Stigma related to mental health issues, low mental health literacy level and the lack of knowledge regarding on and off campus resources form the three key barriers that prevent young people from seeking professional help for mental health issues (Shahwan et al., 2020). Considering that the stressful academic and social settings at universities coincide with the peak age-risk for the onset of serious mental illness, higher institutions should take constructive actions to better mental health resources and its accessibility (Watkins, Hunt, & Eisenberg, 2012). In this paper, I explore the strength and weaknesses of a community based anti-stigma program implemented at the University of Indiana. By looking into the demographics of participating students, I suggest the development of more culturally and linguistically sensitive programs for underrepresented subgroups in order to more effectively connect students with the support they need.
Pescosolido et al. (2020) documented the effect of the University Brings Changes to Mind program supported by the institution of the University of Indiana. The intervention functioned on two levels—at the university level, the College Toolbox Project (CTP) offers faculty mentorship, research-based assessment and interdisciplinary collaboration; at the student-body level, UBC2M organized by students target specific communities(e.g. POC) and carry out stigma-reducing activities, advocate for changing school policies and try to create a safe and stigma-free zone. The influence of this intervention is assessed through a pre and post comparison of students’ perceived stigma against mental illnesses. Results suggested that there is an overall statistically significant decrease in both general and college-specific prejudice. Perceived college-specific social distance also decreased over time. It is interesting that active participation in student-led events result in significant positive changes in general and college specific prejudice. Additionally, passive exposure to anti-stigma posters and flyers also leads to more favorable perception of the college mental health culture. The findings of the study indicated a wide range of avenues through which mental health related stigma can be addressed on a college campus. Especially in times like the pandemic when in person activities are strained due to safety regulations, school cultural symbols including posters, flyers, and logos that normalize mental illnesses and reiterate the importance of psychological health serve as important tools to shape viewers’ behaviors and attitudes (Swidler, 1986).
Despite the integrative intervention model that centers student voices and creates space for student employment, the study has its limitations in terms of student demographics. For instance, the researchers mentioned that the majority of the participants who finished follow-up assessment were female and white students. Without a method to assess the demographics of those who didn’t participate in the study, it is hard to infer whether the two subgroups who were willing to participate in the current anti-stigma study were also more receptive to changes initially. In response to the overrepresentation of women and white students in the current sample, it is important for future studies to target specific subgroups (e.g. student of color and male students) through both qualitative and quantitative follow up assessments so as to better understand their perceived accessibility of mental health resources on and off campus. Additionally, I would like to point out that the accessibility of student-led empowerment activities cannot be fully equated with students’ actual preference for mental health services. An individual student’s social background and family upbringing might allow them to express acceptance for mental health intervention on campus without necessarily being willing to utilize these resources themselves.
In order to delineate how culture might influence college and graduate students’ intention to seek help from mental health services, Lian et al. (2020) looked into the help seeking pattern of Chinese International students and its correlates including coping self-efficacy, level of social support, level of stigma, whether or not being an undergraduate and previous employment history. Chinese international students, though making up only two percent of the entire Asian community in the United States, is the largest international student body in the country (Institute of International Education, 2019). While international students share certain cultural heritage with the local Asian community, they are less likely to have immediate social support networks and more often rely on friends, local or school based international student community and e-communication with family members. Being a Chinese International student myself, it is interesting to see the result of the 2020 study, showing that recruited Chinese students are more likely to seek help from an intimate partner, family and friend rather than utilizing mental health service. In general, recruited students display a higher level of stigma against mental health. Additionally, graduate students with a previous history of employment have a lower level of general help seeking intention compared to those who are still undergraduate students. Note that the majority of the recruited students are in graduate schools. This finding should be interpreted with caution.
While appreciative of Lian et al. (2020)’s intention to focus on a specific subgroup under the umbrella of help-seeking pattern among college students, I am curious about a few interpretations drawn from the statistical results, first being the assumed embarrassment and shame associated with having mental illnesses. The study postulated that in Chinese culture, the symptoms of mental illnesses are oftentimes associated with “weak character” that would devastate the morale of one’s entire family, which in turn reduces the likelihood of help-seeking behaviors (Lian et al., 2020). However, the study did not directly explore the reason behind reduced help-seeking behaviors from the participating students. When operationalizing perceived stigma for seeking psychological help, the questionnaire inquired whether or not “they want their family or friends to know if they are seeking psychological help/counseling/mental health services in the U.S.” The reasons for not wanting to inform friends and family of their mental condition can vary from shame and embarrassment proposed by the researchers in the study to not wanting to worry parents who reside in a different country who cannot contribute directly to the mental wellbeing of their children. Given that filial piety is also deeply valued in Chinese culture, it is not uncommon for children to feel uneasy at the thought of worrying their elder parents.
Moreover, as the researchers noted, the majority of the recruited students are self-supporting graduate students who face the challenge of sustaining an individual life abroad. The relatively lower help-seeking intention can also be associated with the complication in navigating the network of health insurance, posing as an obstacle discouraging students from China who mainly deal with state-owned insurance facilities that do not require separate billing or additional paperwork. Interestingly, Shawan et al. (2020) on exploring the potential impact of an anti-stigma intervention on mental health help-seeking attitudes among university students in Singapore found that older age is correlated with higher psychological openness and help-seeking propensity. Studies suggest that compared to junior, senior and graduate students, freshmen and sophomores face more challenges seeking professional help (Vidourek, King, Nabors, & Merianos, 2014). College students gain more knowledge about mental health and mental illnesses through campus outreach efforts, peer-help and other psychology workshops offered by the school. Having more experience interacting with mental health service, students from higher grades consequently develop a more positive attitude. However, one has to be mindful that the recruited samples in the aforementioned two studies are very different. Lian et al. observed Chinese students who left their home country and resettle in a novel environment while Shawan et al. focused on students who live and study locally. The comfort residing in a familiar environment can reduce the difficulty navigating an entirely new educational and healthcare system, which serves as an encouraging factor for the pursuit of mental health service. It will be interesting to see whether graduate students recruited by Lian et al. have also previously gone through undergraduate studies in American Institutions.
Whether or not longer settlement in the U.S context leads to increased healthcare literacy is an interesting question for educational programs across the country to consider. Drawing from my own experience participating in the international orientation program at Vassar, which is comparatively longer and more comprehensive than other institutions based on several students’ account, I still feel the challenge navigating health insurance and related services. Studies focusing on the correlation between perceived complexity of the US healthcare system and service utilization intention might have the potential to enrich the field’s understanding over Chinese international students’ relative reluctance when it comes to seeking mental health services.
Finally, I would like to emphasize that the term “Chinese culture”creates a sense of generalizability that does not necessarily encompass the diverse regional context. For instance, students who lived in major cities or enrolled in international schools/IB programs prior to pursuing an education in the United States might not embody the same sets of Chinese culture as those from more secluded rural areas. The extent to which a more globalized education (more accessible in major cities) might change cultural interpretation of mental illnesses remains a topic in need of further investigation.
When taking into account all of the studies discussed above, it is evident that anti-stigma interventions are necessary on college campuses and that implementation has to account for the cultural and social background of the participating students. As Pescosolido et al. (2020) eloquently pointed out, the battle against stigma cannot be easily achieved by one institution or one non-for-profit organization. The necessity of creating a web of care lies in fostering collaboration between students and faculties and students and communities in terms of increasing mental health literacy and improving service accessibility. It is equally important to bring family members and intimate others both domestic and abroad into this process of battling stigma. Mental health literacy is not only about more than understanding why things happen and how, but also about how to address them under stressful academic settings and navigate the system when the procedures can be foreign and complicated.
Work Cited: Institute of International Education. (2019). 2019 Fact Sheet: China. Retrieved from https://www.iie.org/Research-and-Insights/Open-Doors/ Fact-Sheets-and-Infographics/Leading-Places-of-Origin-Fact-Sheets
Lian, Z., Wallace, B. C., & Fullilove, R. E. (2020). Mental health help-seeking intentions among chinese international students in the U.S. higher education system: The role of coping self-efficacy, social support, and stigma for seeking psychological help. Asian American Journal of Psychology, 11(3), 147-157. https://doi.org/10.1037/aap0000183
Pescosolido, B. A., Perry, B. L., & Krendl, A. C. (2020). Empowering the next generation to end stigma by starting the conversation: Bring change to mind and the college toolbox project. Journal of the American Academy of Child and Adolescent Psychiatry, 59(4), 519-530. https://doi.org/10.1016/j.jaac.2019.06.016
Shahwan, S., Lau, J. H., Goh, C. M. J., Ong, W. J., Tan, G. T. H., Kwok, K. W., Samari, E., Lee, Y. Y., Teh, W. L., Seet, V., Chang, S., Chong, S. A., & Subramaniam, M. (2020). The potential impact of an anti-stigma intervention on mental health help-seeking attitudes among university students. BMC Psychiatry, 20(1), 562-562. https://doi.org/10.1186/s12888-020-02960-y
Swidler, A. (1986). Culture in action: Symbols and strategies. American Sociological Review, 51(2), 273-286. https://doi.org/10.2307/2095521
Vidourek, R. A., King, K. A., Nabors, L. A., & Merianos, A. L. (2014). Students' benefits and barriers to mental health help-seeking. Health Psychology & Behavioral Medicine, 2(1), 1009-1022. https://doi.org/10.1080/21642850.2014.963586
Watkins, D. C., Hunt, J. B., & Eisenberg, D. (2012). Increased demand for mental health services on college campuses: Perspectives from administrators. Qualitative Social Work : QSW : Research and Practice, 11(3), 319-337. https://doi.org/10.1177/1473325011401468
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