Volume 3, Number 1, 2005 Edition

Study Abroad and Mental Health: Identifying, Assisting, and Referring Students in Distress

by Wendy Settle

The possibility of known, or new, emotional and mental problems emerging overseas is seen by many experienced education abroad administrators and advisors as a health and safety concern second only to alcohol abuse in its potential negative impact on an education abroad experience… What is clear is that pre-existing emotional difficulties are often intensified by living in a foreign culture. – NAFSA's Guide to Education Abroad for Advisors and Administrators, 2nd ed.

Students experience distress when their stress level exceeds their coping resources, which can easily happen in an unfamiliar environment. Emotional distress can have a profound impact on students' academic progress, personal relationships, and enjoyment of their experiences abroad. The ability to recognize signs of serious emotional distress and the courage to acknowledge concerns directly are often later noted by students as the most significant factor in their problem resolution.

Signs of Distress Checklist
Behavioral Changes	Physical Changes	Personality Changes
Decline in the quality of work, assignments not completed Frequent absences from class Inability to sit through classes Disruptive behavior in classes Repeated requests for special accommodations such as extensions or postponed  examinations Turning in coursework that has suicidal or  homicidal themes Impaired speech or thought patterns	Marked change in physical appearance and personal hygiene Dramatic weight gain or loss Chronic tiredness, headaches, gastrointestinal problems without amedical explanation Change in sleep patterns: insomnia, sleeping too much, not needing sleep Disordered eating: restricting, bingeing, purging, over-exercise Panic attacks; overwhelming anxiety	Extreme sadness and tearfulness Severe depression Irritability Hostility Marked anxiety Outbursts of anger Withdrawn Hyperactive Excessive dependency on others Mood swings Confusion, indecisiveness Much more talkative than usual, sentences are tangential or incoherent
Safety Risk Changes and …	Other Risk Factors
Expressions of hopelessness, powerlessness, or worthlessness Verbal statements or notes that have a suicidal or homicidal tone to them Expressions of concerns about death or life after death Giving away important possessions Self-injurious or self-destructive behaviors Violent threats against others Out of control behavior	Inability to adjust or inappropriate reactions to local cultural norms Secretive about experiencing severe emotional distress Poor self esteem; extreme difficulty in working out own identity Lack of close, supportive friends, or family ties Increased isolation Death of a close friend or family member Sexual assault; sexual harassment Break-up of a relationship Poor academic performance Intense academic pressures Serious illness Substance abuse issues Poor problem solving and coping skills

Some Suggestions for Assisting Students in Distress

Establish a Climate of Trust and Safety, Gather Information, & Explore Possible Solutions

• Be friendly without being a "friend" -- maintain a professional relationship and establish clear and consistent boundaries. Show interest and support.
• Ask to see the student in private to minimize embarrassment and defensiveness.
• Acknowledge with care that you are concerned about the student's welfare.
• Use constructive self-disclosure to acknowledge your observations of the student's situation and express your concern directly and honestly. Strange or inappropriate behavior should not be ignored. Comment directly on what you have observed with non-judgmental descriptions.
• Listen respectfully and provide empathy without necessarily agreeing or disagreeing with the student's point of view. Try not to minimize his/her pain. Try to refrain from making quick judgments.
• Ask follow-up questions for better clarification and understanding. Demonstrate that you understand what the student is disclosing by paraphrasing what the student has told you.
• Assist the student in identifying several options and a plan for action. Review past coping strategies. Explore the possible consequences of the student's action and non-action. Develop a backup plan.
• Keep the lines of communication open. Arrange time to follow-up with the student.

Suggestions for making referrals

• State clearly why you believe a referral would be helpful.
• Be open to listening to any concerns or fears that the student might have about seeking help.
• Try to normalize seeking help by conveying that everyone has problems at times that require assistance.
• Communicate that you view seeking help as a sign of courage instead of a sign of weakness.
• Demonstrate that you are hopeful that change is possible.
• Learn about available referral resources so that you can provide specific and appropriate information. Have a list readily available that includes the names, phone numbers, and locations of referral sources.
• Encourage the student to take responsibility for whether he/she will seek assistance.

Guidelines for International Educator Program Directors

Referring a Student for an Evaluation or Treatment

Students who are experiencing significant mental health problems can be referred to a local mental health practitioner, a psychiatrist, or a physician for an evaluation. Please note that in some countries (e.g., the U.K) a referral to a mental health practitioner must be made by a medical physician and in other countries a mental health practitioner must make the referral to a psychiatrist. Consult your local embassy to learn about referral procedures in your country and to obtain sources for referrals. Ask the student to sign the practitioner's release of information form so that you may consult with the practitioner to obtain his/her recommendations. It is possible in a few cases that treatment may be able to be handled locally on an outpatient basis if the mental health problem is mild and intervention is begun early. After the student has begun treatment, or if the student's problem is evaluated not to be severe enough for treatment, refer the student to self-help resources (refer to the web sites listed in the international educator's handbook online). Continue to provide support but do not attempt to provide treatment yourself. If the student's mental health problem is moderate to severe, significantly impacting the student's cultural adjustment and/or academics, or significantly impacting the learning environment for other students in the program, the student should be counseled to go home for treatment. These decisions can be made through consulting with the student's local mental health practitioner or physician. Consulting with the student's family, Student Affairs, and the University Counseling Center is also recommended.

Assisting the Study Abroad Student Who Needs to Withdraw

A student in your program may manifest or report psychological distress at a level that suggests he/she needs to withdraw from the program and return home. Should something like this happen (e.g. suicidal ideation, out of control eating problem, severe depression) you need to follow a number of steps in managing this situation. The decision to have the student stay or to go home should have the support of someone trained in the assessment of human behavior, such as a psychologist, psychiatrist, or social worker. It may be useful to contact your university’s counseling center when you have had the student assessed so that a staff member can discuss options with you.

Notifications (family, etc.) should be handled on a need-to-know basis. Usually other students in the program do not need to know any details of the situation. If and when the student decides to return, the fact that privacy has been maintained may ease reentry.

Students who are given a medical withdrawal for psychological reasons might be expected to take time off before returning to coursework. This usually means that the student withdraws during one semester and then takes the following semester off. For example, if the student withdraws in the fall, they cannot return until the following fall rather than the spring semester. During their time away from school, they are also usually expected to obtain treatment with a mental health professional. The student and/or his or her parents should speak to the Office for Student Affairs to discuss the timeline and procedures for reapplying to Notre Dame after taking a withdrawal for psychological reasons.

In working with a distressed student, it may be helpful to tell them that a high percentage of students who take this type of withdrawal are able to return to school and successfully graduate.

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You will not be able to identify every student in distress nor will every student in distress be receptive to your assistance. However, your taking the time to directly share your concerns with and listen to a distressed student may be one of the most significant and powerful contributions that you can make. Your assistance can help the student experience positive changes, growth, and resolution.

Refer to the following resource online: Mental Health and Crisis Management: Assisting University of Notre Dame Study Abroad Students, 2nd ed. http://www.nd.edu/~ucc/Faculty_Staff_Resources.html#international

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Wendy Settle, Ph.D., serves as Staff Psychologist at the University of Notre Dame University Counseling Center.