Brunhild Kring, MD

A wide cultural gap exists between Western-trained college mental health clinicians and mainland Chinese international college students, which we as clinicians attempt to bridge in counseling sessions. Our interventions aim to help these emerging adults cope with life in a different society, progress in their psychological maturation, and become their own individual while staying in connection with their family and culture of origin. In therapy, we delve into a number of languages beyond the spoken ones: the idiom of cognitive behavioral skills, the vocabulary of emotions, the physical symptoms of emotional distress, and the language of therapy itself. We take into account the student’s immigration history, and the sequelae of the multigenerational trauma wrought by the social upheaval of the Cultural Revolution and China’s one-child policy. Multicultural counseling competencies help us devise culturally appropriate interventions while guarding against imposing Western social expectations or stigmatizing differences in separation/individuation patterns in Asian families.

 largest number of international students

 mainland Chinese students underutilize counseling sessions. They are concerned about cultural stigma and have doubts about the efficacy of the treatment, and therefore often wait until they experience a crisis before reaching out for 

 This struggle is well-depicted in the animated 8-minute movie 

 by New York-based filmmaker Wendy Cong Zhao.

 The story follows Fan Jiang, who overcomes her initial hesitation to therapy and begins to open up to her therapist. Much to Jiang’s surprise she feels accepted, not judged. After completing her master’s degree in counseling in the US, Jiang is now co-leading a mental health start-up in China. In conversation with the authors, Jiang revealed that talking to strangers about interpersonal conflicts or psychological distress is not in the toolbox of an average Chinese individual. Even though young people in contemporary China have heard about psychological counseling, psychoeducation about the therapy process remains insufficient. They often have little experience in formulating mental health concerns in psychological terms and imagine talking about them to be unhelpful.

For reasons of confidentiality, we changed any identifiable information in this composite case. The scenario describes a frequently encountered reaction in psychotherapy with many mainland Chinese international young adults. This can be understood in the context of several generalizable themes regarding this specific population. 

Mr L, a 19-year-old freshman from northern mainland China, had difficulty making friends in an American university. Even though his English was quite fluent, adjusting to American social customs (eg, saying hello to strangers, making small talk with unfamiliar schoolmates) was uncomfortable. He experienced these interactions as superficial, or fake. Unsure about how to connect socially, he felt isolated and homesick.

He presented to the counseling service of his college with symptoms of 

 and anxiety. The intake coordinator informed him that he would be referred to a bilingual therapist, which he happily agreed to. During our first session, I greeted him in Mandarin, his native tongue. For reasons I later came to understand, the student responded in English. He explained that speaking Mandarin would be too painful for him because it reminded him of happier days back home. He stated his goal in therapy was to get advice on how best to overcome anxiety and self-criticism.

He was an only-child from an affluent family. During childhood, he was often left in the care of his grandparents or a nanny, while his parents were attending to their expanding business. At age 12, the family enrolled him in an international boarding school in China. Students in these private boarding schools are privileged. They can apply to overseas universities directly and do not have to prepare for the widely feared competitive Chinese local college entrance exam called Gao Kao.

In our second session, he spoke Mandarin. When asked about the language switch, he explained that he was feeling better and therefore did not mind speaking Mandarin. Our sessions continued in his native language but were peppered with English expressions.

He filled his therapy sessions with accounts of events and facts without acknowledging any personal feelings. My attempts to help him identify his thoughts and emotions were met with staunch resistance. As time went on, he became increasingly dismissive of my interventions, and criticized our efforts to identify feelings as “too Western” an approach. He believed that paying such close attention to emotions resulted in rampant rates of depression in the US and therefore should be avoided. He often denied feeling anything. He looked dysphoric and fell silent, because he was frustrated at not getting useful advice from the therapist. We found ourselves at an impasse.

Historical and Socio-cultural Factors in Mainland China

Social upheavals in 20th century China pushed millions of families into survival mode. The Cultural Revolution (1966-1976) forced one-third of Chinese youth to leave home for reeducation programs in rural areas.

 In addition, families suffered separation through other forms of forced labor or imprisonment. The mainland Chinese students in treatment with us were often unaware of how their families lived through decades of war, famine, and political terror, as their elders tried to protect them from the painful past. 

China’s one-child policy (1979-2015) ended only recently. The current cohort of mainland Chinese international college and graduate students in the US belong to the one-child generation. They are the sole carrier of the older generation’s hope for a more prosperous and successful future. Attending a prestigious university in the US is a dream come true for the parents and grandparents, helping them compensate for their own lost opportunities for higher education.

The decision of a Chinese family to enroll their young adult children in universities in the West, thousands of miles away from home, is motivated by a host of factors and often requires advance preparation in the student’s childhood. Many prosperous Chinese families choose to register their children in boarding schools at quite an early age, believing these schools to be educationally superior to day-schools. For children, it is adaptive to refrain from expressing sadness or anger about these separations from their parents dictated by cultural norms and economic ambition. Educational attainment is a filial obligation and economic exigency trumps yearning for family togetherness.

When boarding their children in this culturally normative fashion, the parents may not be aware of the unconscious repetition of the traumatic family separations they themselves were subjected to during the Cultural Revolution.

The Complexities of Acculturation in Late-Adolescence

The student in our vignette entered an international boarding school when he was an early adolescent. He was launched on an educational trajectory aimed toward higher education overseas. His lack of control in this preordained decision-making process resulted in sadness, homesickness, and grief about being exiled from his familiar community. These sentiments would be worth exploring in therapy; however, the student had never been permitted to question his parents’ plans for him. He expressed his 

 by being frustrated with what western psychotherapy had to offer.

Acculturation to a foreign society while transitioning from late adolescence to adulthood and forming one’s identity is extremely challenging. Chinese young adults grow up in a quasi-monolithic authoritarian society; they are typically not encouraged to express emotions or differences of opinions but are educated to function as a cog in the collective social machine. Being asked to articulate their personal reactions in the service of individual freedom leaves them in a state of identity and value confusion.

The most frequently encountered psychological and psychiatric issues in mainland Chinese students are social isolation, mood and anxiety disorders, eating disorders,

 as well as low self-esteem, procrastination, and maladaptive perfectionism. Acculturation stress can trigger these issues or exacerbate pre-existing mental health conditions. Unfamiliarity with talk therapy and mental health stigma constitutes another barrier to treatment. Asian students in general and only-children in particular are hesitant to reach out for professional help and prefer a more directive style.

In dynamically-oriented psychotherapy, we explore childhood memories, which can easily cause a loyalty conflict for the student. The centuries-old Confucian practice of stipulating filial piety, obedience, and indebtedness to the parents is still at the center of a child’s moral development in modern China.

 Given these cultural and moral tenets, any questioning of the parents’ authority might provoke feelings of shame and guilt that the student needs to defend against. Seeking advice from a professional authority figure rather than confronting family conflicts aids the students in protecting their loyalty to family and culture of origin. 

The vast majority of mainland Chinese students have sufficient English-language skills to get them through language tests and coursework. They acquire English as a second language from textbooks primarily as a practical tool for professional activities, not for the description of emotions. With family and friends, they still speak Chinese, think in Chinese, and use Chinese words to describe experiences. Speaking English in therapy will require a translation in mind.

Although having therapy sessions in one’s native language is a major advantage in a multicultural context, it is not a magic wand. In addition to the linguistic translation, Chinese students also have to reconceptualize psychological concepts in order to communicate their inner world to a counselor. Studies have found that non-English languages have fewer words describing emotions, and that cultural-specific variance is significant.

 Chinese culture rarely encourages one to verbalize one’s feelings. There is also evidence suggesting that Chinese parenting style promotes less emotional valence to memory sharing.

Many Chinese students rely on somatic complaints to draw attention to their emotional distress. They often present to primary care physicians but are reluctant to acknowledge underlying psychological suffering. In therapy, they often defensively bypass their emotions and define their experience as culturally normative. By way of describing their quandaries, they may quote 1 of the very popular idiomatic Chinese sayings called Cheng Yu.

 These idioms are usually quotations from ancient Chinese literature. Used in a psychological context their meaning can be blurry and is reminiscent of proverbs or cultural clichés. As Mr L liked to say, “Shun Qi Zi Ran,” or “go with the flow.” This saying is derived from a concept of Taoism, which he cited as a reason for not wanting to make any decisions that could elicit conflicts. However, therapy can feel stuck in the superficial if this culturally normative defense is not further explored.

Sometimes, the shared native language and 

 can hinder, rather than facilitate the progress of treatment. The role of speaking the mother tongue in a foreign country, together with the specific associations and transference issues that it elicits is a topic worth in-depth examination. Understandably, recent immigrants would prefer counselors who speak their native language. While this preference may be motivated by convenience, communicating in one’s native language can generate intense and possibly overwhelming affective states. Psychoanalysts who treated Holocaust survivors post-WWII in German or Yiddish highlighted the association of the mother tongue with the emotional weight of early childhood experiences and attachment.

 Later psycholinguistic studies also found that emotional and physiological reactions to taboo words are much stronger in the native language.

A native-language-speaking therapist also adds more than his or her language skills to the therapy. Invariably the students will wonder about the therapist’s immigration history and their political stance. Because expatriate communities typically are small, Chinese students will benefit from a specific reassurance of confidentiality.

For students who are fluent in both Chinese and English, the choice of language or a language switch can carry meanings beyond what is communicated semantically. Analyzing the meanings of native words in the second language (ie, English) facilitates exploring topics that might be traumatic or too emotionally charged to discuss in the original language. In the vignette above, it was tremendously helpful to use English to carry us through our first session when Mr L was overwhelmed by sadness and grief.

Hopefully, the case presented here will inspire therapists to become proficient in multicultural counseling techniques. The Association for Multicultural Counseling and Development has operationalized multicultural counseling competencies.

 Counselors are encouraged to become knowledgeable about the cultural background of mainland Chinese students, who (especially at the beginning of therapy) might best respond to cognitive behavioral interventions. For a bilingual therapist, it is crucial to examine the impact of the native language on therapeutic relationships. Simply matching the student with a therapist who is a native Chinese speaker might not be a universal solution, because this commonality is not sufficient to create a therapeutic connection. Depending on their immigration or trauma history, students will have specific preferences. In university orientation sessions, mainland Chinese international students might respond well to bilingual handouts to educate them about process of counseling services. Peer-to-peer outreach by other Chinese students might increase the recently arrived students’ ability to navigate the new society and make them confident enough to seek help. Finally, counseling staff might suggest that university student services create affinity groups that are not clinically focused.

Drs Qi and Kring acknowledge the contributions of the College Student Committee in the Group for the Advancement of Psychiatry (GAP): Alexandra Ackerman, MD; Helene Keable, MD; Malkah Notman, MD; Lorraine Siggins, MD; David Stern, MD; and Julia Shiang, PhD.

is a psychiatry resident at NYU School of Medicine.

is a college mental health psychiatry specialist at NYU Student Health Center.

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Journal of Multicultural Counseling and Development.

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Articles

The cultural gap between clinicians and students from mainland China is a barrier inhibiting productive sessions. 

Speaking the Language: Psychotherapy With Students From Mainland China

Providing psychiatric care for college students is different from treating other grown-ups. These emerging adults are in the midst of a tremendous emotional growth spurt and a leap of neurocognitive maturation. During this bewildering life transition, they often cannot articulate straightforwardly what bothers them. They appear mercurial: at times, they may speak in hyperbole and sound very dramatic. At other times, they shroud what ails them in secrecy because of embarrassment, fear, and hopelessness. Eventually, school stress and academic performance problems propel students to seek assistance. Mental health clinicians attending to this population need to keep an open mind and consider a host of differential diagnoses.

"Jerry" is a 19-year-old sophomore at a liberal arts college in the Northeast who wants to transfer to a prestigious business school. Two months into the fall semester and 1 week before midterms, Jerry reluctantly comes to the counseling service of his college. His dean accompanies him after receiving several alerts from professors about flagging academic performance.

Jerry unenthusiastically agrees to meet with a psychiatrist. He appears tired and says that he feels unmotivated. He is upset with his parents. As an only child, he feels pressured to succeed in business, but is hopeless about ever measuring up to their ambitions for him. He admits to relying on alcohol and marijuana daily for sleep initiation and anxiety management. When asked what would be most helpful to him, Jerry seems surprised by the question: “Everyone tells me that I have an attention problem; my roommate gave me Adderall, and it worked!”

The psychiatric conditions most frequently observed among college students are anxiety, depression, ADHD, substance abuse, and bipolar disorder. Eating disorders carry a high risk for medical comorbidity. Stress and anxiety may worsen during exam periods. Moreover, most psychiatric disorders have their onset during late adolescence and young adulthood. Students in crisis may present with suicidality or psychotic symptoms. Excessive use of alcohol and marijuana pose further health hazards.

When they hit a roadblock with their academic work students like Jerry, who initially reach out to the counseling service for urgent help, often request anxiolytic or stimulant medications for immediate relief. Emboldened by societal opinion and the stubbornly persistent urban myth that stimulants are “smart drugs,” students expect our assistance with cognitive enhancement to prevail in competitive contexts.

Studies estimate that about half of cases with childhood onset of ADHD persist into adulthood.1 However, because of the well-known rates of diversion and abuse, psychiatrists in college health services are wary of prescribing stimulants without a thorough diagnostic work-up.2 An in-depth psychiatric interview, screening with the Adult ADHD Self-Report Scale, and a referral for neuropsychological testing are recommended by a fair number of counseling services before any prescriptions for stimulants are issued. Ideally, the psychiatric work-up should include a basic medical exam, EKG, and routine lab testing. Students are also made aware of the university’s academic support resources.

Students who have come to rely on alcohol and marijuana during adolescence for alleviating anxiety, depression, self-esteem issues, camouflaging inter-personal conflict, and for fun are loath to give this up. They feel culturally emboldened to take advantage of the “medicinal” effects of the various marijuana strains. “I only smoke Blue Dreams,” Jerry announces, referring to a variety of marijuana high in cannabidiol content with purported anxiolytic properties.

How best to treat comorbid mood, anxiety, and substance use disorders has been the subject of a longstanding debate. A review of recent evidence-based studies recommends the integrated treatment of co-occurring mood and substance use disorders to achieve a superior outcome.3 The FDA has approved medications to address alcohol, opiate, and nicotine dependence, but the treatment for excessive marijuana use consists of psychosocial interventions.

Yet, psychiatrists should keep in mind that academic performance problems are a multifactorial phenomenon. They may be related to poor study habits, or academic under-preparedness. This can create a loss of confidence and narcissistic injury among competitive peers or result in oppositional behavior towards authority figures. There can be a lack of motivation because the student’s major was not his or her first choice. Students may be disappointed about not being accepted by their dream school and therefore not apply themselves.

Undergraduate students, in particular, face the difficult task of being away from home and adjusting to life on their own. Despite frequent electronic communication with parents and friends, they may be suffering from homesickness. Maintaining good self-care is surprisingly difficult to achieve. Sometimes the success or failure of the semester is in question because the student fails to establish a predictable sleep/wake cycle and get to class on time. Chronic sleep deprivation is a major contributor to lack of concentration and focus. Without the infrastructure their families provided, students need to learn to eat 3 nutritious meals a day rather than rely on unhealthy snacks. Similarly, in times of stress, it is a challenge to achieve a reasonable work/life balance and have time for leisure activities such as socialization with peers or exercise. Relationship difficulties and romantic disappointments loom large.

Back to Jerry, a fictionalized, albeit typical case. In the initial visit, the psychiatrist explores the nature of the concerns in a non-judgmental fashion, forms rapport with the student, and gains an understanding of his level of psychological maturity and ability to collaborate in making decisions about health care. Creating a shared language about what the basic issues are builds the foundation for a working alliance.

After meeting with the psychiatrist for several sessions, Jerry acknowledges his passion for creative writing. With encouragement, Jerry opens up to his parents. To his surprise, they respond supportively. His anxiety ebbs and he decreases his daily marijuana and alcohol consumption. He is discouraged from using his roommate’s Adderall. He agrees to a referral for CBT for anxiety and insomnia. Jerry’s parents are quite willing to participate in family sessions by conference call. The psychiatrist decides that treatment with medication does not seem necessary for now.

Dr. Kring is Associate Director, Psychiatry Services, Counseling and Wellness Services, New York University, NY.

-Dr. Kring acknowledges the contribution of the GAP Student Committee: Helene Keable, MD, Alexandra Ackerman MD, Malkah Notman, MD, and David Stern, MD.

 Faraone S, Biederman J, Spencer R, et al. Attention-deficit/hyperactivity disorder in adults: an overview. Biol Psychiatry. 2000 48:9-20.

 Prosek E, Giordano AL, Turner KD, et al. Prevalence and correlates of stimulant medication misuse among the collegiate population. J College Student Psychother. 2017. 

https://www.tandfonline.com/doi/abs/10.1080/87568225.2017.131369

 Pettinati HM, O’Brien CP, Dundon. Current status of co-occurring mood and substance use disorders: a new therapeutic target. Am J Psychiatry. 2013;170:23-30.

Emerging adults in the midst of a tremendous emotional growth spurt and a leap of neurocognitive maturation often need guidance articulating what bothers them.

Brunhild Kring, MD

Articles

Speaking the Language: Psychotherapy With Students From Mainland China

College Students Under Stress