org.uk/Information/Factsheets/History+of+mental+health/A+brief+guide+to+w
hos+who+in+mental+health.htm

National Institute for Mental Health in England (NIMHE)

Project on Spirituality in Mental Health (2003). Inspiring Hope.
http://mentalhealth.org.uk/html/content/spirituality_project.pdf

Rethink (2005). Spirituality and Mental Illness.

http:www.rethink.org/publications/pdfs/advice-factsheets/spirituality.pdf

Royal College of Psychiatrists

www.rcpsych.ac.uk/info/index.htm

Student depression
www.studentdepression.org

Students in mind
www.studentsinmind.org.uk

UKCOSA (2004). International Students and Culture Shock.

http://www.ukcosa.org.uk/images/shock.pdf

STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health 7
 References
1. Weissman, D. & Furnham, A. (1987). The expectations and experiences of a sojourning temporary resident abroad: a
preliminary study. Human Relations, 40 (5), pp. 313-326.
2. UKCOSA. (2004). International Students and Culture Shock. From: http://www.ukcosa.org.uk/images/shock.pdf
3. Kuo, C.-L. & Kavangh, K. H. (1994). Chinese perspectives on culture and mental health. Issues in Mental Health Nursing,
15 (6), pp. 551-567.
4. Kareem, J. & Littlewood, R. (1992). Intercultural therapy: theories and techniques. Oxford: Blackwell Science.
5. Eimer, D. (2005). China struggles to cope with suicide epidemic. The Independent, 19 September 2005.
http://news.independent.co.uk/world/asia/article313526.ece
6. Adler, P. S. (1975). The transitional experience: an alternative view of culture shock. Journal of Humanistic Psychology,
15 (4), pp. 13-23.
7. Ward, C., Bochner, S. & Furnham, A. (2001). Psychology of culture shock. Hove: Routledge.
8. Winkelman, M. (1994). Cultural shock and adaptation. Journal of Counselling and Development, 73 (2),
pp. 121-126.
9. Martin, J. N. & Rohrlich, B. (1991). The relationship between study-abroad student expectations and selected student
characteristics. Journal of College Student Development, 32 (1), pp. 39-46.
10. Furnham, A. & Alibhai, N. (1985). The friendship networks of foreign students: a replication and extension of the
functional model. International Journal of Psychology, 20 (6), pp. 709-722.
11. Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology: An International Review, 46 (1),
pp. 5-34.
12. Barty, A. & Raven, S. (2003). Reaching out to international students. AUCC Journal.
13. Yanhong Li, R. & Kaye, M. (1998). Understanding overseas students' concerns and problems. Journal of Higher
Education Policy and Management, 20 (1), pp. 41-50.
14. Cadieux, R. A. J. & Wehrly, B. (1986). Advising and counselling the international student. New Directions for Student
Services, 36 (Win), pp. 51-63.
15. Mak, A., Westwood, M., Barker, M., et al. (1998). Developing sociocultural competencies for success among
international students: The ExcelL Programme. Journal of International Education, 9 (1), pp. 33-38.
16. National Institute for Mental Health in England (NIMHE) & Mental Health Foundation (2003). Inspiring hope: recognising
the importance of spirituality in a whole person approach to mental health. Leeds: NIMHE. See
http://www.mentalhealth.org.uk/html/content/spirituality_project.pdf
17. Rethink (2005). Spirituality and mental illness. London: Rethink. See
http://www.rethink.org./publications/pdfs/advice-factsheets/spirituality.pdf
18. Barty, A. & Lago, C. (2003). Working with international students: a cross-cultural training manual: 2nd Edition. London:
UKCOSA. See http://www.ukcosa.org.uk/
19. Bui, K.-V. T. & Takeuchi, D. T. (1992). Ethnic minority adolescents and the use of community mental health services.
American Journal of Community Psychology, 20 (4), pp. 403-417.
20. Brinson, J. A. & Kottler, J. (1995). International students in counselling: some alternative models. Journal of College
Student Psychotherapy, 9 (3), pp. 57-70.

8 STRESSED OUT & STRUGGLING: Higher Education Institutions and International Students’ Mental Health
© YoungMinds 2006
This paper has been co-written by YoungMinds, the leading children’s mental health charity, and Alison Barty,
Senior Student Counsellor and Student Services Co-ordinator at SOAS (University of London). We would like
to thank the Committee for the Promotion of Mental Well-being in Higher Education for commenting on drafts
of this publication and helping to distribute it.
The paper has been produced as part of the YoungMinds Stressed Out and Struggling Project which aims to
highlight the mental health needs of 16-25 year-olds, and campaigns to improve access to and acceptability of
mental health services for this age group.
For more information about the project, visit: www.youngminds.org.uk/sos
YoungMinds, PO Box 52735, London EC1P 1YY
Tel: 020 7336 8445
Fax: 020 7336 8446
YoungMinds Order Line: 0870 870 1721 (membership and publications)
YoungMinds Parents Information Service: 0800 018 2138 (freephone supplied by Verizon Business)
Email: policy@youngminds.org.uk
www.youngminds.org.uk

YoungMinds is a registered charity no. 1016968.