





































136

Graduate Student Journal of Psychology
2023, Vol. 21

Copyright 2023 by the Department of Counseling and Clinical Psychology
Teachers College, Columbia University

Beyond Language and Culture: A Qualitative 
Exploration of Mental Health Barriers for Chinese

 International Students Seeking Therapy in the U.S.
Yuanruo Xu

Derner School of Psychology, Adelphi University

  International students are individuals who enroll 
in educational institutions outside their country of 
origin (Altbach & Knight, 2007). The United States 
continues to be a top destination for international 
students, hosting 914,095 in the 2020-2021 academic 
year according to the Institute of International Edu-
cation’s Open Doors 2021 Report. Chinese students 
constitute the largest cohort among these, making 
up 34.7 percent of the total international student. 
Given their sizable representation, Chinese interna-
tional students (CIS) bring with them unique cul-
tural, academic, and personal experiences, creating 
a diverse landscape within U.S. educational institu-
tions. Consequently, this significant demographic 
necessitates in-depth understanding and focus from 
educators and researchers, especially in addressing 
the unique challenges faced by this group of students.
 CIS face significant mental health challenges. A 
recent report revealed that nearly half of these stu-
dents experience moderate stress, depression, and 
anxiety. Shockingly, 70% have never sought men-
tal health services. Furthermore, 40% primarily re-
sort to emotional suppression as a coping mech-
anism, and one-third report having had suicidal 
thoughts. Of those contemplating suicide, merely 
40% have reached out for mental health support. 
The Covid-19 pandemic intensified these problems: 
60% noted a decline in their psychological health, 

and 20% faced challenges accessing mental health 
services (The White Paper on Mental Health, 2020).
 Despite the evident need for mental health sup-
port, existing research has not adequately explored 
the unique challenges CIS encounter when seeking 
mental health treatment in the U.S. Gaining insight 
into these barriers is critical to devise effective in-
terventions and strategies to support their mental 
well-being. This study seeks to answer: What barri-
ers do CIS face accessing and using psychotherapy 
services in the U.S., and how do these barriers influ-
ence their attitudes toward mental health treatment?
 A comprehensive meta-analysis conducted by 
Jing et al. (2020) assimilates data from 3,685 perti-
nent journal articles published between 1900 and 
2018, providing invaluable insights into the global 
landscape of international student studies. This ex-
tensive body of work enriches our understanding 
of the demographic central to our current investiga-
tion. The marked increase in articles since 2006 un-
derscores a growing research interest in international 
students. Key topics covered in these articles include 
second-language acquisition, cultural difference and 
stigma, and mental health knowledge. These factors 
dovetail with the challenges that CIS frequently face 
when studying in the U.S. Not only do these barri-
ers shape their experience as international students, 
but they also have potential ramifications on their 

This qualitative study explores the experiences and attitudes of Chinese international students in the U.S. to-
wards psychotherapy, with an emphasis on identifying potential barriers and facilitators to their mental health 
treatment. Data were drawn from individual experiences of undergraduate and graduate Chinese international 
students who had engaged in therapy in the U.S. A grounded theory approach was employed to dissect these ex-
periences and assess their attitudes towards psychotherapy. The grounded theory identified several themes from 
the students’ therapeutic experiences such as: the inconsequential role of language barriers, the significant yet not 
prohibitive impact of cultural differences, the critical role of health insurance, the influence of therapists’ profes-
sional demeanor, and the correlation between mental health knowledge and attitudes towards therapy. Interesting-
ly, the study also unveiled an emergent theme concerning professional boundaries within therapy. These findings 
suggest that while language and cultural differences might not be direct obstacles to therapy, factors such as ther-
apists’ backgrounds and attitudes, insurance coverage, and accessibility can pose substantial challenges to Chinese 
international students seeking mental health treatment. Importantly, a heightened level of mental health knowl-
edge was associated with more positive attitudes towards therapy. As a culmination of these findings, we formu-
lated a triadic model emphasizing cultural understanding within the therapeutic setting, service accessibility, and 
mental health knowledge as key influences on the psychotherapy experiences of Chinese international students.

Keywords: psychotherapy barriers, attitudes towards treatment, mental health knowledge, Chinese international 
students, grounded theory



137

mental health. This intricate relationship further 
influences their attitudes towards, and engagement 
with, mental health treatment in a foreign setting.
Second-language Acquisition
 While proficiency in the English language is of-
ten viewed as a key factor in international students’ 
adjustment to both life and education in the U.S. 
(Alharbi & Smith, 2018; Park et al., 2016), many CIS 
still grapple with self-doubt regarding their linguistic 
capabilities. This persists even after they have demon-
strated English fluency through various language tests 
for college admission. For example, in a focus group 
study, Chinese international graduate students iden-
tified English proficiency as a significant issue despite 
researchers’ observations that the students expressed 
themselves effectively in English (Swagler & Ellis, 
2003). Notably, O’Reilly et al. (2010) found that 
engaging with university’s mental health service—
which involves in-depth English conversations with 
a psychologist or healthcare professionals—could 
facilitate international students’ adjustment. This 
finding emphasizes the dual role of second-language 
acquisition: facilitating not only academic and so-
cial adjustment but also accessing mental health care.
Cultural Difference and Stigma
 Cultural practices between China and the 
U.S. are often seen as opposites on a cultural con-
tinuum, implying a maximum level of cultur-
al distance (Hofstede, 2011; Samovar & Porter, 
1997). Consequently, CIS are at a heightened risk 
for psychological issues (Lian & Wallace, 2018).
 Hofstede’s cultural framework underscores the 
disparities between Chinese and Western cultural 
norms, pointing out how these differences might shape 
the perspectives of CIS towards psychotherapy (Juneja, 
2015). China is characterized by a large power distance, 
reflecting a societal structure that considerably values 
authority. This factor could shape how CIS perceive 
and interact with mental health professionals, who 
are often regarded as authority figures. The collectivist 
nature of Chinese society might also prompt students 
to prioritize group harmony over individual mental 
health issues, potentially discouraging them from 
seeking help (Juneja, 2015). While there are similarities 
between China and Western societies in terms of gen-
der equality, China’s high uncertainty avoidance index 
indicates a preference for adhering societal norms and 
expectations (Wang, 2021). This tendency might defer 

CIS from seeking therapy, as it can be seen as a depar-
ture from traditional values. Lastly, the long-term ori-
entation intrinsic to Chinese culture, characterized by 
a focus on future outcomes, perseverance, and respect 
for tradition, could further impact their perceptions 
of therapy, making them potentially more hesitant to 
seek help for mental health challenges (Juneja, 2015).
 In Chinese culture, mental illnesses are often 
linked to personality flaws, moral deficiencies, genet-
ic anomalies, or retribution for misconduct (Shi et al., 
2020). This perspective contrasts with Western views 
where mental illnesses are often seen as temporarily 
linked to challenging life events (Li et al., 2014). These 
contrasting belief systems between U.S. and Chinese 
cultures influence attitudes towards mental health 
help-seeking behaviors. While Western beliefs tend to 
promote a favorable view of mental health services, tra-
ditional Asian beliefs may deter such behaviors (Chen 
& Mak, 2008). Chinese cultural values, such as valu-
ing emotional restraint, evading shame, and upholding 
one’s reputation, could make self-disclosure and emo-
tional expression—central to American therapeutic ap-
proaches—more challenging (Shea & Yeh, 2008). Fur-
thermore, De Vaus et al. (2017) highlight that cultural 
disparities between Eastern and Western societies influ-
ence the strategies used to manage negative emotions.
 The notable underuse of therapy services by CIS, 
despite a clear psychological need, can be attributed to 
cultural factors. Lu et al. (2013) posit that these stu-
dents often perceive seeking mental health support as a 
potential source of shame and loss of esteem, especially 
if their engagement with such services becomes known 
among peers. This fear of humiliation decreases their 
likelihood of holding positive attitudes towards seek-
ing help (Chen et al., 2014; Yakunina, 2011), using 
mental health services (Li et al., 2016), initiating dis-
cussions about personal issues (Chen & Mak, 2008), 
or conveying personal emotions to mental health pro-
fessionals (Mak & Chen, 2006). Numerous studies 
emphasize that stigma linked to mental issues plays a 
significant role in influencing help-seeking behaviors 
across diverse samples (Corrigan et al., 2014; Vogel et 
al., 2017). As a result, it’s vital to implement programs 
tailored to Chinese cultural perspectives on emotion-
al distress and mental well-being (Lian et al., 2020).
Mental Health Knowledge
 Mesidor and Sly (2016) found that a student’s 
perception of available resources plays a significant role 

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS



138

XU

in their intention to seek mental health services. Sev-
eral studies have noted that the level of mental health 
awareness and knowledge about available help-seeking 
options within the university student community, es-
pecially among international students, is less than op-
timal (Lu et al., 2013; Raunic & Xenos, 2008; Shea & 
Yeh, 2008). Ensuring that international students are 
both knowledgeable about and comfortable with ac-
cessing these services is paramount (Chen et al., 2020). 
Institutions of higher education must proactively ed-
ucate international students about the advantages of 
counseling services (Onabule & Boes, 2013). Yet, there 
is limited research investigating the determinants that 
influence international students’ awareness of these ser-
vices. This gap is noteworthy, given the crucial impact 
that the availability and accessibility of on-campus men-
tal health services have on shaping students' help-seek-
ing intentions and behaviors (Lian et al., 2020).
Study Aims
 The goal of this study was to investigate the experi-
ences, perceptions, and attitudes of CIS toward mental 
health, mental health treatment, and stigma in the U.S. 
The study aimed to answer the following questions: 
(1) What are the barriers CIS encounter throughout 
the treatment process? (2) To what extent do lan-
guage or cultural differences present obstacles during 
treatment? (3) How can we enhance their attitudes 
toward mental health treatment and improve psy-
chotherapy integration for second-language speakers?
 Given the reluctance of CIS in seeking mental 
health help and their suboptimal utilization of such 
services (Lian et al., 2020), it is imperative to contin-
uously address their mental health needs. Limited 
awareness about mental health and available resources 
within the university community might exacerbate ex-
isting psychological challenges. This study emphasizes 
the significance of addressing communication barri-
ers, Chinese cultural attitudes, beliefs, and strategies 
to elevate mental health services awareness. By exam-
ining the factors influencing the therapy experience 
of CIS, this research aims to address their perceived 
barriers to psychotherapy and foster a more accom-
modating approach to utilizing mental health services.

Method
 The present research adopted a qualitative de-
sign, utilizing semi-structured interviews to explore 
the psychotherapy experiences of CIS studying at 

U.S. universities. Participants included undergrad-
uate and graduate individuals who were at least 18 
years old, born and raised in China, currently studying 
full-time in the U.S. on an F-1 student visa as inter-
national students. These individuals had engaged in 
at least one psychotherapy session with a non-Chi-
nese therapist while pursuing their education in the 
U.S. These individuals were reached out to through 
a coordinated effort between the research team and 
international student offices at randomly selected 
universities across the U.S. The international student 
offices facilitated the recruitment process by forward-
ing the recruitment email to their respective listservs 
of international students. The study obtained ap-
proval from Adelphi University’s Institutional Re-
view Board, with all participants provided written 
informed consent prior to enrollment in the study.
 In the initial phase, participants were drawn from 
respondents to an electronic survey investigating their 
basic demographic details and The Mental Health 
Knowledge Schedule (MAKS). The MAKS is de-
signed to assess knowledge in mental health, encom-
passing six stigma-related areas: help-seeking, recogni-
tion, support, employment, treatment, and recovery. 
Additionally, it includes six items pertaining to knowl-
edge of mental health conditions. The MAKS uses an 
ordinal scale from 1 to 5 for scoring. A “Agree Strong-
ly” with a correct statement yields a score of 5, while 
a “Disagree Strongly” receives a score of 1. “Don’t 
know” responses are neutrally scored as 3. Notably, 
items 6, 8, and 12 are reverse-coded. The scale has an 
overall test-retest reliability of 0.71, as indicated by 
Lin’s concordance statistic. Item retest reliability varies 
between 0.57 to 0.87, suggesting moderate to signifi-
cant agreement over time. For items 1 to 6, the inter-
nal consistency, reflected by a Cronbach’s α of 0.65, is 
moderate (Evans-Lacko et al., 2010). Sample MAKS 
items include: “Most people with mental health prob-
lems seek paid employment” and “Most people with 
mental health issues consult a healthcare profession-
al”. Given its focus, MAKS is particularly apt for our 
study, aiding in understanding the mental health per-
ceptions of college students, with an emphasis on CIS.
 This survey also contained an invitation for 
a Zoom interview, with participants providing 
contact details and available schedules. Eligible 
participants were approached via the email pro-
vided to schedule Zoom interviews. A total of 



139

nine individuals participated in the interviews.
 The interview guide was centered around the par-
ticipants’ mental health treatment experiences and at-
titudes. The participants were first asked to recall their 
past psychotherapy experiences. The following ques-
tions were aimed at eliciting their views on the effec-
tiveness of treatment, perceived barriers during treat-
ment, the impact of language and cultural differences, 
the necessity of psychotherapy, and future psychother-
apy intentions. All interviews were conducted in Man-
darin Chinese, the participants' native language, en-
suring an open and comfortable space for expression. 
 The interviews were conducted by two research 
assistants (RAs) who were master-level graduate stu-
dents from a psychology program. Both RAs identi-
fied as Chinese international students and were bilin-
gual, with Mandarin Chinese as their first language 
and fluent English proficiency. They received rigorous 
training in conducting semi-structured interviews. All 
interviews were conducted in Mandarin Chinese, re-
corded (with participants’ consent), anonymized, and 
transcribed verbatim in Chinese. To preserve the accu-
racy of participants’ narratives, the translated English 
transcripts were prepared only after all coding had 
been completed, ensuring a faithful representation 
of the original Mandarin Chinese responses. Upon 
transcription, the original recordings were deleted.
 In the analysis of our qualitative data for this 
study, we employed the grounded theory methodol-
ogy. Grounded theory is a systematic qualitative re-
search methodology that emphasizes generating theo-
ry from data (Glaser, 1965). We initiated our analysis 
process with open coding. This phase involved care-
fully reading the interview transcripts and assigning 
distinct codes to data segments representing unique 
concepts (Charmaz, 2006). We then proceeded with 
axial coding, where we sought relationships between 
the identified open codes, grouping them into cate-
gories based on these connections (Corbin & Strauss, 
2008). For instance, if several codes related to various 
aspects of “language barriers” were identified during 
the open coding (e.g., ‘misunderstanding concepts’, 
‘difficulty expressing emotions in second language’, 
‘struggle with cultural translation’), these could be 
grouped into a broader category titled “Language and 
Communication Challenges”. This allowed us to or-
ganize themes or categories and understand their in-
terrelationships. The subsequent stage of selective 

coding involved refining these categories into a theo-
retical framework. We identified a core category, and 
all other categories were related to this central theme 
(Glaser, 2017). Throughout the coding process, we 
consistently wrote memos capturing emerging ideas, 
potential hypotheses, and connections (Tie et al., 
2019). Finally, theory development was the last stage, 
which culminated in an explanatory framework ac-
counting for the identified patterns in the experiences 
of CIS accessing mental health services (Glaser, 2017).
 It’s noteworthy to mention that our analysis 
process was iterative. Insights gained during selec-
tive coding often necessitated a return to the data 
for further open or axial coding. We also employed 
the constant comparative method throughout the 
process, continuously comparing new data with pri-
or data and codes to refine our categories (Glaser, 
1965). By employing grounded theory, we ensured 
that our analysis was thorough, and our findings 
were truly reflective of our participants' experiences, 
thus generating a theory that is grounded in our data.
 Data coding was conducted by a team of 10 RAs 
under the supervision of the principal investigator. 
Each of the RAs is a master’s student currently en-
rolled in a U.S. psychology program, with a shared 
background of being CIS. This distinctive profile—na-
tive Mandarin Chinese speakers who are fluent in En-
glish, holding at least 6 years of education in the U.S., 
and possessing specific training in the field of psychol-
ogy—equipped them with the ability to connect with 
the experiences of the participants on a deeper level. 
This shared cultural perspective facilitated their under-
standing and interpretation of the data, enabling them 
to capture subtleties that may be otherwise overlooked, 
and thus contributing crucial depth to the analysis.
 To ensure the reliability of our coding, we uti-
lized the concept of inter-rater reliability. Each tran-
script was independently coded by two RAs, and 
any discrepancies in their assigned codes or identi-
fied themes were resolved through discussion un-
til consensus was reached. If necessary, the princi-
pal investigator would intervene to provide a final 
judgment. This rigorous process ensured that the 
resulting codes, categories, and themes accurately 
represented the participants' experiences and perspec-
tives while minimizing potential individual biases.
 Further, the principal investigator of this study 
was an international student from China and spent 

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS



140

XU

a decade studying psychology in the U.S., bringing 
an essential insider perspective to the research. This 
shared cultural and educational background with 
the study participants allows for a profound under-
standing of their experiences, enabling nuanced in-
terpretation of the data. The researcher’s advanced 
psychological training further complements this cul-
tural lens, providing robust analytical capabilities and 
comprehension of the psychological processes in play. 
Nevertheless, the shared experiences of the principal 
investigator and RAs as CIS in the U.S. also pose a 
potential for bias, as prior experiences and cultural 
backgrounds might influence the interpretation of 
the findings. To manage potential bias, reflexivity was 
practiced throughout the research process. This in-
volved weekly team meetings in which the researchers 
reflected on and discussed their thoughts, reactions, 
and potential biases that might have arisen during 
interviews and coding. It is through this continuous 
self-examination that we aimed to preserve the integ-
rity of the research and maintain a balanced and ob-
jective perspective on the participants' experiences.

Results
 The following description of themes combines 
and summaries answers from all interviews. Table 1 
provides the demographic details of the participants in-
volved in this study. Out of the nine participants, seven 
were female, highlighting a significant gender skew in 
the sample. Age ranged between 18 to 30 years, with a 
majority falling within the 18-22 and 23-26 age brack-
ets. In terms of socioeconomic status (SES), scores 
varied from five to seven on our scale. The students 
hailed from diverse locations, though there was a high-
er representation from New York. As for their academ-
ic details, four were graduate students while the rest 
were either college seniors or freshmen. The primary 
academic majors were psychology and social science, 
though biology and education were also represented. 
Lastly, the duration of their stay in the U.S. varied, with 
most having spent between two to nine years, and one 
participant having spent over nine years in the U.S. All 
participants in this study identified as Han Chinese, 
the dominant ethnic group in China, and their pre-
ferred language was Mandarin Chinese without any 
regional dialects. The participants in our study sought 
psychotherapy primarily due to distressing events they 
encountered while studying in the U.S. These experi-

ences, such as ending a romantic relationship, having 
conflicts with friends, or facing issues with family com-
munication, caused feelings of depression, stress, and 
anxiety, which prompted their search for professional 
help. The therapeutic journey for all participants be-
gan within their respective university counseling cen-
ters. This set the stage for their interaction with an ar-
ray of therapists, ranging from full-time professionals 
to interns and externs working at these centers. While 
these therapists had diverse ethnic and cultural back-
grounds, none identified as Asian/Chinese or fluent 
in any Chinese language. The lack of Chinese-speak-
ing therapists provided a unique opportunity to delve 
into the cultural dynamics and potential language 
barriers within the therapeutic context. Some partic-
ipants chose to expand their mental health treatment 
into community resources for ongoing treatment. 
Language Barrier Dissolution
 Our findings suggested that language, despite 
not being their native tongue, did not constitute 
a barrier during psychotherapy for most partici-
pants. Communication between participants and 
their therapists, none of whom were conversant in 
any Chinese dialect, transpired entirely in English. 
This implies that mutual comprehension between 
client and therapist can potentially neutralize the 
language impediments in the treatment process:
 “I don’t think language is not a barrier. I think it’s 
actually okay. I can tell my own experience in English.” 
“I did not perceive any language barriers. I can under-
stand the therapist and the therapist can understand 
what I was talking about.” 
 “In terms of language, I think it’s okay. I came to 
America at a very young age and since then I use En-
glish for all communication. Sometimes I feel hard to 
expressed myself clearly in English, but no major com-
munications barriers. I think it is not a big problem in 
psychotherapy.” 
 “Language is not a big problem, because I have been 
in the United States for a long time, and now our de-
partment has no other Chinese students beside me, and 
there are no Chinese speakers around. Friends around 
me, they all speak English, I have no issues with speaking 
English with my therapist.” 
 We propose that these findings may be influenced 
by the participants’ length of residency in the U.S., a 
factor that could affect their language proficiency and 
comfort in communicating in English. Notably, all 



141

participants in this study had resided in the U.S. for at 
least two years before their participation. This tenure, 
coupled with their academic engagement, likely neces-
sitated substantial English language use, fostering their 
fluency and comfort in communication. Consequent-
ly, most participants expressed comfort and relative 
ease in English-mediated communication, indicating 
a reduced perception of language as a barrier in their 
psychotherapy sessions. Such findings lead us to hy-
pothesize a potential correlation between the dura-
tion of U.S. residency and the perception of language 
barriers in psychotherapy. Specifically, it is plausible 
that a longer period of residency, and hence greater 
immersion in an English-speaking environment, may 
diminish perceived language barriers in psychotherapy. 
This hypothesis necessitates further exploration in fu-
ture studies with larger and more diverse sample sizes. 
Importance of Therapist's Characteristics in 
Therapy Selection and Perception
 Our findings highlighted that the partic-
ipants prioritized certain factors such as the 
therapist's therapeutic orientation, cultural 
background, and gender when choosing their ther-
apists and evaluating their therapeutic experiences:
 “I can’t seem to work with a CBT oriented thera-
pist. I might prefer other orientations. I think it is very 
important to see which orientation the therapist uses. I 
know which ones are suitable for me and which ones are 
not suitable for me.” 
 “CBT…is more biased...I am less focused, and I am 
more resistant to this therapy. And then I didn't stick to 
it at all.” 
 “I want an Asian therapist, someone with an orien-
tal background. I think a therapist with the same cultur-
al background is more useful in terms of the treatment.” 
 “We talked about visas, and then the policy and so 
on. At that time, it was more difficult to talk to Amer-
ican therapists, they don’t know much about this aspect. 
Ummmm, there are limitations. I prefer someone from 
relevant to my culture.” 
 “Because I was more inclined to choose a female 
therapist at the time. And I was more inclined to find 
such therapists who were more experienced in psychody-
namics.” 
 “The communication feels a little bit safer with the 
male therapist, which is what he might have been able to 
do…” 
 Based on our participants’ experiences, the char-

acteristics of therapists, specifically therapeutic orien-
tation, cultural background, and gender, substantial-
ly impacted their experience within psychotherapy. 
These factors shaped how they perceived their ther-
apeutic relationship and, in turn, influenced their 
overall satisfaction and progress within the treatment.
 While participants in this study expressed a pref-
erence for therapeutic orientations distinct from CBT, 
it is essential to recognize that efficacy of psychothera-
py is not limited to a single orientation. Research has 
shown that both psychodynamic and CBT approach-
es, among others, have proven effectiveness in various 
settings (Driessen, 2013; Julien & Connor, 2016). The 
expressed preference in this study does not undermine 
the potential effectiveness of CBT or any other orien-
tation. Instead, it emphasizes that therapeutic orienta-
tion is a significant factor in these participants’ ther-
apy experience and satisfaction levels. It is important 
to understand that the synergy between therapist and 
client is integral to therapeutic effectiveness. With-
in this synergy, aspects like therapeutic orientation, 
understanding of cultural backgrounds, and even 
therapist’s gender plan a role. Therefore, these find-
ings should not be interpreted as a general statement 
about the superiority or inferiority of particular ther-
apeutic orientations, but rather as an emphasis on the 
significance of individual alignment in psychotherapy.
Cultural Difference: A Significant Factor, not a 
Barrier
 Our participants largely did not perceive cul-
tural differences as an impediment to their therapy 
process. Instead, they recognized it as an influen-
tial element within their therapeutic experiences. 
Most participants reported that having a therapist 
from a similar cultural background could potential-
ly enhance the treatment experience, but they did 
not consider a different cultural background as an 
obstacle negatively impacting therapy outcome.
 “Cultural differences are not a barrier, because the 
topic itself is not a relatively cultural specific topic.”
 “Although the therapist is not Chinese, they still un-
derstand what I said about discrimination.”
 Interestingly, some participants believed that 
cultural diversity within the therapeutic relation-
ship could potentially yield more positive outcomes. 
They appreciated the unique perspectives that thera-
pists of different cultural backgrounds could provide. 
 “Because my psychologist is an American, and they 

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS



142

XU

know the American school system very well, they also 
gave me a lot of useful advice. Different cultures are 
sometimes a good thing.”
 “He (the therapist) has a unique world view that 
was not an Eastern or traditional Chinese view, but I 
felt that he could understand more of me.”
 These observations illustrate the nuanced role 
that cultural differences can assume in the thera-
peutic relationship. The findings suggest that ther-
apists’ cultural congruity with their clients might 
foster a deeper, immediate understanding of cli-
ents’ culturally specific, thus potentially facili-
tating rapport building and therapeutic alliance.
 Our findings also highlight that cultural dif-
ferences, rather than serving as an obstacle, can en-
rich the therapeutic process. The intersection of 
diverse cultural backgrounds between the thera-
pists and the clients can foster a milieu of exchange, 
introducing unique viewpoints, fresh insights, and 
broadened perspectives. Moreover, these cultural 
differences can offer clients the chance to assimilate 
new coping techniques not common in their native 
culture, bolstering their adaptability and resilience. 
Such results emphasize the imperative for thera-
pists to exhibit cultural sensitivity, skillfully harness-
ing these differences to further therapeutic goals.
School Counseling Services: Time Limitations 
and Focus Concerns
 Participants shared mixed feelings about their 
experiences with school-provided counseling ser-
vices. A recurring concern revolved around the lim-
ited number of sessions offered by these services.
 “There is a limit to the sessions that the school of-
fering for each quarter. You can only see a therapist for 
a couple of times, which cannot be done for a long-term 
treatment.” 
 “I am less interested in the school provided counsel-
ing services due to time restrictions of the sessions. I hope 
the schedule can be more flexible. Most of the time there 
are only one therapist available.”
 “But at that time, the school's... emm… the support 
for students’ mental health was not very strong.”
 Furthermore, some participants expressed concern 
about what they perceived to be a disproportionate 
focus on suicide prevention during therapy sessions: 
 “I feel that the therapists from our school only care 
about the suicidal prevention rather than what I really 
want to talk about during the session.”

 “I personally feel that ‘thoughts to hurt others’ or 
‘suicidal thoughts’ are key points during the sessions. I 
think because the school must focus on this.”
 These findings highlight potential challenges with-
in school-provided counseling services, which could 
significantly influence students’ therapeutic journeys 
and eventual outcomes. Limiting the number of thera-
py sessions, for example, might not fully accommodate 
students needing extended treatment, leading to inade-
quately care or unachieved therapeutic goals. While the 
emphasis on certain topics such as suicide prevention 
is essential, there is a risk of sidelining or diminishing 
mental health concerns that students want to discuss. 
Such perceptions can cause students to feel misinter-
preted or overlooked, potentially affecting the ther-
apeutic alliance. This could result in students feeling 
dissuaded from seeking help or continuing their ther-
apy, thereby limiting the effectiveness of such services.
Health Insurance: A Key Player in Psychotherapy 
Access and Continuity
 Participants unanimously emphasized the piv-
otal role of health insurance in their therapeutic ex-
periences, highlighting its influence in their choices 
and decisions at various stages of therapy. This indi-
cates the relevance of financial aspects when access-
ing mental health services, affecting both the selec-
tion of the therapist and the continuity of treatment.
 “The one therapist I chose at the time was largely 
influenced by my insurance… Our insurance was too 
limited, so there was not much room for me to choose…… 
The first three months where I didn't have insurance, so 
I had to stop it (the previous treatment).” 
“Insurance. They (the therapists) must take my insur-
ance.”
 “I still want to try it (psychotherapy), but of course if 
it doesn’t takes my insurance, I’d rather not go if I need 
to pay for the sessions.”
 These statements bring attention to the signif-
icant impact of health insurance coverage on accessi-
bility to psychotherapy for CIS. Clearly, the scope of 
insurance coverage can influence therapist selection, 
possibly limiting the therapeutic options accessible 
to students. Moreover, the extent of insurance cov-
erage can decide the treatment’s continuity, with a 
lack of coverage posing a financial burden that may 
lead to interrupted or discontinued therapy. The fact 
that all participants mentioned health insurance in-
dicates its crucial role in their psychotherapy journey, 



143

suggesting a broader systemic issue at play. Access to 
affordable mental health services is a major concern, 
highlighting the need for policies and practices that 
address these financial barriers. This might involve 
increasing the mental health coverage provided by 
insurance companies, making therapy more afford-
able, or exploring alternative funding options that 
can help CIS maintain continuity in their treatment.
Therapist’s Professional Boundaries
 The theme of ‘Therapist’s Professional Bound-
aries’ emerged in an unexpected way through our 
participants’ accounts of their previous therapy expe-
riences. Several of them shared instances where they 
perceived their therapists’ behavior as unprofessional, 
ultimately leading to the termination of treatment.
 “My therapist may not be very on time for the ses-
sions, he is always may be 10 minutes late., but he will 
apologize every time.”
 “He (the therapist) will eat in the middle of my ses-
sion, and he will drink coffee. Coffee is fine because it’s 
like water. But I noticed he will also eat oatmeal. Oat-
meal is… is like very solid food. I was surprised at the 
time, but I didn't say much.”
 “One time after I left, I forgot to take my back-
pack, and then I came back…my therapist was crying…
and talking to other colleague because she (the therapist) 
thinks I treat her like an emotional trash can…Oh, I 
heard this accidentally…I felt embarrassed, really...I 
never went to any therapy after that…It feels wrong.”
 These incidents underscore the importance of 
therapists maintaining professional boundaries during 
therapy sessions. An infringement of these boundar-
ies can significantly affect clients' trust, therapeutic 
experience, and willingness to continue treatment.
Limited Accessibility to Therapy
 While all participants initially sought treatment 
through their respective school counseling centers—
services that they accessed free of charge—their nar-
ratives painted a picture of the considerable challeng-
es they faced as international students in accessing 
therapeutic services beyond these initial provisions. 
Furthermore, although some participants were able 
to continue their therapy—either via referral to com-
munity resources from their schools or through their 
insurance—the process was not straightforward for all.
 “I discontinued the sessions because the semester was 
almost over. They (the school) said that it is possible to 
come back and continue in the second year. But it never 

does.”
 “Yes, I thought about finding a therapist outside of 
the school, but it is hard to find. It was inconvenient be-
cause I do not have a car.”
 “School counselling is useful and inspiring for fu-
ture search for psychotherapy. I want to find someone 
outside the school through insurance. But I do not know 
how to do it… and I do not think my insurance support 
it?”
 These narratives emphasize the need to enhance 
the accessibility and support structures for CIS when 
they seek and continue therapeutic services beyond 
initial school counseling. The lack of easy access, as 
well as potential service fees, could adversely affect 
their mental health and overall well-being. These in-
sights accentuate the critical role universities and re-
lated institutions play in addressing this issue to bet-
ter support their international student population.
Knowledge of Mental Health Enhances Treat-
ment Attitudes
 The MAKS is designed to gauge a person's under-
standing of mental health conditions and awareness of 
related stigmas (Evans-Lacko et al., 2010). According 
to Evans-Lacko’s work, these higher scores signify a 
more informed understanding of mental health, po-
tentially including the nature of mental health con-
ditions, recognition of symptoms, and understanding 
of appropriate treatments and coping strategies. Par-
ticipants with higher MAKS scores exhibit a greater 
degree of knowledge and awareness about mental 
health issues. Table 2 reflects participants’ MAKS 
scores and attitudes toward mental health treatment. 
 In our study, participants with higher MAKS 
scores generally expressed more favorable attitudes 
toward mental health treatment. Their responses 
reflected a better understanding of the therapeutic 
process, a greater openness to seeking and continuing 
therapy, and a more nuanced perspective on its po-
tential benefits and challenges. These attitudes may 
stem from their higher level of mental health literacy, 
suggesting that knowledge can enhance individuals' 
attitudes towards mental health treatment, making 
it more likely that they seek help and engage actively 
in their own therapeutic process. This finding under-
scores the potential benefits of mental health educa-
tion programs for students. By increasing students’ 
knowledge about mental health, we may enhance 
their perceptions of therapy, encourage help-seeking 

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS



144

XU

behavior, and ultimately improve their mental health 
outcomes. Further research is needed to confirm 
these findings and explore the most effective ways 
to increase mental health literacy among students.
 Building on these findings, our subsequent 
analysis and synthesis of the data revealed a more 
comprehensive framework that encompassed 
the broader determinants influencing CIS’ per-
ception and engagement with psychotherapy. 
This led us to the formulation of a triadic model, 
which we introduce and unpack in the discussion.

Discussion
 Utilizing grounded theory, our study culminated 
in the formulation of a triadic model titled “Cultur-
al Understanding, Accessibility, and Mental Health 
Knowledge: Key Influences on Chinese International 
Students’ Perception and Engagement in Psychother-
apy.” This conceptual model proposes that the triad 
of cultural understanding within the therapeutic set-
ting, service accessibility, and knowledge about mental 
health collectively shape the psychotherapy experienc-
es of CIS. The various themes that emerged from our 
analysis find resonance within this theoretical structure.
 Our findings challenge traditional assumptions 
about cultural differences being a barrier in thera-
py (Leong & Kalibatseva, 2011). A recent compre-
hensive literature review demonstrates how culture 
influences mental health care in multifaceted ways, 
often posing considerable barriers to effective treat-
ment (Ahad, 2023). However, the perspectives 
shared by our CIS participants offer an alternative 
viewpoint. Rather than seeing cultural differences 
as a barrier in therapy, they viewed them as influen-
tial factors that can be either beneficial or detrimen-
tal, depending on the issues addressed in sessions.
 It is vital to differentiate between the notions of 
“barrier” and “factor” in this context. According to 
the American Psychological Association, a “barrier” 
restricts, impedes, or obstructs progress or the at-
tainment of a goal. In contrast, a “factor” influences 
an outcome or holds a causal relationship with a phe-
nomenon or event. In psychotherapy, while a “bar-
rier” negatively impacts treatment progress or out-
comes, a “factor” can be either adverse or beneficial.
 This revelation aligns with the principles of Cul-
turally Responsive Therapy (CRT), which posits that 
cultural differences can be harnessed as assets rather 

than barriers in the therapeutic process (Asnaani & 
Hofmann, 2012). CRT and similar approaches in 
multicultural therapy emphasize the significance of 
understanding, respecting, and integrating clients’ 
cultural backgrounds into the therapeutic frame-
work (Zigarelli et al., 2016). By doing so, therapists 
can foster a stronger alliance with clients and pave the 
way for more meaningful therapeutic outcomes (Lee, 
2010). Recent studies further highlight the potential 
of cultural differences as tools for deeper understand-
ing and richer, tailored psychotherapy experiences 
(Barnett & Bivings, 2002). Hence, while some view 
cultural differences as challenges (Edge & Lemety-
inen, 2019), our findings underscore their poten-
tial as valuable tools for therapeutic transformation.
 Building on the cultural understanding dimen-
sion, our participants stressed the importance of vari-
ous therapist characteristics during their assessment of 
therapeutic experiences. These characteristics includ-
ed cultural background, gender, and therapeutic ori-
entation. A preference for non-Cognitive Behavioral 
Therapy (CBT) was identified in our study. This re-
flects a trend identified by Huang and Kirsner (2020), 
wherein modern Chinese individuals demonstrate 
an increasing openness towards psychoanalysis and 
psychodynamic psychotherapy as potential solutions 
to psychological difficulties and internal conflicts. 
Furthermore, our study found that students with a 
more sophisticated understanding of mental health 
treatments exhibited a preference for specific thera-
pist genders and therapeutic orientations, a finding 
that aligns with prior research (Blow et al., 2008). This 
deepens our understanding of cultural sensitivity in 
the context of mental health services, highlighting its 
importance in fostering therapeutic relationships and 
facilitating meaningful treatment experiences for CIS.
 Interestingly, language was not perceived as a 
barrier in psychotherapy for international students, a 
finding that contrasts with Karp and Vögele’s (2016) 
assertion that language significantly impacts the prac-
tice and success of psychological interventions. Our 
participants felt capable of expressing themselves 
adequately and of understanding their therapists in 
English. In instances where they lacked the appro-
priate English words to express their feelings, they 
found alternate ways to communicate their emo-
tions and thoughts. This contrasts sharply with sev-
eral studies that emphasize the efficacy of conducting 



145

psychotherapy in a patient’s dominant language to 
access deeper cognitive processes (Cofresi & Gor-
man, 2004; Marrero et al., 2002; Shamsi et al., 2020).
 However, this finding might be significantly in-
fluenced by several factors, including language de-
velopment, the age at which international students 
arrived in the U.S., their duration of stay, and En-
glish proficiency. A prior linguistic study suggest-
ed that second language grammar-learning ability is 
optimally retained until approximately 17.4 years of 
age, after which it steadily declines (Hartshorne et 
al., 2018). In our study, we lack specific data on the 
age at which participants were exposed to a native 
English-speaking environment and other linguis-
tic context details. Various factors could shape these 
outcomes, highlighting the need for a broader, po-
tentially quantitative, study in future investigations.
 The second crucial component of the triad shap-
ing CIS’ psychotherapy experiences is accessibility. 
This theme is underpinned by three sub-themes: the 
role of school counseling services, limited accessibili-
ty to therapy, and health insurance. According to the 
2019 Annual Survey conducted by the Association for 
University and College Counseling Center Directors 
(AUCCCD), approximately 90% of counseling center 
directors reported a rise in students seeking services, 
with about 44% of college counseling centers adding 
staff in response (Leviness et al., 2019). College coun-
seling centers, as primary mental health resources, are 
often the first point of contact for international stu-
dents seeking mental health support (Lipson et al., 
2022). In our study, participants identified two main 
concerns with school counseling center (SCC) services: 
(1) schools providing a limited number of sessions for 
international students, which could lead to suboptimal 
treatment outcome, and (2) a perceived overemphasis 
on suicide prevention in the interventions of SCCs.
 Addressing the first concern regarding the opti-
mal number of therapy sessions, a review of literature 
reveals varied findings on the optimal number of ses-
sions for psychotherapy outcomes. Some studies sug-
gest a minimum of 20 sessions are necessary for stu-
dents to exhibit noticeable change (Hansen, 2002), 
while others indicate that bi-weekly sessions are more 
effective than weekly ones (Cuijpers et al., 2013). 
Certain research posits that the duration of psycho-
therapy has minimal correlation with its outcome 
(King, 2015). Given these varied findings, the impact 

of therapy duration, intensity, and session count on 
both treatment outcomes and therapeutic experi-
ences is multifaceted (De Geest & Meganck, 2019).
 Most participants from our study felt the lim-
ited sessions provided by their SCC adversely im-
pacted their therapeutic experience. However, data 
from the AUCCCD (2019) reveals that 54.4% of 
SCCs do not impose session limits on students, 
and 36.7% have flexible limits. Further correlation-
al investigations are needed to fully understand 
the number of sessions provided by the SCC and 
the therapy experiences of international students.
 Several participants expressed criticism regarding 
the second point of concern, a perceived overempha-
sis on suicide prevention within the interventions of 
SCCs. They felt that the SCCs overly focused on sui-
cide prevention, often overshadowing their specific 
concerns and issues. It’s essential to note the limitations 
of our study, as our sample size may not be sufficient to 
provide a definitive conclusion on this matter. How-
ever, considering the gravity of the issue, the emphasis 
may not be misplaced. A study by Drum et al. (2009) 
shows that over a 12-month period, 69% of undergrad-
uates and 63% of graduate students reported consider-
ing suicide more than once, with a substantial num-
ber formulating specific plans or gathering materials 
for suicide. Research indicates that risk management 
strategies employed by SCCs can significantly reduce 
the incidence of suicide within educational settings 
(Paschall & Bersamin, 2018). Thus, it is crucial that 
SCCs maintain a vigilant focus on potential suicidal 
ideation, balancing this concern with addressing the 
diverse mental health needs of the student population.
 When SCCs are unable to meet students’ needs, 
they often turn to external resources. Due to the high 
costs associated with psychotherapy, most participants 
opted to find therapists through their health insur-
ance (Cummings, 2015). However, this approach 
elicited concerns among international students, as 
many are unfamiliar with navigating U.S. insurance 
systems. As such, the onus lies with the school’s men-
tal health department to educate students about the 
importance of mental health and the accessibility of 
services both on and off campus. The development of 
initiatives aimed at increasing international students' 
understanding of available resources within their 
community could prove highly beneficial. Research 
indicates that increased accessibility to mental health 

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS



146

XU

treatment promotes greater participation in mental 
health interventions and encourages self-help behav-
iors (Lattie et al., 2022). Potential interventions could 
include public seminars, informational outreach ses-
sions, comprehensive resources on school websites, 
and the distribution of informational brochures.
 In discussing the third element of the triad, men-
tal health knowledge, we observed two clear connec-
tions: a distinct link between higher mental health 
knowledge and more favorable attitudes towards 
therapy, as well as a similar connection with attitudes 
towards psychotropic medication. The participants’ 
understanding and perceptions of mental health 
significantly shaped their attitudes towards thera-
peutic interventions. It became evident that a deep-
er knowledge about mental health can profoundly 
influence an individual’s attitude towards and en-
gagement with therapeutic services and treatments.
 Prior research, including a survey on CIS by Lu 
et al. (2013), indicates that common barriers to seek-
ing professional mental health treatment are mul-
tifaceted including: limited knowledge of available 
mental health services, lack of recognition of psycho-
logical distress symptoms, and underestimation of 
their severity. This finding was echoed in a study by 
Forbes-Mewett and Sawyer (2016), revealing that 
international students, due to unfamiliarity with 
western therapeutic approaches, limited access to 
local medical systems and facilities (Cheng, 2020), 
and insufficient knowledge about available services 
(Skromanis et al., 2018), were less likely to use men-
tal health services compared to their domestic peers. 
Our findings align with this pre-existing research. 
Higher mental health knowledge in our study pop-
ulation was associated with more positive attitudes 
towards mental health treatment. Students majoring 
in psychology or those with a greater understanding 
of mental health reported better experiences with the 
treatment process and exhibited more positive atti-
tudes towards therapy options. These results not only 
offer valuable empirical evidence for clinicians work-
ing with CIS but also inspire us to consider integrating 
psychoeducation within and prior to the treatment 
process. Such an integration could potentially foster 
improved attitudes towards mental health treatment.
 The unexpected emergence of a theme related 
to therapists’ professional boundaries presents an in-
triguing dimension for future exploration and could 

potentially be integrated into our grounded theory 
with further research. Professional boundaries are 
fundamental to conducting therapy, significantly in-
fluencing students' treatment experiences and atti-
tudes toward psychotherapy (Wilmots et al., 2019). 
Many of our participants reported instances where 
they perceived their therapists as unprofessional 
during sessions, citing behaviors such as eating during 
the session, leaving the door open, answering phone 
calls, and being overheard when discussing the client's 
case. While our findings might be skewed due to the 
limited sample size, it raises interesting questions. 
For example, do these situations arise due to under-
lying factors? Would different student populations 
experience the same issues? Does the nature of the 
session, whether remote or in-person, impact these 
incidents? Future research with larger sample sizes 
is warranted to address these intriguing questions.
 To conclude, this grounded theory highlights the 
interplay between three factors and how they influence 
the psychotherapy experience for CISs. It emphasizes 
the need for cultural sensitivity, accessibility, and men-
tal health education in creating a supportive and ben-
eficial therapeutic environment for this population.
Clinical and Research Implications
 Based on the findings of our current study, 
there are several strategies and recommendations 
to enhance therapeutic engagement with CIS in 
treatment. Grounded in our research findings, 
the following clinical implications are proposed:
 1) Cultural Acknowledgement: Therapists 
should recognize the significance of a student's cultur-
al background. Establishing a therapeutic alliance may 
be facilitated when therapists share a similar cultural 
background with the student. Rather than viewing 
cultural differences as barriers, therapists can see them 
as opportunities to better understand and connect 
with students.
 2) Language Considerations: If mutual under-
standing exists between the student and therapist, 
language barriers may not necessarily hinder the treat-
ment process.
 3) Educational Empowerment: Encourage stu-
dents to acquire additional knowledge about mental 
health through educational resources. This under-
standing can enhance their engagement in therapy.
 4) Extended Mental Health Care: Many interna-
tional students require more extensive mental health 



147

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS

care than what school counseling centers currently 
offer. Providing additional resources or referrals might 
bridge this gap.
 5) Professionalism and Compassion: Therapists 
should offer care that extends beyond suicide preven-
tion and always maintain professional boundaries. 
Conducts, such as eating during the session or leaving 
the door open, can impact student's therapy experi-
ence negatively.
 This study serves as a small-scale exploratory qual-
itative investigation. To establish the generalizability 
of these findings, larger-scale quantitative studies will 
be necessary. As attitudes are known to shift over time 
based on experiences, future research could benefit 
from employing a longitudinal approach. This study 
underscores the potential utility of pre-therapy psy-
choeducation interventions to improve treatment 
outcomes and empower school counseling centers 
to cater to more students with mental health needs. 
Administratively, furnishing additional information 
about available mental health resources could poten-
tially benefit the international student population. 
Further investigation into the institutional barriers 
obstructing Chinese international students from ac-
cessing needed mental health support could prove 
insightful, providing opportunities for improvements 
in both governmental and institutional educational 
policies. Future researchers might consider conduct-
ing a randomized controlled trial to examine the effi-
cacy of combining psychoeducation with therapy for 
international students. Such a strategy could poten-
tially enhance treatment outcomes and enable school 
counseling centers to accommodate more students 
requiring mental health support. Additional studies 
could further explore the accessibility of mental health 
resources for international students and identify the 
institutional-level hurdles preventing them from avail-
ing mental health support. Addressing these challeng-
es could provide valuable insights for improving the 
mental health outcomes of international students.
Strengths and Limitations
 Our study might face limitations due to its sam-
ple size and potential sampling bias. Those who vol-
unteered might have had predominantly positive 
experiences with psychotherapy, making them more 
inclined to participate and share their insights. Such 
individuals might also be naturally more expressive 
and perhaps face fewer challenges when accessing psy-

chotherapy services, thus skewing the data towards 
positive experiences. Additionally, the gender imbal-
ance in our sample due to a significant majority being 
female, further compounds this bias. This disparity 
could have influenced the results as male perspectives 
and experiences might be underrepresented. Howev-
er, we mitigated these limitations by reaching out to 
as many schools as possible across the U.S., thereby in-
cluding participants from diverse regions of the coun-
try. There is a risk to the validity of the findings if par-
ticipants were not entirely candid in their responses. 
To counter this, we employed strategies like allowing 
participants to use preferred names and ensuring them 
of the anonymity of their data, reducing the inclina-
tion to provide socially desirable answers. During the 
interviews, we conversed with the participants in their 
native language to ensure their comfort in expressing 
their thoughts, experiences, and attitudes fully. Our 
coders, fluent in both Chinese and English, ensured a 
smooth and accurate translation and coding process.
 Our study contributes to the currently sparse qual-
itative research focusing on the psychotherapy process, 
filling a significant gap. The qualitative approach also 
enhances the flexibility of our research, allowing par-
ticipants to provide greater detail and depth to our 
findings, as well as contributing unique perspectives.

References
Ahad, A. A., Sanchez-Gonzalez, M. A., & Junquera, 

P. (2023). Understanding and addressing mental 
health stigma across cultures for improving psy-
chiatric care: a narrative review. Cureus. https://
doi.org/10.7759/cureus.39549

Alharbi, E. S., & Smith, A. (2018). Review of the lit-
erature on stress and wellbeing of international 
students in English-speaking countries. Interna-
tional Education Studies, 11(6), 22. https://doi.
org/10.5539/ies.v11n6p22

Altbach, P. G., & Knight, J. (2007). The interna-
tionalization of higher education: motivations 
and realities. Journal of Studies in Internation-
al Education, 11(3–4), 290–305. https://doi.
org/10.1177/1028315307303542

Asnaani, A., & Hofmann, S. (2012). Collaboration in 
multicultural therapy: Establishing a strong ther-
apeutic alliance across cultural lines. Journal of 
Clinical Psychology, 68(2), 187–197. https://doi.
org/10.1002/jclp.21829



148

Barnett JE & Bivings (2002). Culturally sensitive treat-
ment and ethical practice. American Psychologi-
cal Association Divisions. Division 31: State, Pro-
vincial and Territorial Psychological Association 
Affairs.     

Blow, A. J., Timm, T. M., & Cox, R. B. (2008). 
The role of the therapist in therapeutic change: 
Does therapist gender matter? Journal of Femi-
nist Family Therapy, 20(1), 66–86. https://doi.
org/10.1080/0895280801907150

Charmaz K. (2006). Constructing grounded theory: a 
practical guide through qualitative analysis. CiNii 
Books. http://ci.nii.ac.jp/ncid/BA79601482

Chen, H., Akpanudo, U., & Hasler, E. (2020). How do 
Chinese international students view seeking men-
tal health services? Journal of International Stu-
dents, 10(2), 286–305. https://doi.org/10.32674/
jis.v10i2.765

Chen, H., Fang, X., Liu, C., Hu, W., Lan, J., & Deng, 
L. (2014). Associations among the number of 
mental health problems, stigma, and seeking 
help from psychological services: A path analysis 
model among Chinese adolescents. Children and 
Youth Services Review, 44, 356–362. https://doi.
org/10.1016/j.childyouth.2014.07.003

Chen, S. X., & Mak, W. W. S. (2008). Seeking profession-
al help: Etiology beliefs about mental illness across 
cultures. Journal of Counseling Psychology, 55(4), 
442–450. https://doi.org/10.1037/a0012898

Cheng, R. (2020). Higher ed institutions aren’t sup-
porting international students enough during the 
COVID-19 crisis (opinion). Inside Higher Ed | 
Higher Education News, Events and Jobs. https://
www.insidehighered.com/views/2020/03/19/
higher-ed-institutions-arent-supporting-interna-
tional-students-enough-during-covid

Cofresí, N. I., & Gorman, A. A. (2004). Test-
ing and assessment issues with Spanish-En-
glish bilingual Latinos. Journal of Counseling 
and Development, 82(1), 99–106. https://doi.
org/10.1002/j.1556-6678.2004.tb00290.x

Corbin, J., & Strauss, A. L. (2008). Basics of Qualitative 
Research (3rd ed.): Techniques and Procedures 
for Developing Grounded Theory. SAGE Publica-
tions. https://doi.org/10.4135/9781452230153

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). 
The impact of mental illness stigma on seeking 
and participating in mental health care. Psycho-

logical Science in the Public Interest, 15(2), 37–70. 
https://doi.org/10.1177/1529100614531398

Cuijpers, P., Huibers, M. J., Ebert, D. D., Koole, S. L., 
& Andersson, G. (2013). How much psychothera-
py is needed to treat depression? A metaregression 
analysis. Journal of Affective Disorders, 149(1–3), 
1–13. https://doi.org/10.1016/j.jad.2013.02.030

Cummings, J. R. (2015). Rates of psychiatrists’ partici-
pation in health insurance networks. JAMA, 313(2), 
190. https://doi.org/10.1001/jama.2014.12472

De Geest, R. M., & Meganck, R. (2019). How do time 
limits affect our psychotherapies? A literature re-
view. Psychologica Belgica, 59(1), 206–226. https://
doi.org/10.5334/pb.475

De Vaus, J. E., Hornsey, M. J., Kuppens, P., & Bastian, 
B. (2017). Exploring the East-West divide in preva-
lence of affective Disorder: a case for cultural differ-
ences in coping with negative emotion. Personal-
ity and Social Psychology Review, 22(3), 285–304. 
https://doi.org/10.1177/1088868317736222

Driessen, E., Van, H. L., Don, F. J., Peen, J., Kool, 
S., Westra, D., Hendriksen, M., Schoevers, R. A., 
Cuijpers, P., Twisk, J. W., & Dekker, J. J. (2013). 
The efficacy of cognitive-behavioral therapy and 
psychodynamic therapy in the outpatient treat-
ment of major depression: a randomized clinical 
trial. The American journal of psychiatry, 170(9), 
1041–1050. https://doi.org/10.1176/appi.ajp. 
2013.12070899

Drum, D. J., Brownson, C., Denmark, A. B., & Smith, 
S. J. (2009). New data on the nature of suicidal cri-
ses in college students: Shifting the paradigm. Pro-
fessional Psychology: Research and Practice, 40(3), 
213–222. https://doi.org/10.1037/a0014465

Edge, D., & Lemetyinen, H. (2019). Psychology across 
cultures: Challenges and opportunities. British 
Journal of Medical Psychology, 92(2), 261–276. 
https://doi.org/10.1111/papt.12229

Forbes‐Mewett, H., & Sawyer, A. (2016). Interna-
tional Students and Mental health. Journal of In-
ternational Students, 6(3), 661–677. https://doi.
org/10.32674/jis.v6i3.348

Evans-Lacko, S., Little, K., Meltzer, H., Rose, D., 
Rhydderch, D., Henderson, C., & Thornicroft, G. 
(2010). Development and psychometric proper-
ties of the mental health knowledge schedule. The 
Canadian Journal of Psychiatry, 55(7), 440–448. 
https://doi.org/10.1177/070674371005500707

XU



149

Glaser, B. G. (1965). The constant comparative meth-
od of qualitative analysis. Social Problems, 12(4), 
436–445. https://doi.org/10.2307/798843

Glaser, B. G. (2017). The discovery of ground-
ed theory. In Routledge eBooks. https://doi.
org/10.4324/9780203793206

Hartshorne, J. K., Tenenbaum, J. B., & Pinker, S. 
(2018). A critical period for second language ac-
quisition: Evidence from 2/3 million English 
speakers. Cognition, 177, 263–277. https://doi.
org/10.1016/j.cognition.2018.04.007

Hansen, N. B. (2002). The Psychotherapy Dose-Re-
sponse Effect and its implications for treatment 
delivery services. Clinical Psychology-science and 
Practice, 9(3), 329–343. https://doi.org/10.1093/
clipsy/9.3.329

Hofstede, G. (2011). Dimensionalizing Cultures: 
The Hofstede Model in context. Online Read-
ings in Psychology and Culture, 2(1). https://doi.
org/10.9707/2307-0919.1014

Huang, H., & Kirsner, D. (2020). The history of psy-
choanalysis in China. Psychoanalytic Inquiry, 
40(1), 3–15. https://doi.org/10.1080/07351690.
2020.1690876

IIE - Institute of International Education. (2023, Febru-
ary 1). Fall 2017 International Student Enrollment 
Hot Topics Survey | IIE - The Power of Interna-
tional Education. IIE - the Power of International 
Education. https://www.iie.org/Research-and-In-
sights/Publications/Fall-2017-International-Stu-
dent-Enrollment-Hot-Topics-Survey

IIE Open Doors. (2022, November 14). International 
Students - IIE Open doors. IIE Open Doors / In-
ternational Students. https://opendoorsdata.org/
annual-release/international-students/

Jing, X., Ghosh, R., Sun, Z., & Liu, Q. (2020). Map-
ping global research related to international stu-
dents: a scientometric review. Higher Education, 
80(3), 415–433. https://doi.org/10.1007/s10734-
019-00489-y

Julien, D., & Connor, K. O. (2016). Comparing treat-
ment efficacy of Cognitive-Behavior Therapy and 
short-term dynamic psychotherapy in high-quality 
studies: a systematic review and effect size approach. 
Journal of Psychology & Clinical Psychiatry, 5(4). 
https://doi.org/10.15406/jpcpy.2016.05.00293

Juneja, P. (2015). Hofstede’s cultural framework as ap-
plied to China. https://www.managementstudy-

guide.com/hofstedes-cultural-framework-as-ap-
plied-to-china.htm

Karp, M., & Vögele, C. (2016). Does anyone still un-
derstand me? Psychotherapy and multilingualism. 
Verhaltenstherapie, 26(3), 156–157. https://doi.
org/10.1159/000448818

King, M. J. (2015). Duration of psychotherapy has little 
association with outcome. British Journal of Psychi-
atry, 207(2), 93–94. https://doi.org/10.1192/bjp.
bp.114.160978

Lattie, E. G., Stiles‐Shields, C., & Graham, A. K. 
(2022). An overview of and recommendations for 
more accessible digital mental health services. Na-
ture Reviews Psychology, 1(2), 87–100. https://doi.
org/10.1038/s44159-021-00003-1

Lee, E. (2010). Revisioning cultural competencies in 
clinical social work practice. Families in Society: The 
Journal of Contemporary Social Services, 91(3), 272–
279. https://doi.org/10.1606/1044-3894.4005

Leong, F. T., & Kalibatseva, Z. (2011). Cross-cultur-
al barriers to mental health services in the United 
States. Cerebrum: the Dana Forum on Brain Sci-
ence, 2011, 5.

Leviness, P., Gorman, K., Braun, L., Koenig, L., & 
Bershad, C. (2019). The Association for University 
and College Counseling Center Directors Annual 
Survey: 2019. Association for University and Col-
lege Counseling Center Directions. https://www.
aucccd.org/assets/documents/Survey/2019%20
AUCCCD%20Survey-2020-05-31-PUBLIC.pdf

Li, J., Marbley, A. F., Bradley, L. J., & Lan, W. Y. 
(2016). Attitudes toward seeking professional 
counseling services among Chinese international 
students: Acculturation, ethnic identity, and En-
glish proficiency. Journal of Multicultural Coun-
seling and Development, 44(1), 65–76. https://
doi.org/10.1002/jmcd.12037

Li, S., Hatzidimitriadou, E., & Psoinos, M. (2014). 
“Tangled wires in the head”: older migrant Chi-
nese’s perception of mental illness in Britain. 
Journal of Aging Studies, 30, 73–86. https://doi.
org/10.1016/j.jaging.2014.04.001

Lian, Z., & Wallace, B. C. (2018). Prevalence of past-
year mental disorders and its correlates among 
Chinese international students in US higher edu-
cation. Journal of American College Health, 68(2), 
176–184. https://doi.org/10.1080/07448481.20
18.1538147

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS



150

XU

Lian, Z., Wallace, B. C., & Fullilove, R. E. (2020). Men-
tal health help-seeking intentions among Chinese 
international students in the U.S. higher educa-
tion system: The role of coping self-efficacy, so-
cial support, and stigma for seeking psychological 
help. Asian American Journal of Psychology, 11(3), 
147–157. https://doi.org/10.1037/aap0000183

Lipson, S. K., Zhou, S., Abelson, S., Heinze, J. E., Jirsa, 
M., Morigney, J., Patterson, A., Singh, M., & Eisen-
berg, D. (2022). Trends in college student mental 
health and help-seeking by race/ethnicity: Findings 
from the national healthy minds study, 2013–
2021. Journal of Affective Disorders, 306, 138–147. 
https://doi.org/10.1016/j.jad.2022.03.038

Lu, S. H., Dear, B. F., Johnston, L., Wootton, B. M., & 
Titov, N. (2013). An internet survey of emotional 
health, treatment seeking and barriers to accessing 
mental health treatment among Chinese-speaking 
international students in Australia. Counselling 
Psychology Quarterly, 27(1), 96–108. https://doi.
org/10.1080/09515070.2013.824408

Mak, W. W. S., & Chen, S. X. (2006). Face concern: Its 
role on stress–distress relationships among Chinese 
Americans. Personality and Individual Differ-
ences, 41(1), 143–153. https://doi.org/10.1016/j.
paid.2005.12.016

Marrero, M. Z., Golden, C. J., & Espe‐Pfeifer, P. 
(2002). Bilingualism, brain injury, and recov-
ery. Clinical Psychology Review, 22(3), 463–478. 
https://doi.org/10.1016/s0272-7358(01)00109-x

Mesidor, J. K., & Sly, K. (2016). Factors that contrib-
ute to the adjustment of international students. 
Journal of International Students, 6(1), 262–282. 
https://doi.org/10.32674/jis.v6i1.569

Onabule, A. I., & Boes, S. R. (2013). International stu-
dents’ likelihood to seek counseling while study-
ing abroad. Journal of International Students. 
https://doi.org/10.32674/jis.v3i1.518

O’Reilly, A., Ryan, D., & Hickey, T. (2010). The psy-
chological well-being and sociocultural adaptation 
of short-term international students in Ireland. 
Journal of College Student Development, 51(5), 
584–598. https://doi.org/10.1353/csd.2010.0011

Park, H., Lee, M., Choi, G., & Zepernick, J. (2016). 
Challenges and coping strategies of East Asian 
graduate students in the United States. Interna-
tional Social Work, 60(3), 733–749. https://doi.
org/10.1177/0020872816655864

Paschall, M. J., & Bersamin, M. (2018). School-based 
health centers, depression, and suicide risk among 
adolescents. American Journal of Preventive Med-
icine, 54(1), 44–50. https://doi.org/10.1016/j.
amepre.2017.08.022

Raunic, A., & Xenos, S. (2008). University Counsel-
ling Service utilisation by local and international 
students and user characteristics: a review. Inter-
national Journal for the Advancement of Counsel-
ling, 30(4), 262–267. https://doi.org/10.1007/
s10447-008-9062-0

Samovar, L. A., & Porter, R. E. (1997). Intercultural 
communication: A Reader.

Shamsi, H. A., Almutairi, A. G., Mashrafi, S. A., 
& Kalbani, T. A. (2020). Implications of lan-
guage barriers for healthcare: a systematic review. 
Oman Medical Journal, 35(2), e122. https://doi.
org/10.5001/omj.2020.40

Shea, M., & Yeh, C. J. (2008). Asian American students’ 
cultural values, stigma, and relational self-constru-
al: correlates of attitudes toward professional help 
seeking. Journal of Mental Health Counseling, 
30(2), 157–172. https://doi.org/10.17744/me-
hc.30.2.g662g5l2r1352198

Shi, W., Shen, Z., Wang, S., & Hall, B. J. (2020). Barriers 
to professional mental health help-seeking among 
Chinese adults: a systematic review. Frontiers in 
psychiatry, 11, 442. https://doi.org/10.3389/fp-
syt.2020.00442

Skromanis, S., Cooling, N., Rodgers, B., Purton, T., 
Fan, S., Bridgman, H., Harris, K. M., Presser, J., 
& Mond, J. (2018). Health and well-being of in-
ternational university students, and comparison 
with domestic students, in Tasmania, Australia. 
International Journal of Environmental Research 
and Public Health, 15(6), 1147. https://doi.
org/10.3390/ijerph15061147

Swagler, M., & Ellis, M. A. (2003). Crossing the dis-
tance: Adjustment of Taiwanese graduate students 
in the United States. Journal of Counseling Psycholo-
gy, 50(4), 420–437. https://doi.org/10.1037/0022-
0167.50.4.420

The White Paper on Mental Health. (n.d.). Weixin 
Official Accounts Platform. https://mp.weixin.
qq.com/s/6pqHA75wlkgAZL7XSAVK_g

Tie, Y. C., Birks, M., & Francis, K. (2019). Grounded theo-
ry research: A design framework for novice research-
ers. Sage Open Medicine, 7, 205031211882292. 



151

https://doi.org/10.1177/2050312118822927
Vogel, D. L., Strass, H. A., Heath, P. J., Al-Darmaki, F. 

R., Armstrong, P., Baptista, M. N., Brenner, R. E., 
Gonçalves, M., Lannin, D. G., Liao, H., Macken-
zie, C. S., Mak, W. W. S., Rubin, M. A., Topkaya, 
N., Wade, N. G., Wang, Y., & Zlati, A. (2017). Stig-
ma of seeking psychological Services: Examining 
college students across ten countries/regions. The 
Counseling Psychologist, 45(2), 170–192. https://
doi.org/10.1177/0011000016671411

Wang, X. (2021). The role of perceived suscepti-
bility and collectivist values in support for us-
ing social distancing to prevent COVID-19 in 
the United States. Journal of Prevention and 
Health Promotion, 2(2), 268–293. https://doi.
org/10.1177/26320770211015434

Wilmots, E., Midgley, N., Thackeray, L., Reynolds, S., 
& Loades, M. (2019). The therapeutic relationship 
in Cognitive Behaviour Therapy with depressed 
adolescents: A qualitative study of good‐outcome 
cases. British Journal of Medical Psychology, 93(2), 
276–291. https://doi.org/10.1111/papt.12232

Yakunina, E. S. (2011). Asian international students’ 
intentions to seek counseling: Integrating cog-
nitive and cultural predictors. Asian American 
Journal of Psychology, 2(3), 219–224. https://doi.
org/10.1037/a0024821

Zigarelli, J. C., Jones, J. M., Palomino, C. I., & Kawamu-
ra, R. (2016). Culturally responsive Cognitive Be-
havioral therapy. Clinical Case Studies, 15(6), 427–
442. https://doi.org/10.1177/1534650116664984

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS



152

XU

Table 1

Participants’ Demographic Data



153

MENTAL HEALTH BARRIERS FOR CHINESE INTERNATIONAL STUDENTS

Table 2

Participants’ MAKS Scores and Attitudes toward Mental Health Treatment




