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Smith College Studies in Social Work

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International students on campus: A challenge for

counselors, medical providers, and clinicians
a b
Rachel Aubrey C.S.W.
a
Senior Staff Therapist, Mental Health Division , Columbia University Health Service ,
b
Consultant on Cross‐Cultural Issues , International Student Office ,
Published online: 14 Dec 2009.

To cite this article: Rachel Aubrey C.S.W. (1991) International students on campus: A challenge for counselors, medical
providers, and clinicians, Smith College Studies in Social Work, 62:1, 20-33, DOI: 10.1080/00377319109516697

To link to this article: http://dx.doi.org/10.1080/00377319109516697

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 INTERNATIONAL STUDENTS ON CAMPUS: A
CHALLENGE FOR COUNSELORS, MEDICAL
PROVIDERS, AND CLINICIANS
RACHEL AUBREY, C.S.W.*

ABSTRACT

The special needs of growing numbers of international students and

other sojourners in the US. can be addressed preventively. Confu-
sion about American academics, customs, and interpersonal rela-
tionships may lead to loneliness and stress. Students often present to
a medical provider with physical symptoms, but few accept referral
to a counselor or clinician. Close teamwork among all staff serving
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international students is needed to lessen adjustment problems and

prevent crises. Special issues of technique in counseling interna-
tional students are discussed. A model for learning key aspects of an
unfamiliar culture, using the student as teacher, is presented.

INTRODUCTION

Many campuses across the United States host large numbers of inter-
national students. In 1988-89 some 366,000 were enrolled in over
2,500 accredited institutions of higher learning. Increasingly they are
graduate students; international students from Asia currently account
for 63% of the nation's graduate student population (Institute for Inter-
national Education, 1989). In the Fall of 1990 Columbia University
enrolled 3,077 international students, constituting 13.7% of the total
student body. They represented 102 countries, the leading five being
the People's Republic of China (PRC), Japan, Korea, Taiwan, and
India. Nationally the most significant growth in the last five years has
been in students from China; at Columbia the PRC continues to baffle
the experts by showing an increase of 42 students in 1990 in spite of the
aftermath of the 1989 Tienamen Square massacre. Twice as many
international men as women enrolled, but the gender gap in lessening;
Fall 1990 saw a one-year increase of 10% in international women at
Columbia {Columbia University, 1990).

*Rachel Aubrey, C.S.W., is Senior Staff Therapist, Mental Health Division, Columbia
University Health Service; Consultant on Cross-Cultural Issues, International Student
Office, and in private practice. She has done cross-cultural work in England, Sweden,
Turkey, and continental Europe.
 INTERNATIONAL STUDENTS 21

International students come here for academic, political or personal

reasons, with academic achievement nearly always the single most
important goal. Many come to obtain graduate or professional training
not available at home. Some cannot get into the field of their choice,
among them members of China's "lost generation" whose education
was interrupted by the Cultural Revolution. Others wish to leave a
politically volatile university; others hope to escape traditionally-
arranged marriages. Their studies completed, most students return home,
although some elect to stay and work. Political refugees must find ways
of staying here. This group currently includes nationals of Iran, Leba-
non, Cuba, Vietnam, the U.S.S.R., South Africa, Ethiopia, and China.
Most foreign students seeking help focus on academic issues even if
their problems are not primarily academic. Campus personnel likely to
have early contact with these students include foreign student advisors,
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admissions officer, deans, administrative assistants, and primary care

medical providers, especially nurses and internists. International stu-
dents rarely come to a mental health service on their own. Therefore,
unless clinicians establish close team-work with all key members of the
university community, they are likely to see few foreign students, and
those they do see are likely to be in crisis. This paper identifies com-
mon stress manifestations, discusses preventive interventions, outlines
useful modifications in treatment technique, and presents a model for
learning key aspects of an unfamiliar culture.

SOURCES OF STRESS

Academic Stress
Stress, a Western folk model that has been "scientified" (Jacobson,
1987), may have academic and non-academic causes. Most foreign
students focus on academic issues. A typical American classroom dif-
fers greatly from those in all but a few Western countries. In the United
States, active class participation is expected, especially at the graduate
level. American teachers tend to question their effectiveness unless
students are visibly involved and final grades often reflect classroom
discussion. This situation can be very confusing for Asian, Middle-
Eastern, and African students. They have been taught to sit in class
silently, taking verbatim notes that will be studied, memorized, and
then reproduced on exam or paper. They may feel at a real disadvan-
tage compared to other students. For example, Tomoko, a 32-year-old
Japanese graduate student, spoke bitterly about her English language
class, stating:
 22 RACHEL AUBREY
Before I am quite sure of the right answer all the non-Asian
students have their hands up, ready with an answer that is often
wrong, yet they get credit for class discussion. I usually have
the right answer but I never speak in class; in Japan this is
considered very rude.
Discussing such concerns with the teacher is rarely a viable option; it
might suggest lack of respect or imply fear of failure. Issues of self-
esteem are ever present. Many international students belong to the
intellectual elite of their country and have been considered special at
home. Chinese students, often individual children in the family as a
result of China's one-child policy, may not be accustomed to the com-
petitive interactions typical of larger families or of Western education.
Receiving a bad grade not only adds to a foreign student's fear of
failure but is likely to accentuate feelings of isolation from American
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peers perceived as doing better.

At Columbia, the International Student Office addresses significant
differences in educational systems during its orientation program, which
precedes registration. A panel presentation by students and faculty,
SURVIVAL AFTER ARRIVAL, highlights specific characteristics of
the U.S. system. Strategies for coping with unfamiliar situations are
offered, and peer advisors assigned to help with problem issues. The
initial presentation is followed by an optional six-session weekly group
called "INTERNATIONAL CONVERSATIONS," starting in mid Oc-
tober after jet-lag and initial euphoria have worn off. This self-selected
group is popular among those who attend but it may not reach those
who need it most Advisors, faculty, counselors, deans, and fellow-
students must be alert to early manifestation of stress so that serious
academic and personal problems can be prevented. Resources permit-
ting, preventive efforts will include spouse and children of international
students.

Non-Academic Stress
Unfamiliar living arrangements can be very stressful. At Columbia,
many graduate students must live off-campus. While American stu-
dents may welcome this, foreign students often find life in a single
room or small apartment very lonely. Many have never lived away
from home, or only in large dormitories. Having a room of one's own is
rare outside the United States. Sharing with a roommate may raise
specific cross-cultural problems. Tsen, a 28-year-old male Chinese stu-
dent, reported great joy at meeting his American roommate who, he
was sure, would now become his best friend. He was shattered when
the roommate asked him to leave for a few hours each day so that he
could have his privacy. Tsen finally posted his class schedule and
 INTERNATIONAL STUDENTS 23

withdrew, deeply hurt, to seek friendship among his countrymen. The

American concept of individual privacy is largely unknown in the non-
Western world. Many cultures define privacy in the context of the
group, usually the extended family. In India and Japan a "familial self'
predominates, rooted in the emotionally hierarchical relationships of
family and group (Roland, 1988). China's official language, Mandarin,
has no word for individual privacy; the term closest in meaning is
slightly pejorative.
When a student's accustomed values differ significantly from those
of the host culture, he or she is likely to experience some degree of
culture shock. This has been described as a continuum of stress reac-
tions to experienced conflict. Culture shock may range from mildly
heightened vulnerability to extreme depression, fear, and suspicion.
Views of depression as loss are consistent with the loss of social an-
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chorage, loss of status, disruption of basic social skills and ties with
loved ones (Klein, Miller, & Alexander, 1981). Foreign student advi-
sors identify three stages of adjustment to the host culture. First, there
is a honeymoon stage: The newly arrived student, happy to be here,
finds everything and everyone great and exciting. Then comes a period
of increasing disillusionment and irritability; nothing feels right and the
host culture is increasingly belittled. Perceptions of Americans become
more negative; they are now seen as rude, self-centered and unavail-
able. The burden of making friends seems entirely on the newcomer
who tends to withdraw and/or seek out fellow nationals. The third stage
is one of partial adjustment to the new culture; some things are ac-
cepted, others rejected. There may be a double dip in stage two, (disil-
lusionment), the second dip deeper than the first, especially when ear-
lier angry feelings have not been worked through. This sequence closely
parallels the usual stages of recovery from loss. The international stu-
dent is coping with loss of family, country and native language (Aubrey,
1988). The losses can be very painful when a student prepared for
many years to come here or, as a political refugee, cannot return home.
Yet to admit one is unhappy in a country long idealized may imply loss
of face, a situation very threatening to Asian, African and Middle-
Eastern students taught not to express negative emotions overtly. When
such feelings are denied or repressed stress often results.

Somatization of Stress
American students tend to experience stress as anxiety and/or de-
pression; non-Western students nearly always develop physical com-
plaints and a coping pattern of seeking medical help. In many socie-
ties, including some rural, ethnic and lower class groups in the West,
stress is expressed primarily by physical symptoms. In China even
 24 RACHEL AUBREY

biomedically-trained physicians do not distinguish between physical

and emotional problems and treat all symptoms with medication
(Kleinman, 1986). Most non-Western students seen by medical provid-
ers have experienced prior treatment focused entirely on the body, and
they may present with a wide range of symptoms. While differences in
climate, food, and life-style are often involved, less tangible factors
may also be at work. A growing body of research in psycho-
neuroimmunology links loss and bereavement with depressed immune
function (Bartrop, Lazarus, Luckherst, Killoh, & Penny, 1977; Schleifer,
Keller, Camarino, Thornton, & Stein, 1983). Some international stu-
dents may have reduced immunocompetency and thus impaired ability
to fight infection. Physicians may be able to measure alterations in
immunological function to determine more accurately the magnitude of
a student's stress response.
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Medical providers in the Student Health Service are often the first
and only professionals to notice symptoms of stress in foreign students.
They are thus in a unique position to do preventive work. Unfortunately
they often do not have time to fully engage these students and may opt
for quick referral. Efforts to refer to mental health clinicians often meet
resistance, since mental problems are severely stigmatized in all but a
few Western countries. "Talking therapy" is virtually unknown and the
concept difficult to explain. Students present with specific symptoms
for which they expect concrete advice or medication. Yet medication is
often not indicated or may already have been used; self-medication
with antibiotic or psychoactive drugs, readily available in many coun-
tries, is not infrequent. Nevertheless, many international students are
eventually seen in a mental health service. How do we best engage and
work with them? Are our usual clinical interventions effective with
non-Westem students and others who are therapeutically naive? Per-
sonal experience, discussion with colleagues, and a still scant literature
suggest that considerable flexibility in therapeutic technique is indicated.

CLINICAL INTERVENTIONS

In working with international students, certain issues need always be

born in mind:
1. Cultural background is integral to our frame of reference.
Students must be approached in a manner at least somewhat congru-
ent with their world view. We need to accept presenting symptoms as
valid even when they do not fit our diagnostic impression, DSMIII-R,
or ICD-9 (Kleinman, 1988). If we fail to do so, serious problems, often
of crisis proportions, may develop, as our experience with Philippe was
 INTERNATIONAL STUDENTS 25

to teach us. Philippe is a 28-year-old male, a solidly-built native of

French West-Africa who presented to the Health Service with epigas-
tric pain, bodily weakness, and inability to study. He attributed these
symptoms to not having anyone to cook for him and thus having to eat
unfamiliar foods. Though the physical exam was normal Philippe in-
sisted he was ill. Blood was drawn for a work-up; again the results were
normal. When told so by a female nurse, Philippe became very agitated
and loudly demanded to have his blood back. Neither the nurse, a male
physician, nor a psychiatrist could establish rapport with Philippe and
he appeared about to attack in what seemed like a psychotic episode.
University security was called to take him to a nearby emergency room
by ambulance. One of the volunteer ambulance men, a student, began
talking to Philippe softly in French. After a few minutes he asked for a
glass of tomato juice and gently urged Philippe to drink it. Philippe
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calmed down visibly and soon insisted on going home, rejecting any
exploration of his stress. The ambulance man, a former Peace Corps
volunteer in Africa, then explained to the puzzled staff that Philippe, as
a proud member of the Wolof tribe, felt deeply ashamed and his man-
hood threatened by his symptoms. Having to lose vital blood to a
white-coated stranger, then to be told again he is not ill, was more than
Philippe could tolerate. Fear and panic turned into aggression and
paranoid-like behavior. Speaking with a fellow student in a familiar
language calmed Philippe, as did the suggestion that red juice would
help replace his lost blood. He endowed the ambulance man with some
of the powers of a marabout or native healer.
In parts of Africa and Asia Western-trained physicians work side-by-
side with indigenous healers to help integrate a biomedical approach
with local illness-related beliefs. Collignon (1978) describes this ap-
proach as highly successful in the Senegalese psychiatric teaching-
hospital, Fann-Dakar. American physicians may profit from consulta-
tion with native healers, found in many large cities, in treating students
from developing nations.
In Rethinking Psychiatry, Kleinman (1988) proposes an international
vision of mental illness and mental health which challenges some basic
tenets of American psychiatric training and practice. He points out that
the reification of one cultures's diagnostic categories and their projec-
tion on to patients in another culture, where their validity has not been
established, is a category fallacy.

2. There may be difficulties in developing a treatment relationship.

We may actively have to seek a holding environment (Winnicott,
1960) to allow meaningful work. Reliance on a primarily verbal-
symbolic method is rarely successful when a person's conceptual frame-
 26 RACHEL AUBREY

work is based on a somatic mode of containment (Goldberg, 1988). In

non-Westem cultures people rarely focus on abstract concepts but think
very concretely. It is also considered inappropriate to speak of personal
matters with anyone outside the extended family. Expecting a student
to initiate personal discussion in a clinical office may arouse feelings of
shame, betrayal, or fear that others might hear about the problem. A
session predicated on the student talking while the clinician listens may
also be in direct violation of accustomed deference to authority. The
clinician is invested with the absolute power of a medical doctor or
healer, and expected to tell a patient exactly what to do to get well.
Familiar patient-therapist transferences, on which much of Western
analytically-oriented therapy is based, may not develop; instead differ-
ent transferences occur. Taketomo (1989) has described a teacher trans-
ference in the treatment of a Japanese patient. In India the therapist may
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stand in for someone in the extended family. I learned this in working

with Mary, a very Westernized Indian professional woman who only
after several years of therapy was finally able to express some anger at
me. When I interpreted this as transference feelings from her cold and
critical mother, Mary, visibly shocked, stated that I would always stand
for a nice "auntie" one might sometimes get mad at; in her culture it
seemed unthinkable to express anger about one's mother.
When a holding environment is not established quickly foreign stu-
dents are likely to withdraw. Some will simply not come back after the
first session and be counted as drop-outs. Others will return, sit tensely
in the office, deferentially silent except to answer some direct ques-
tions. It is tempting to label such behavior resistance when it may
instead reflect our lack of flexibility in creating a culturally more ap-
propriate treatment environment. Some clearly troubled students may
need repeated brief contact with a therapist before they are able to trust
the process of treatment. Susanne, a sophisticated professional woman
from Western Europe, first came to Mental Health at age 27, presenting
with a history of destructive relationships with men. Though she could
intellectually relate these to severe physical abuse by her mother, Susanne
left after a few sessions, stating that she did not need the "crutch" of
therapy. Only 11 years and four brief contacts later was Susanne ready
to commit to treatment and to work productively on the severe child-
hood abuse which had continued to haunt her in frequent nightmares.

3. Countertransference issues need to be considered.

While most clinical work involves countertransference, international
students tend to affect us in special ways. Their eagerness to adapt in
spite of personal losses and their deference to the perceived authority of
the clinician may evoke unusual compassion and make them seem
 INTERNATIONAL STUDENTS 27

"good" patients; their focus on somatic symptoms, psychological naivete,

neediness, and demand for advice may be annoying. It is rarely pos-
sible or desirable for the therapist to maintain a state of complete
clinical neutrality. Foreign students need a sense of real relationship—
outside of transference—to begin trusting the unfamiliar process of
therapy. Work with Yuan was predicated on a "real" relationship. A
28-year-old married Chinese graduate student, Yuan was referred by a
nurse in the second month of pregnancy. She presented with headaches,
insomnia, and concern that an occasional aspirin might have hurt the
baby. Yuan had lost her first pregnancy six months earlier; the present
child was conceived a few days after the 1989 Tienamen Square Mas-
sacre in Beijing where her father and step-mother live. Early in our
sessions, soon spaced a month apart at her request, Yuan revealed that
her father had divorced her mother when Yuan was four years old, for
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reasons shrouded in secrecy. Yuan had always felt unloved by father

and step-mother yet was now, in July, 1989, keenly worried about their
safety in Beijing. As the daughter of intellectuals persecuted during the
Cultural Revolution, Yuan was brought up to be ready for future politi-
cal crises. Instead of yearned-for piano lessons she was taught the use
of herbal medicines, to help her cope should she, too, be sent to the
countryside for "reeducation." Yuan asked many questions about preg-
nancy, childbirth, infant care, and even circumcision, not customary in
China. Giving her concrete and reassuring answers gradually allowed
Yuan to confront her lonely childhood, resentment at her husband, a
medical resident who spent little time with her, and the secret fear she
was carrying a "bad seed," like father's description of mother. This
prompted Yuan to ask for CVS (chorianic villus biopsy), a very early
fetal diagnostic procedure rarely done in the absence of known risk
factors. The nurse and I suggested she wait for amniocentesis later in
her pregnancy. Only when this test gave normal results could Yuan
finally relax and look forward to her baby. Referral to childbirth classes
provided another reassuring mother person as well as American peers.
These classes also involved her husband so that the pregnancy became
a shared experience. Yuan gave birth to a healthy boy whom she named
for an American president. At his father's request he was circumcised
"to avoid any future medical problems." Throughout our contact Yuan
related to me as a real person who had herself raised children and who
believed she would be a good mother in spite of her earlier history.

Treatment Modalities
Crisis intervention and/or brief therapy focused on the presenting
problem appear to be the treatments of choice for a majority of foreign
students. In selecting among various modalities the therapist must often
 28 RACHEL AUBREY

attend to practical problems in the student's social and physical envi-

ronment. Concrete interventions such as referral to academic advisor,
nurse, physician, or international student group will often address the
presenting problem and then allow exploration of other issues.
Experience suggests that few international students opt for long-term
therapy or analysis; for those who do, the interface between culture and
neurosis is a constant challenge. Hazal, a Muslim woman from the
Middle East, likened the culture-personality interface to a braid—the
strands are tightly interwoven but still remain separate. Students may
be reluctant to deal with issues of loss. At some point we may have to
help them acknowledge and mourn loss of home, status, and language
(DeVryer, 1989; Pollock, 1985). While such issues are usually ad-
dressed in individual therapy, group therapy also can be a useful mo-
dality. Indrani, a 26-year-old dark-skinned Indian graduate student,
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presented with stomachache and loneliness. The middle and darkest of

three daughters, Indrani avoided men since she felt slated by culture
and fate to remain single. She worked well in weekly individual therapy
but after a few months clinic pressures ruled out further individual
therapy. Lack of funds precluded referral so, rather uneasily, I offered
her a place in my weekly therapy group. This turned out to be the
treatment of choice. The group soon became Indrani's new family.
With their support she began to confront issues of sibling rivalry and
rebellion against parents. Cultural inhibitions would not have allowed
this in one-on-one treatment.
Brief crisis-oriented therapy, focused on a specific symptom or situa-
tion, may help some students accept longer-term treatment immediately
or at a later time. If students can be actively engaged, allowed to
terminate when they wish but encouraged to return as needed, some
will do so, often more ready to sustain therapy on a second or even
third encounter.
At times of political upheaval abroad active outreach by university
staff may be indicated. During the days preceding the 1989 Tienamen
Square Massacre, Student Services at Columbia set up a China Re-
source Room with newspapers and a bulletin board for students to list
relevant meetings. Though few Chinese students were seen using the
space they were said to be glad it was there. Several faculty members
invited Chinese students to their homes, resulting in a mutually-enrich-
ing experience. In January, 1991 Student Services sponsored a Gulf
Support Group for students directly affected by the Middle East con-
flict. Using a modified version of "International Conversations" (see p.
5), the goal was to encourage free expression of feelings with the help
of a facilitator. About half of those who attended were concerned
 INTERNATIONAL STUDENTS 29

American students. Their presence contributed to a rich and moving

experience. Familiar stereotypes gave way to real people as Arabs,
Israelis, Europeans and Americans sat together sharing feelings for
eight weekly meetings. Several of the international students later re-
ferred themselves to Mental Health for individual therapy.

Modes of stress manifestation

International students usually present with physical symptoms rather
than with study blocks, anxiety, depression, or the break-up of a rela-
tionship, although such concerns are often present. Presenting with a
body part as the cause of distress is culturally determined; it also allows
the student to avoid feelings of shame or social isolation, as was illus-
trated by Philippe, the West African student. Focusing on physical
symptoms need not preclude feelings; some students seem to feel with
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their body but will talk about sadness or stressful events only upon
careful inquiry. Presenting symptoms commonly seen among foreign
students include epigastric pain, colds, headaches, dizziness, fatigue,
insomnia, skin disorders, and a generalized feeling of body weakness
or "neurasthenia." While no longer diagnosed in North America and
Western Europe, neurasthenia is still a common diagnosis in Eastern
Europe, China, Hong Kong, Taiwan, and several South-East Asian
societies (Kleinman, 1988). Internists and urologists who see young
Chinese males may also encounter the shen-k'uei (kidney weakness)
syndrome. Wen and Wang (1981) describe this as a culture-specific
psychosexual neurosis, involving various symptoms, often including
specific complaints of sexual dysfunction. In the popular view shen-
k'uei is always attributed to masturbation, with the resulting loss of
vital energy leading to neurasthenia. Kleinman (1990) reports several
cases of shen-k'uei among Asian students at Harvard.

Communication
Communication, the basis of any clinical relationship, can be a major
problem. Students' command of English is often limited, especially
when under stress. Use of an interpreter, though sometimes unavoid-
able, can lead to complications. When a student does not speak English
well, non-verbal affect and body language take on added meaning.
Here again we must bear in mind cultural norms. Avoidance of eye
contact may signify politeness rather than distrust; moving very close
or pulling away may also be rooted in cultural tradition. A rich source
of communication can be found in dreams, considered of great impor-
tance in many societies, and often freely shared with family and friends.
Interest in dreams can be used diagnostically in brief therapy, or help
 30 RACHEL AUBREY

overcome resistance in long-term treatment. This I was to learn in my

work with Hazal.
Hazal, a 30-year-old female Muslim student from the Middle East,
presented with insomnia and concern about academics. She had almost
completed a professional program but planned to stay on a few years
hoping to find a suitable husband. A somewhat masculine-appearing,
lonely, and angry woman, Hazal had often been sexual with men yet
refused "to go all the way" and had repeatedly been "rejected." Hazal's
mother was described as a traditional Muslim housewife, yet she had
read about therapy and urged Hazal to try it. Hazal approached treat-
ment with great resistance though my familiarity with certain cultural
behaviors of her country helped a little. While she talked a great deal
we seemed unable to make progress. After several months, quite frus-
trated, I asked about dreams. Surprised at my interest, Hazal immedi-
ately shared a recent dream:
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I am swimming backwards in an unfamiliar sea. The water is

darker than at home but I like it. I do not know my destination
but I am swimming from East to West. My legs are still in the
East and my head is in the West Though I am not in control, I
am not anxious.
These were her associations: "Dark water is less pure (virginal) than
our lighter water at home. I have defied tradition by refusing two
arranged matches and by coming to the States against my parents'
wishes. My chances of still finding a suitable husband at home are very
small." Hazal could accept some transference elements in her dream
and volunteered that she had begun to trust me. From then on she often
began sessions with a dream she had "seen," first telling me specific
meanings from her country's dream books, then moving on to her own
increasingly free associations. Our shared interest in her dreams helped
Hazal stay in therapy and do very productive work.

The Meaning of Time

Time concepts vary in different cultures but rarely approximate our
own. Students may arrive for appointments late, early, or even on the
wrong day, and still expect to be seen, just as a trusted family member
would always be available. The notion of a time-limited appointment or
a weekly therapy hour is alien and may need repeated explanation. In
many cultures it is rude ever to seem rushed; any discussion of business
is preceded by polite social exchange. A hard-pressed clinician may
find it trying to wait empathically until a clearly upset student finally
comes to the point If these early moments or even sessions are used to
inquire about the student's native country, prior educational experi-
 INTERNATIONAL STUDENTS 31

ence, current living arrangements, and family, a treatment relationship

is more likely to develop. In working with Yuan, some of the early
sessions were spent in a two-way psychoeducational manner. Yuan
shared with me relevant aspects of the Cultural Revolution while I
answered her questions about pregnancy and childbirth. Her decision to
reduce sessions to once a month made sense in view of a heavy aca-
demic program and increasing fatigue as the pregnancy progressed.

Cultural Learning
Cultural learning is vitally important for all clinicians. It can also be
very stimulating. Our best teachers are the very students we are here to
help. By enlisting international students as active interpreters of their
culture we accomplish several things: We help them overcome their
passive deference to us, the perceived experts on life in America; we
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enlist them as equal partners in the helping process, and we restore to

them some of the self-esteem so often hurt in the painful process of
adjustment. This approach takes time but can be most rewarding. Clini-
cal skills are enriched when informed by the findings of anthropology
and other social sciences. Once we have built a personal information
base on different cultures, future international students will benefit.
This occurred in the case of George. A 28-year-old male Indian stu-
dent, George was referred by the dean of a professional school since he
was about to drop out. George already had a master's degree in psy-
chology. He spoke fluent English, liked the program, and had almost
completed the first year. However, when told to finish some incompletes
by a fixed date, George stated he could not go on due to "severe culture
shock" (his words). As we began to address George's angry resistance
to American academics and therapy my earlier work with an Indian
student from the same culturally-distinct community was very useful.
Gradually I could help George confront major personal problems long
hidden beneath cultural issues. After a semester of treatment and a
reduced course load he finished his program.

LEARNING ABOUT UNFAMILIAR CULTURES

The following suggestions for learning key aspects of an unfamiliar

culture, grounded in the Eriksonian life-cycle approach (1959) use the
student as teacher. These suggestions may be adapted to a conversation
over lunch or to an educational digression in a clinical session. In either
case it will help establish rapport with an international student.
Begin by explaining what you need to know to better understand the
student's problem. Start with the area of immediate concern, usually an
 32 RACHEL AUBREY

academic one. This is a safe topic which allows the student to teach you
as rapport develops. Then focus on milestones in the life cycle, starting
with the student's current stage of development, usually young adult-
hood. Invite him or her to compare experiences here with normative
behavior at home. When appropriate, move into other relevant areas,
such as family relationships, including important members of extended
family or clan, and friendships. Listen for issues of loss and distinguish
between normative and catastrophic crises. Inquire about the impact of
forced uprooting due to political upheaval, as in China's Cultural Revo-
lution and Tienamen Square Massacre, or of war, famine and disease,
as in parts of Africa and the Middle East. Pay close attention to the
student's affect before proceeding to the more sensitive topics of lone-
liness, relationships, belief systems, fate, marriage, and sex.
In conclusion I believe that an interdisciplinary and cross-cultural
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approach, involving professionals and selected others, is the most ef-

fective way of reaching a rapidly growing and underserved minority
group, our international students. This approach facilitates early identi-
fication of problems, prevents avoidable crises, and serves as a power-
ful antidote to professional burnout.

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