Stories from CAPS Users: Combating Mental Health Stigma (Part II: International Students)

Editor’s note: This article was initially published in The Daily Gazette, Swarthmore’s online, daily newspaper founded in Fall 1996. As of Fall 2018, the DG has merged with The Phoenix. See the about page to read more about the DG.

I have conducted interviews with four users of Swarthmore College’s Counseling and Psychological Services (CAPS), all of whom come from backgrounds that may stigmatize mental health. I investigated how they found their way to counseling. In Part 1, I focused on the experiences of three domestic (non-international) students. This part concentrates on the experiences of a Chinese international student, hereafter referred to as Derek, a pseudonym adopted to protect his privacy.  I suggest reading Part 1 first to provide a stronger sense of contrast, but Part 2 can be read as an individual piece.

In the fall of 2017, his first semester at Swarthmore, Derek found that he often could not sleep at night.  He would go to bed at 12:00 AM––relatively early for him––but he couldn’t fall asleep until 3 or 4 AM; sometimes he would lie in bed until the sun came up, exhausted yet restless.

Derek’s persistent insomnia had consequences. In addition to making him more lethargic during classes and more stressed in general, he also missed deadlines for his assignments. He sought help from his class dean and Student Academic Mentor, both of whom directed him to CAPS. As of the time of the interview, Derek had been visiting CAPS for several months. His “sleeping disorder,” which he describes as a physical problem unrelated to other mental disorders or medical conditions, seemed to be somewhat under control. Yet he does not feel any relief from the thoughts that usually harassed him during sleepless nights and plagued him on stressful days.

“I went to CAPS for academic, not therapeutic, reasons.  For one thing, after I talked to the dean, I went to CAPS because I had to go. Also, because I was missing assignments––my professor was pissed,” he said. “So I told myself, ‘OK, maybe I should at least, um, you know, show the tip of the iceberg of my problems and let CAPS write a letter for me [to prove to my professor that I am going through some problems],’ even though I didn’t eventually end up needing the letter. ”

Derek heeded the advice given to him, but his reasons for following the advice were different from what his advisors had intended. Even though he ultimately justified to himself that he should go to CAPS, he still resists the idea to some degree. He understands that, given the overwhelming stress he is experiencing from all corners of his life, it is possible that his insomnia is a byproduct of a mental health condition instead of a stand-alone physical condition.  To me, a fellow student coming from a similar background and capable of speaking the same language, Derek articulated many of these sources of stress and talked about the long hours he spent identifying, analyzing, and agonizing over them on his own. To his current counselor, or any of the American counselors at CAPS, however, he didn’t divulge much of his actual struggle, not trusting that they can fully understand.

Much of this distrust stems from the huge cultural gap Derek perceives between himself and his therapist.  Derek is an international student from China who completed and excelled in the entire 12 years of China’s notoriously grueling education system. While Derek is quite proud of this achievement, he also realizes this disconnects him from many of his Chinese international peers, who went to high schools in English-speaking countries to better transition into American colleges.  Successfully coming out of such a rigid school system made Derek very high-achieving––a trait that was also bolstered by his home environment: raised by loving parents who were also extremely successful in their respective fields, Derek feels both grateful and that he has a lot to live up to.

Derek’s upbring and his own awareness of how fortunate and privileged he already is have shaped his self-expectations:  he is supposed to be completely self-sufficient––whether he can solve a problem depends entirely on his own willpower and diligence; he was trained to be competitive––he feels that there is very little space for him to make mistakes or slow down, because there will always be someone who may catch up and beat him; feeling exhausted is an indication of the lack of determination or diligence; vulnerability is a sign of weakness and defeat.   

“I feel like [the counselors at CAPS] don’t really understand where I am coming from. I feel like a lot of my problems are caused by my upbringing and my environment. One thing that a lot of my friends and myself absolutely hate is when someone who can’t actually understand what you are going through still say ‘I get it.’ Is this a typical American social norm? These kinds of people will say ‘Oh, I totally get it.’ Or say ‘That must have been hard’ or something like that.  When actually they don’t get it at all,” he said. “I guess I ultimately don’t trust CAPS entirely. I trust that they’ll give me the same advice I tell myself and not actually accomplish anything.”

Derek also did not quite trust his counselor because he feels like he has a lot to prove to his new American environment. Being in a foreign country, he is very conscious of his Chinese background and feels a responsibility to give the best representation of his home country.  For him, his counselor seems to be just another foreigner, someone who is, by default, going to judge him and the background he represents––to whom he needs to prove himself, the same way he feels like he needs to prove himself daily to his American peers. Derek’s wish to be a good representation of his home country, however, is thwarted by the difficulties he feels when adjusting to a new culture and a new language. He frequently feels that he is no longer comfortable with who he has become in America.  

“Going to therapy also feels like a social occasion. When I was in China, my social personality was confident and popular––that completely changed when I came to an American college. But even when––or maybe because––I am speaking English, not my native language, I feel like I have the pressure to appear as eloquent, as competent as I could, because I always feel the pressure that I should be as confident while I am speaking English as I am speaking Chinese––and that I should be as popular here as I was in China,” he said. “So maybe using the language itself when talking to my therapists reminds me of certain problems or certain goals I have yet to achieve.”

Another aspect of “proving” himself to his American counselor and his new American environment in general, Derek feels, is to disprove certain stereotypes––something he also finds to be very difficult because he is in the process of struggling out of habits and mindsets that could be seen as stereotypical.  

“I was hesitant [to talk to my counselor] because I am very clear at least to myself––the way I identify my problem is [sic]––that most of my problems came from the competitive environment I was brought up in. So I guess doing therapy I was hesitant to actually discuss this because I didn’t want to strengthen the stereotype of Asians being competitive against their peers,” he said. “Also, that’s an image I battle with myself very often already––I already don’t want to be like that. It was really hard for me to actually admit all this to my therapist.”

This need to appear as a put-together person to his therapist, coupled with how exhausting and complicated explaining his non-American background makes him feel, characterizes visits to CAPS as a burden instead of an aid for Derek.  

“Speaking for myself––sometimes I actually don’t want to go into CAPS that often. I often feel a lack of energy to deal with my problems. I just feel like I am trying to let it go. Just like, you know, my problems are going to go away at some points, and I’ll know that maybe I’m getting better––just by forgetting my problems” he said. “But either way, I’ll get better in the future. Going to CAPS takes a lot of the energy that I don’t necessarily want to spend. While I was actually in the office, the feeling that I already lack energy and that I need to spend more energy to explain myself to my therapist––that kind of feeling makes therapy not work at all.”

Derek acknowledges that the exhaustion, frustration, and anxiety he experiences daily, in addition to his insomnia, can be a reflection of more serious mental health issues. Derek also supports the idea that a person who is stressed to the point that they cannot produce work on time can go to CAPS for therapeutic reasons; and he does believe that this person can get effective help for their mental and emotional wellbeing by going to CAPS.  It is, however, very difficult for Derek to reconcile what he has learnt and believes about mental health counseling with his own situation, especially when he always thought that had he tried harder, he would have overcome his problems on his own. For Derek, there is also always an underlying fear that maybe he is pathologizing what other Swarthmore students would consider a routine and normal process. To utilize his therapy sessions not for academic reasons––getting proof for his professors to understand what’s happening, so his grades wouldn’t suffer too much––but for “actual” therapy feels like defeat.  

“I guess for myself, I admit that it’s just too is damaging to my self-identity, as someone who is high-achieving and self-sufficient to [go to CAPS for therapeutic reasons]. Especially when I’ve taken a lot of Psych classes myself, I think I am supposed to defend or arm myself with the knowledge I have, which is not happening right now,” he said. “So actually admitting that I have a mental health situation can be a problem to me.”

The official diagnosis provided by a medical professional can sometimes give students a sense of certainty and community––a feeling that they are suffering from a treatable illness which other people in the world share. Derek, however, revealed that he does not really want to be officially diagnosed, as he thinks that getting an official label will cause him to make excuses.  

“I definitely would argue that, if someone comes to me and tells me that I have a condition or an illness, that’s not going to help me that much. I feel like I will lower my self-standards to accommodate my condition, or use my condition as an excuse to stop working hard, and I don’t think that’s going to help my kind of self identity, my self-understanding, my ambition, my drive,” he said. “Especially when everyone here at Swarthmore is so successful. No one seems to have any problems at all, even though I know some of them do have problems.”  

Derek also does not want an official diagnosis because he thinks that may “negatively affect a lot of people’s evaluation of him.” His distrust towards CAPS counselors also extends to his distrust of CAPS’ promise of confidentiality.  He fears that whatever he divulges to his counselor, or whatever official diagnosis he receives, can potentially impair his academic and social standing with the College.

“I feel like even though CAPS claims that everything is confidential, they are still school-affiliated. Since a large part of my goal is to actually do well in school, and to apply for fellowship or to apply for positions, a part of me is also afraid that disclosing this information will somehow make me appear to be not as good for my sort of application or whatever I want to do in school,” he said.

Derek’s existing uncertainties about his old self, the culture-shock he is currently experiencing, and what absorbing American ideas means to the ideas he grew up with in China, bombard his thought process when it comes to CAPS.

“When I’m talking to CAPS, I’m sort of exposing my weak side, which is something I actually don’t want people to have access to.  Because a large part of me before coming to America is to do the best on everything I could do, actually showing my––I want to say mental health condition––but for me it is actually really weakness, sickness––everyone can get sick[sic]––But the problem is that to my understanding and to the understanding of Chinese cultural society, it is sort of a weakness. It is a way for people to evaluate another person.  I don’t want to be in that situation [and be evaluated negatively]. So if I’m asking for funding or applying for leadership position, or being involved in organizations where they didn’t want someone with a ‘weakness’ to be involved in––I don’t want to expose that to other people, even though I know they might not actually evaluate me in this way––There’s still a fear that this might happen.”

Some of Derek’s unresolved concerns are tethered to or exacerbated by the unfamiliar concepts and situations he observed at CAPS.  

“Because I know that CAPS has the power to potentially write you something that helps you get housing accommodations or helps your professor understand what’s happening––I’m inclined to think [that they have considerable influence on such higher-level, bureaucratic decisions.],” he said. “But this is unconfirmed. I don’t know if someone is actually not being equally treated for funding or whatnot, just because they have a mental health condition.”

Ultimately, Derek believes that had there already been a CAPS counselor who comes from a background similar to his own, he would be more inclined to visit CAPS for therapy. For the time being, however, he relies on conversations with close friends and his own resilience to get through his daily struggles.  

Director of International Student Services, Jennifer Marks-Gold, observes that there are challenges for international students when it comes to using counseling services, or interpreting the policies of medical confidentiality in America’s medical system.  

“I think that being a visitor and not being a permanent resident, international students have so many extra stressors that they have to think about. They have to follow the rules as a visitor, and I can see why [medical confidentiality] would be something that they would be hesitant about, and that they don’t quite understand the system,” she said. “We at the Office of International Student Services try to make it as easy as possible with all the regulations and explain everything, but for the students, there is still the added layer of worrying about, well, if I go down there to [CAPS], how would the information be released?”

The Office of International Student Services integrates information about CAPS and other related resources into International Orientation, a five-day event, specifically for international students, that happens prior to general Orientation. Marks-Gold described setting up a CAPS “round table,” which is an event somewhat similar to “speed dating” campus resources and avails international students with the opportunity to talk with CAPS counselors and ask questions about the service without any pressure and at their own convenience. Helping international students understand this sensitive issue and the resources available to them, however, is a delicate operation and hard to maneuver.  

“Sometimes I’ve been able to just take a student, walk them down there [to CAPS] and just be with them to make the appointment. And I think that really helps sometimes if someone’s just not sure about it––it’s a scary thing to do, something that’s unknown. So basically showing them that our office is here for them no matter what––if it’s even driving them or taking them [to off-campus counseling facilities], finding the right [counselor] for them,” she said. “Sometimes there’s not a right person [currently available at CAPS], there is no connection––I always tell the students, ‘go to the session, see how it goes.’ Or ‘you’re the consumer, you have to really get something out of the session and if you’re not, then come back and let me know.’ Or ‘we can either find somebody else for you or do what we can. So I research the right person for you.’”

Marks-Gold commented that it could be harder for international students to find the right counselor at CAPS considering how diverse the on-campus international student body is, and she suggested off-campus resources.

“We do mention at International Orientation that, if the students go down [to CAPS] and they don’t connect with someone, then perhaps we could find somebody else outside the school for them that might be able to relate to their culture and their background. There may be counselors [at CAPS] who share or relate to the international experience to a better degree, but I think it would still be hard,” she said. “We have over 50 different countries represented, and what the students actually need, it is hard to predict.  That’s why I would hope that they would come to me.”

Marks-Gold talked about her own experience of trying to be more informed regarding this issue and providing better support for her students.  

“A lot of what I do personally to keep myself on top of things [related to students’ mental health] is that I belong to the National Association of Foreign Student Advisors, and at least once or twice a year I go to a session just for mental health for international students. So then I learn the best ways to reach out to students. You always have to keep educating yourself and make sure that you do have the right resources for them and make sure that students feel comfortable enough,” she said. “And again, I always say ‘if it’s not me, then let’s find somebody else who will be able to support you as far as you need, like on-campus student groups et cetera.’”

Marks-Gold also explained how this particular issue is challenging because it is so specific to the individual, and difficult to address en masse.  

“This is an issue that varies from year to year and how the students are. It’s so individual.  It’s very hard to know. I mean sometimes students will come [to the Office of International Student Services] and talk about something else and then I’ll notice something, maybe they tear up, or I see something’s happening with their roommate or any other little things,” she said. “Many times I just keep the conversation going, I listen and then if I feel that they do need some more help, well, I’ll say ‘have you tried to go to CAPS?’ ‘Are you interested in that? How do you feel about that?’ And then they let me know what their culture is and how they feel about asking for help.”

“Because you just can’t assume––even if you have had three or four students from a certain culture with the same experience where they may feel uncomfortable about going to CAPS, that doesn’t mean that the fifth person from that culture will feel the same. Maybe the fifth student will say ‘hey, I want to go [to CAPS]’ and ‘send me, where do I sign up?’ You just have to keep an open mind because everyone is unique,” she said. “Everyone’s an individual and everyone’s coming from a different family. The way they were raised, the openness regarding this specific issue, that kind of thing. The culture definitely plays a part in someone’s willingness to go, but it’s not the only source of influence.”

Marks-Gold also believes that while each student’s needs is individual, the increasing culture of open discussion and acceptance both on and off campus regarding mental health can be very helpful for helping international students reach out for the right resources.  

“The more you hear, and the openness of [discussions regarding mental health]––it can make you feel more comfortable. And again, even if you want to talk about America in general, where a lot of high profile people have come out and said, ‘you know what, I suffer from depression’ or ‘my family has a history of suffering from bipolar’ and all those things are open––it does help international students become more comfortable with this idea,” she said. “But still, there are so many different cultures, so many different aspects, and so many different layers to the ways international students are hearing about mental health issues coming from there. But I do think we adapt, we grow while we are here.”

Nicole Liu

Nicole Liu is probably majoring in some combination of English, Chinese, and Psychology. Eugene Onegin has remained her favorite book for 3 years, and she is on her third attempt to complete Middlemarch.

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