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. 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