is a fourth-year medical student at Georgetown University School of Medicine.

Karen Quan, MS4

As immigrant-origin students increasingly become the face of US higher education,

 there is a need for mental health professionals—particularly those in college counseling centers—to better understand the acculturation process, as well as the relationship between acculturative stress and well-being of young adults, in order to more effectively address the ongoing mental health crisis in college students.

“Christine” is an 18-year-old young woman in her first year of college. At 14, she immigrated from South Korea to the United States with her parents, who moved to pursue their doctoral degrees. She performed well in her international high school and matriculated into a prestigious predominantly white college on academic scholarship while her parents wrapped up their programs and returned to South Korea. During the first semester of her freshman year, Christine had trouble maintaining the high grades that seemed to come naturally to her in high school. She could not seem to manage her time and was often late for or missed classes. In class, she had difficulty following the instructors. She joined the Korean American Student Association, a small student club, seeking out advice on how she could better manage in her first year of college. However, she had difficulty connecting with her US-born peers, as she felt “too Korean.” She missed her family and the ease of connection she had with her peers back home. By the second semester, in the context of the pandemic isolation, and aggression toward people of Asian descent, Christine lost the drive to attend her classes and subsequently began failing a class. Feeling disappointed with herself and too ashamed to speak with her parents, she sought help at her college’s student mental health center after being recommended to do so by her dean.

A nationwide survey showed a rapid deterioration of mental health among the college student population during the COVID-19 pandemic, worsening the preexisting college student mental health crisis.

 Colleges have been struggling to meet the increasing demand for student counseling and mental health services. US college counseling centers are insufficiently staffed and underfunded, and often operate on waitlists.

 Further, college mental health centers are often not equipped to work with immigrant and international students, as opportunities for cultural responsiveness training in professional psychology are scarce within both doctoral training programs and professional development contexts.

 In addition to the developmentally appropriate stressors of individuation and identity exploration,

 immigrant students like Christine are at risk for an additional, unique type of stress known as acculturative stress.

Acculturative stress refers to the specific stress reaction of immigrants in response to their acculturation process, which can be described as the “changes following contact between culturally different people.”

, a term that implies involvement of a singular culture and negative connotations in its name

is a preferred term to describe the phenomenon that affects performance, mental and physical health, and sociocultural adjustment.

 Stressors can be social, cultural, familial, environmental, institutional, or perceived difficulties (

Acculturative stress can lead to anxiety, depression, somatization, and behavior problems, as well as exacerbate underlying psychiatric disorders.

 Thus, recognizing acculturative stress may be one integral aspect in an immigrant student’s mental health care to consider in their psychiatric evaluation. In Christine’s case, going to college led to the loss of the social support of family, friends, and community that may have provided the scaffolding to buffer acculturative stress.

Students need to feel that they have adequate support to handle the stress around them. Stress arises when individuals believe they do not have the tools or coping response to handle a demanding or threatening situation. Although stress and stressful situations are parts of life, managing stress in a healthy, productive way does not always come naturally. Identifying and reinforcing buffers can help mitigate the pathogenic effects of stress. More simply put, keeping the stress at bay can prevent it from boiling over. According to the stress-buffering hypothesis, having social support—even the perception of social resources—could buffer the stress response and lessen the perceived potential harm of stressful situations.

 By reinforcing to students that they are heard, accepted, and valued in the social and clinical setting, clinicians and counselors can help their students develop better coping efficacy with stressors.

 We provide 4 strategies that mental health counselors and clinicians can adopt to help explore and better support students as they grapple with differences in their culture of origin and their new majority culture.

There are a variety of scales available, including the Acculturative Stress Scale for Chinese College Students scale (ASSCS),

 the Social, Attitudinal, Familial, and Environmental scale (SAFE),

 the Race-Based Traumatic Stress Symptom Scale,

 and the Riverside Acculturation Stress Inventory,

 which address similar factors such as: work/academics stress, language insufficiency, intercultural relationship, perceived discrimination, and social/cultural isolation.

We present a few questions from the Riverside Acculturative Stress Inventory

 for consideration when working with immigrant and international students (

 Riverside Acculturative Stress Inventory

Student responses from targeted acculturative stress exploration can help clinicians better understand how their students might be suffering and what their patients may need. For example, if language plays a large part in the student’s acculturative stress, supporting the student in finding a tutoring program with an emphasis on language skills may be helpful.

2) Provide Language Tools to Combat Social Constraints

While feelings of belonging and support are integral with stress buffering, social constraints interfere with the cognitive and emotional processing of stress. Social constraint refers to an individual's perception that their social networks are unsupportive or unreceptive to discussions regarding stress related to their cultural background. Racial and ethnic minorities who havehigher social constraintsmay experience more psychological distress. In a study on acculturative stress in Hispanic/Latino and Asian immigrant college students, Asians who felt constrained to not express their thoughts and feelings about their acculturative stress by their social network experienced more psychological distress. It is important to recognize that it is not necessarily a lack of support that attributes to acculturative stress, but rather a mismatch between desired and received support.

 Counselors can offer interventions to reduce stress caused by social constraints, such as exercises with students to identify and understand their social constraints and to develop the language to communicate their thoughts, feelings, and needs effectively. Developing alternative outlets for emotional expression, such as expressive writing or online support groups, can give students ownership of their experiences and their voices, which can be helpful in situations where support from their community cannot be attained.

Mental health professionals should encourage students to explore self-agency and develop values that can support them making their own decisions while also preserving their cultural heritage. Those who adopt values of individualism and self-agency are more likely to have positive attitudes toward seeking professional psychological help, which is important for immigrant students who struggle with mental health disorders. If these skills of self-agency conflict with the student’s cultural or ethnic identity and values, it is vital for clinicians to help students integrate and reconcile those incompatibilities and hopefully maintain their bicultural or multicultural identity.

 Taking pride in both cultural backgrounds seems to be associated with well-being for first-generation and second-generation immigrants.

 The discarding of one’s heritage culture, rather than adapting to the United States, is associated with increased health risk behaviors.

 Strong racial identification and racial pride can also provide a buffer against discrimination and distress

 and is connected to positive mental and physical health outcomes.

Most clinicians who work at academic mental health centers are not immigrants and do not have extensive experience working with or treating immigrant students. Therefore, practicing cultural responsiveness, such as keeping an open mind and learning more about different cultures without overgeneralizing, will help providers better serve this population. In the United States, race and ethnicity are often conflated, resulting in racialization—the process of stereotyping a group of peoples—of immigrants who may not fit into their “assigned” racial role.

 For instance, the racial group Black consists of many ethnic groups including but not limited to African Americans, Afro-Caribbean immigrants, and African immigrants, but those classified as Black may not all identify as African American. School-based and clinic-based interventions that work for one group may not apply to another. With this in mind, we must approach each student’s care based on their individual story and context.

For Christine, an essential part of her care involved connecting with a therapist who helped her navigate through the guilt she experienced for struggling academically in the face of her parents’ sacrifices and the shame of “not measuring up” to the expectations of her family. Because the Korean-immigrant community she grew up in had many cultural values that differed from those of her Korean-American peers, she had to reassess her own ethnic identity as a Korean in America, especially during a time of increased Asian hate. Her therapist also recognized that while the acculturative stress caused significant psychological distress, Christine still needed further care. History-taking by her psychiatrist revealed that Christine had symptoms of attention-deficit/hyperactivity disorder (ADHD) as a child. These symptoms were missed due to her parents’ heavy involvement in her education and were exacerbated by the increasing cognitive challenges and acculturative stress of her new environment. She was started on Ritalin, and with continued therapy, she saw improvement in her grades and increased ability to navigate her new environment.

As international students, first- and second-generation immigrants continue to make up more of the higher-education population in the United States, mental health professionals must be equipped to help this growing population with their needs.The ability of mental health counselors and clinicians to recognize acculturative stress and to help provide support for immigrant college students becomes even more pertinent as the school year starts again. Hopefully, this year, we will be more ready.

is a licensed clinical psychologist, clinical director, and assistant professor in the Department of Educational and Psychological Sciences at the University of Miami. 

is a child and adolescent psychiatry fellow at Medstar-Georgetown, board-certified adult psychiatrist with attending privileges at Howard University Hospital, and an American Psychiatric Association SAMHSA fellow.

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