Inside the challenges international students face navigating mental health at Penn

College senior Riya Chandiramani was working out at Pottruck Health and Fitness Center when she got a text from her dad. Now, she can’t remember what the text said. But she thought she’d done poorly on a quiz in her marketing class, and seeing the text from her dad — a successful man who’d always held her to high standards — was too much.

Soon, she was on the floor of the bathroom in Pottruck, breaking down. But the overwhelming feeling of stress wasn’t new to her. It had been a part of her life for years.

She remembers the crushing anxiety of tests she had to take at her international school in Hong Kong, and the feelings of inferiority when her parents compared her to other girls. Trying to find her place in the Penn social scene during her freshman year when she’d never drunk alcohol or hooked up with boys. Feeling her perfectionist personality — what had helped her get here, after all — push her towards eating less and less and less.

And all the while, Chandiramani saw her struggle as a manifestation of her own weakness and failure — something she could push through if she tried hard enough.

That night, Chandiramani called her aunt, a therapist in Los Angeles. They talked for hours. Her aunt told her she was probably suffering from symptoms of depression and encouraged her to get counseling.

Chandiramani didn’t want to believe it. How could she be depressed? Mental health had never been discussed in her family. She was privileged to be studying at Penn. She had every advantage in the world.

Chandiramani soon began counseling, but it would be several months before she began to recover fully from depression and an eating disorder. She ultimately took a leave of absence from Penn — not by choice, but because Student Health Service required it after determining that she was at her 12-year-old weight and had a dangerously low heart rate. Even then, she didn’t want to believe anything was wrong.

All the while, she was halfway across the world from a family who didn’t even want to believe she was struggling. And Chandiramani herself was unwilling to accept that she was suffering from an illness that had always gone unmentioned in her culture.

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Chandiramani is one of hundreds of international students at Penn. Around 12 percent of students hail from outside the United States, according to the 2015-16 Penn common data set. Far from their homes and families and faced with navigating a new country, international students face a myriad of challenges that are entirely unknown to domestic students.

When it comes to mental health — a topic thrust into the spotlight at Penn after a string of student suicides, an outpouring of student activism and a subsequent bundle of administrative policy changes — those challenges can be particularly trying.

On one hand, international students dealing with homesickness can’t just head home for the weekend. Many must learn to operate in a culture that’s completely different from their own. Some don’t speak English as their first language, making it harder to find footing in academic and social life. Even little things, like missing food from home countries, can make international students’ first few months in the United States demanding ones.

“They [international students] may be extremely smart and high-achieving back in their home countries, but just coming to a place where the amount of reading that’s required, or group projects that are required, or class participation ... all of those may end up being, for many, significantly new experiences,” said Meeta Kumar, the director of outreach and prevention at Counseling and Psychological Services.

But many of Penn’s international students also grew up in cultures where mental health is not discussed or even acknowledged. Some of these students, hiding their stress from their peers as well as their family, become isolated and postpone treatment, allowing their problems to worsen.

“If you’re at Penn and you’re supposed to be successful, and if you’re not — ‘what’s wrong with you?’” said Anthony Rostain, a psychiatry professor at the Perelman School of Medicine who was also on the 2015 Task Force on Student Psychological Health and Welfare. “But it’s multiplied even more when you’re talking about someone from another country who is not only supposed to be happy to be here, but is also privileged to be here.”

That’s exactly how Chandiramani felt as her struggles mounted. Growing up as an only child with a mother who suffered from physical illnesses, she was the perfect daughter — always studying, always well-behaved, always in line with what her family expected of her. For years, her academic achievement had also meant pleasing her parents. Even applying to Penn, where her dad received his MBA, was another step in living up to her parents’ expectations.

“You’re downplaying your achievements already, you’re never going to admit to being good at something because the culture is to be humble. And then you’re also feeling guilty by saying, ‘Oh, my dad has given me this much, and I need to make full use of it,’” she said. “And these themes run strongly in what eventually led to me getting really, really, really ill.”

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Chandiramani was raised in Hong Kong but comes from an Indian family. Although acknowledging mental health issues can be difficult for students of all cultures, that difficulty is particularly pronounced for some students from Asian backgrounds.

Michael Jonathan, a College sophomore from Indonesia, said it took longer for him to accept he was struggling with mental illness because of how he was raised.

“I definitely knew that in high school, I was somewhat depressed, but because of how mental health is viewed, especially in Indonesia, it’s typically something that is not a condition, it’s something that’s viewed as a weakness,” he said.

Research has indicated that Asian college students face greater challenges in the mental health realm than their peers. Surveys have found that Asian students are more likely to report feelings of stress, trouble with sleep, and hopelessness — but were less likely to seek counseling. And one study showed that Asian students were more likely than their white counterparts to have considered or attempted suicide.

Jonathan remembered one time in high school when he broke down and shut himself in his room for an entire day. To his parents, that wasn’t acceptable. They couldn’t understand that their son was struggling with an issue that’s almost completely taboo in their culture.

“I personally think it’s representative [of the culture] — if it [a mental health issue] does go badly, parents will recognize it,” Jonathan said. “But then they’ll go back to saying that you were just overreacting, you’re just exaggerating it, and it can’t be that bad.”

Chandiramani first tried to tell her parents she was struggling during winter break of her junior year at Penn, a couple of months after she broke down in Pottruck. Although she’d rehearsed the conversation, it didn’t go as planned — her parents were defensive, and upset that she had started seeing a counselor at CAPS instead of consulting them first.

Months later, during October of her senior year, Chandiramani finally told her parents on the phone that she “couldn’t live like this anymore.” That was when they finally realized that something was wrong, and they flew to the United States to help her through the treatment program that she eventually began.

Heng Guo, a psychiatrist at the Philadelphia VA Medical Center who has helped with mental wellness outreach among Penn undergraduates, explained that some Asian families’ first instinct when their children ask for help may be to search for a direct solution instead of just listening.

“Most East Asian cultures are taught to not interrupt the chain of command too much, not to complain too much,” he said. “And I can say in my experience, a lot of the times when we’re going through something and talking to somebody, we don’t necessarily want the problem to be solved, we just want someone to be there.”

Yuhong He, the international specialist at CAPS, said stress can arise when students feel pressure to live up to their family’s expectations. And when they feel like they can’t meet those expectations, they can end up feeling incredibly alone.

“A lot of students talk about the pressure that they have to be a certain way, or they have to perform a certain level, they have to get a certain job, because that’s the family’s expectations,” He said. “But in reality, it may be very hard to accomplish those goals, or it may take a longer time — so if they can’t have that conversation with their family members, it makes it that much harder for them.”

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Reluctance to accept mental health issues is far from limited to international students. At Penn, a notoriously competitive school where high achievements are the norm, hiding personal struggles is so common that the term “PennFace” is now universally understood.

But for students coming from cultures that don’t always acknowledge the severity of mental illness, expressing their problems can be even harder.

“Most people internalize the values of the way they grew up, and if the value is that you just have to tough it out or you shouldn’t have to get help,” Rostain said, “we call that a double barrier, because you’re not just feeling bad, but you’re feeling bad about feeling bad.”

Kara Hu, a College sophomore from Taiwan, began struggling with homesickness and, eventually, depression during her freshman year at Penn. She’d struggled in high school as well, but was reluctant to tell her mom because of the stigma associated with mental illness in her home country.

“The few people who are actually depressed or experiencing symptoms of depression — they don’t think it’s a big deal because they see that everyone else is working just as hard as them and they seem to be doing okay, so it’s just not a topic that people are comfortable bringing up,” she said.

At Penn, Hu sees a range of openness — some people are willing to openly discuss their mental health, others less so. But in her home culture, talking about things like depression is close to impossible.

“In Taiwan, literally no one is willing to talk about it — there’s just no discussion,” she said.

Once Hu started seeing a counselor at CAPS and taking medication for her depression, she began to feel better. Jonathan struggled at first to get an appointment at CAPS, but he also found its services helpful.

“When I told them that I came from Indonesia, they were so helpful with the fact that I was saying that I was homesick,” Jonathan said. “Because they really do understand that it’s a 24-hour-plane ride to go back home, and I really like that.”

CAPS, the primary source of relief for Penn students struggling with mental illness, says it considers the cultural backgrounds of students seeking treatment, and that counselors are aware that it may be more difficult for some students to open up about how they’re feeling.

“I think, just like all students, we take into consideration their cultural backgrounds, their family history, their presenting concerns and all those different factors in their personality and the current stressors that impact them,” He said.

It’s not unusual for psychological problems to manifest themselves as physical ailments in some cultures, He explained. She said that’s something CAPS tries to keep in mind when students seek help.

Chandiramani believes her stress, which ultimately caused her to develop anorexia, might have manifested itself as a physical problem because she wasn’t fully able to express the way she was feeling.

“When you don’t have the voice to verbally express what’s going on, you show it, and that may have been what I was doing with my body — showing my pain and showing my distress,” she said.

Looking back on her experience at CAPS, Chandiramani wishes she could have seen a counselor from her own cultural background, someone who might have been able to understand her issues on a deeper level. Although she didn’t explicitly request to see an Indian counselor when she started treatment, she said she wanted to switch after her treatment begun, but felt uncomfortable doing so.

CAPS, while making an effort to hire diverse counselors, is not always able to place students with counselors of their same background because of scheduling — and not all international students necessarily want this. However, counselors can do internal referrals to place students with other counselors who might be able to better suit their needs.

“We, definitely, in our selection processes are always keeping an eye on the breadth and depth of backgrounds and diversity within candidates who apply for positions,” Kumar said.

Penn also specifically tailors its outreach to international families to address concerns over stress that might be new to foreign students, educating them about how to seek help if they need it. Kumar and He have both attended orientations in other countries designed to prepare international parents and students for what can be a stressful first couple of months at Penn.

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For international students coming from cultures where mental health isn’t even a topic of conversation, the openness of Penn’s culture surrounding mental illness — particularly over the last couple of years — can feel like a fresh breath of air.

And Jonathan said it’s helpful for international students to support each other, especially in the current political climate.

International students from the seven countries named in President Trump’s executive order face highly uncertain futures, and even students from other countries who want to work in the United States after they graduate don’t know what the availability of work visas will look like — not to mention the rising wave of xenophobia and racism that’s accompanied Trump’s rise.

“It’s great to just talk to other international people because as much as Americans and the American community are able to help with that ... the international community can share those [concerns] with you because you never know, one day, your country might be put on a list,” Jonathan said.

After her leave of absence, Chandiramani returned to finish her senior year and will graduate this spring. Her recovery is ongoing, but she’s much more open with her parents about her illness. Jonathan and Hu, too, are more comfortable discussing their issues with their families than they once were.

In all its efforts to alleviate the mental health crisis on campus, Penn has taken steps to address the needs of students from Asian backgrounds in particular. Guo has held workshops with Asian sororities and fraternities, addressing some of the issues that might apply to their specific cultures and teaching them how to help friends who are struggling.

But, ultimately, mental illness remains a problem on a campus that’s seen twelve suicides in the past four years. Guo is encouraged by the progress he’s seen, but believes there is still room to improve.

“This is still the question [of mental health], all the time,” he said. “And we haven’t come up with a good solution.”