CHINESE INTERNATIONAL STUDENTS STRESS COPING: A PILOT STUDY OF ACCEPTANCE AND COMMITMENT THERAPY
Huanzhen Xu
A Thesis
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
MASTER OF ARTS
May 2019
Committee:
William O’Brien, Advisor
Yiwei Chen
Dryw Dworsky
© 2019
Huanzhen Xu
All Rights Reserved iii ABSTRACT
William O’Brien, Advisor
China has become a leading source of international college students for Western countries, including the USA, the UK, Australia, New Zealand, and Canada. Given Chinese students’ increasingly large contribution to the college population and financial import (tuition, travel expenses, other expenses, etc.) to the host countries, their specific needs in community services such as mental health and counseling should be addressed. Studies across different countries have explored the challenges associated with overseas experiences. These studies indicate that international college students, relative to domestic students, face higher levels of stress given the additional acculturative challenges. Research has further shown that Chinese international students reported high levels of psychological distress (depression, anxiety, stress).
However, there is little research either investigating the measurement of unique stressors experienced by Chinese International Students or developing culturally sensitive interventions for their stress management.
In the current two-part study, we aimed to, first, identify unique stressors of Chinese international students in the United States; and second, further design a culturally relevant
Acceptance and Commitment Therapy intervention focused on helping Chinese international students manage the transition from their home country to the United States. Additionally, we ran a pilot study (randomized clinical trial) to examine the effectiveness of this intervention.
Focus groups results revealed ten major domains of acculturative stress experienced by Chinese
International Students. An acculturative stress measure, the Unique Stress of Chinese
International Students (USCIS), was developed from the focus groups. The USCIS contains 103 iv items and demonstrated excellent internal consistency and convergent validity based on a sample of 30 Chinese International Students. Results of the pilot study based on a sample of 8 participants showed preliminary effectiveness of ACT in reducing depression, anxiety, stress, and acculturative stress reported by Chinese international Students.
v ACKNOWLEDGMENTS
I would like to express my gratitude to my advisor, Dr. William O’Brien, for his instruction and support in the process of conducting this study. I also would like to say thank you to my dear parents for their long-standing caring and support. vi
TABLE OF CONTENTS
Page
INTRODUCTION………………………………………………...... 1
STUDY 1: EXPLORING STRESSORS FACED BY CHINESE INTERNATIONAL
STUDENTS USING FOCUS GROUPS ...... ……………………… 11
Methods……………………………… .... …………………………………………. 11
Participants …………………………………………… ...... 11
Procedures ...... 11
Analysis and Results ...... 12
Discussion …. … ...... 14
Limitations …...... 15
STUDY 2: A PILOT STUDY-FEASIBILITY AND OUTCOME OF AN ACT
INTERVENTION FOR CHINESE INTERNATIONAL STUDENTS …………………… 17
Methods………………………………………………………………...... 17
Participants …………………………………………… ...... 17
Procedures ...... 18
Measures ...... 19
Demographic Questionnaire ...... 19
Acceptance and Action Questionnaire-II ...... 19
Depression, Anxiety, and Stress Scale-21 ...... 20
Patient Health Questionnaire Chinese Version ...... 21
Unique Stress for Chinese International Students Questionnaire ...... 22
Cognitive Fusion Questionnaire ...... 22 vii
Treatment Conditions/Protocol Development ...... 23
Therapist ...... 25
Treatment Group ...... 25
Control Group ...... 25
Treatment Integrity Checks...... 25
Analysis Plan ...... 26
Results ………...... 26
Psychometric Characteristics of New Measure...... 26
Convergent Validity ...... 27
Correlations with Acceptance and Cognitive Fusion ...... 27
Intervention Results ...... 28
Treatment Feasibility and Acceptability ...... 28
Group Level Evaluation of Outcomes ...... 29
Single-Subject Evaluation of Outcomes ...... 31
Discussion…...... 32
Summary of Findings ...... 32
Implications ...... 33
Limitations ...... 37
REFERENCES……...... ……………………………. 40
APPENDIX A: TABLES ...... …………………………………………………………… 49
APPENDIX B: FOCUS GROUP PROTOCOL…………………………………………… 77
APPENDIX C: THE USCIS ...... 80
APPENDIX D: DEMOGRAPHIC QUESTIONNAIRE ...... 91 viii
APPENDIX E: ACCEPTANCE AND ACTION QUESTIONNAIRE II ...... 92
APPENDIX F: DEPRESSION ANXIETY STRESS SCALE-21 ...... 93
APPENDIX G: CHINESE VERSION PATIENT HEALTH QUESTIONNAIRE-15...... 94
APPENDIX H: CHINESE VERSION COGNITIVE FUSION QUESTIONNAIRE ...... 95
APPENDIX I: NEWLY DEVELOPED ACCEPTANCE AND COMMITMENT THERAPY
PROTOCOL………...... 96
APPENDIX J: INTEGRITY CHECKLIST ...... 135
APPENDIX K: CONSORT FLOW CHART ...... 136 1
INTRODUCTION
China has become a leading source of international college students for many Western countries, including the United States, the United Kingdom, Australia, New Zealand, and
Canada. In the United States, approximately 10% (more than 1,000,000) of college students are international students. Further, about 31.5% of these international students are from China
(Institute of International Education, 2016). In the United Kingdom, there are about 436,500 international students enrolled in university-level educational institutions, while about 29% of the total number of non-European college students in the UK are from China (HESA, 2016). In
Australia, there are over 292,000 foreign students, and 33.5% of them are originally from China
(Australian Government Department of Education and Training, 2015). In New Zealand, international education has become one of the country's leading export industries, and about 33% of that industry is contributed by international students from China (Export Education Levy,
2013). In Canada, China is also the leading source of international students: 33.7% of the over
356,000 international students are Chinese citizens (The Canada Magazine of Immigration,
2016). Given Chinese students’ increasingly large contribution to the college population and financial import to the major Western countries, their specific needs in community services such as mental health and counseling should be addressed.
Given that the majority of Chinese international students start living abroad around the age of onset for common psychiatric issues (Chen, Liu , Zhao, & Yeung, 2015), together with the presence of both common stressors among college age population and additional acculturative stressors, Chinese international students possess an increased risk of experiencing psychological distress and developing maladaptive behaviors. For example, Muto and colleagues (2011) conducted a study with 70 Japanese international students at the University of Nevada. These 2 students completed measures of depression, anxiety, stress (DASS-21), and self-perceived health
(GHQ-12). Muto et al. (2011) reported that about 80% of the students were clinically distressed based on their scores on the DASS and 60% of them scored above clinical cut off for the GHQ.
Moreover, Han, Han, Luo, Jacobs, and Jean-Baptiste (2013), conducted a study in which
130 Chinese international students at Harvard University completed an online survey that measured depression (GHQ-9) and anxiety (GAD-7). They reported that 45% of the Chinese international students exhibited depression symptoms (scored at or above the cutoff point for mild depression on GHQ-9) and 29% exhibited anxiety symptoms (scored at and above the cutoff point for mild anxiety on GAD-7). In addition, students who reported having a poor relationship with their advisors endorsed significantly higher levels of depression and anxiety symptoms. Finally, 27% of the students who completed the survey were not aware of the availability of mental health care and counseling services (Han, et al., 2013).
Similar findings were reported by a research team in Australia. Lu, Dear, Johnston,
Wooton, and Titov (2014) conducted a study with 144 Chinese international college students and found that 54% of the participants reported high levels of psychological distress using the
Kessler-10 (scored above the cutoff point for high distress). Lu and colleagues furthered reported that only 9% of the students who reported high distress had received mental health services.
These findings support a conclusion that Chinese international students experience high psychological distress. These findings can be contrasted with prevalence data from a study on
Chinese students in China where 11.7% of students demonstrated moderate and above levels of depression, which was indicated by their elevated scores (14 or above) on Beck Depression
Inventory (Chen et al., 2013). In addition, a recent study conducted by Redfern (2016) reported 3 that, compared to their domestic counterparts, Chinese international college students reported significantly higher levels of stress and anxiety as measured by DASS-42.
As the causes of the excessive self-report psychological burden among Chinese international students appear to be relevant to culture and adjustment, researchers across different countries have conducted studies focused on identifying and defining the challenges associated with their overseas experiences. One commonly identified set of challenges is related to language. Dao and colleagues (2007) reported that perceived language fluency was significantly associated with depressive feelings among Chinese international students as measured by The Center for Epidemiologic Studies Depression Scale. Similarly, Wei and colleagues’ study with 188 Chinese international students indicated that perceived language deficits were associated with self-reported distress as measured by Hopkins Symptom Checklist–
21 (Wei, Liao, Heppner, Chao, & Ku, 2012). Finally, Gu and Maley (2008) interviewed 41
Chinese college students in the UK and reported that insufficient language ability was identified as an important cognitive and affective stressor. In addition, Yoo and colleagues (2009) reported that self-report language discrimination was associated with chronic health conditions among the
Asian population in America.
A second set of acculturative challenge is related to academic success. Chinese international students face unique challenges in this domain because they may have very little experience with Western teaching and learning styles (Gu, & Maley, 2008). This lack of experience can lead to misunderstandings and miscommunication with instructors and peers which, in turn, can lead to distress and academic problems. For example, a study conducted by
Han et al. (2013) indicated that over 40% of the Chinese international students at Harvard
University reported that depression was significantly associated academic stress. They also 4 reported that Chinese international students felt that their academic performance was associated with financial support, which, in turn, was associated with perceived likelihood of academic success (Han, et al., 2013).
Chinese international students also experience emotional challenges. For example, Li and Tse (2015) explained that Chinese international students reported limited attachment to host countries and feelings of isolation from families and friends in China. This separation from their homeland can lead to feelings of loneliness, boredom, and alienation (Gu, & Maley, 2008), as well as maladaptive behaviors such as problem gambling (Li, Tse, & Chong, 2014; Li & Ese,
2015). In addition, given that most families in China have been affected by the “one-child” policy from 1979 to 2015, a majority of the current Chinese international students were raised as single children (Chen, Liu, Zhao, & Yeung, 2015). The experience of being raised as a single child may create two unique sources of stress. First, the single child may have been raised in a family context where there were high levels of attention and support. With arrival in a Western country, this level of attention and support is drastically reduced and this may contribute to a sense of loss, isolation, and loneliness. Second, the single-child Chinese international student bears the burden of high family expectations for success, a possible heightened risk for developing maladaptive perfectionism that has been found to be significantly associated with depression (Wei, Heppner, Mallen, Ku, Liao, & Wu, 2007).
A last common area of stress is related to environmental adaptation in the host country.
For example, the dislike of the local food contributes to distress (Gu, &Maley, 2008). The prevalence of alcohol and drug use in American colleges is also new to many Chinese international students. Further, different styles of dating and relationship formation when studying abroad could further add stress to Chinese international students. Finally, Chinese 5 international students’ expectations of American life are aligned with metropolitan lifestyles.
One important cultural challenge occurs when Chinese students enroll in colleges and universities that are located in rural, suburban, and non-urban locations which limits access to transportation, shopping, and entertainment.
Given the prevalence of perceived distress and the commonality of stressors among
Chinese international college students, the development and evaluation of effective interventions for this group is needed. However, there are very few empirical studies of interventions that focused on the distress of Chinese college students in Western countries (Chen, Liu, Zhao, &
Yeung, 2015).
Sakurai, McCall-Wolf, and Kashima (2010) designed a multicultural intervention program that consisted of bus excursions that were aimed to increase social engagement and facilitate the adjustment of international students. A total of 47 Chinese international students self-selected to participate in the excursion intervention and 51 did not participate. These students completed a set of surveys one month after the excursion intervention and then another set of surveys four months after the excursion intervention. Results showed that excursion participants reported a larger increase in the number of friends made (p < .05, d = .48), including friends from the host country (p < .03, d = .46). Additionally, participants reported that the excursion intervention helped them maintain their interest in the local culture whereas the non- participants showed a significant decrease in their interest in the local culture (p < .05, d = .42).
Sakurai and colleagues concluded that this multicultural excursion intervention facilitated social involvement and they encouraged education providers to use similar interventions.
There are some limitations of the Sakurai et al. (2010) study that need to be considered.
First, participants were not randomly assigned to the excursion and control group. Thus, the 6 treatment and control group could be fundamentally different in terms of their social skills and openness to culture prior to the intervention. Second, the intervention did not significantly improve psychological adjustment as measured by Inventory of Student Adjustment Strain
(ISAS) or alleviate social anxiety as measured by Social Interaction Anxiety Scale (SIAS).
Third, the quality of the newly developed social bonds was not evaluated, and it was not possible to determine how much social support students gained from those new social ties. Finally, the excursion intervention was not based on an evidence-based psychological intervention. It seemed to be based on superficial stressors and indicators of adjustment.
The effectiveness of Acceptance and Commitment Therapy for international students was evaluated in a study conducted by Muto and colleagues (2011). The authors conducted an ACT intervention study with 70 Japanese international students in the U.S. using an ACT self-help workbook. Participants were randomly assigned to receive ACT or a wait-list control group.
Outcome measures were collected at pre-treatment (baseline), post-treatment, and a two month follow up time point. Results comparing baseline data and final follow up data showed that the
ACT workbook was effective in improving general health, psychological distress, and psychological flexibility among Japanese international students as indicated by measures of general mental health (p < .001, d = 2.01), depression and anxiety (depression: p = .007, d = 1.37; stress: p = .000, d = 3.00; anxiety: p = .016, d = .89; severe anxiety: p = .008, d = 1.37), and acceptance ( p = .001, d = .97). The authors further pointed out that moderately depressed and severely anxious students in particular showed significant improvement.
This Muto and Hayes study provided strong evidence that ACT can be effective in addressing mental health concerns among Asian international students. However, Muto and
Hayes pointed out the limitations of using a self-help book and cautioned that personal 7 involvement should not be replaced by ACT manuals (Muto & Hayes, 2011). Further, their ACT workbook was not specifically tailored to address the unique challenges of international students.
Instead, it provided a translation of generic ACT self-help strategies.
In another intervention study, researchers in China recruited 27 Chinese college students who reported being severely depressed and ruminative and then randomly assigned them into a
6-session group cognitive behavioral therapy (CBT) or ACT (Zhao, Zhou, Liu, & Ran, 2013).
Three assessments were carried out at pre-treatment, post-treatment, and 9 weeks post-treatment.
Significant declines in depression and rumination were observed in the ACT group (p < .001, d =
2.2; p = .003, d = 1.4), while only depression dropped in CBT group (p = .003, d = 1.4). Zhao and colleagues concluded that ACT has better short-term and long-term outcomes than CBT in treating depression.
Given that this study validated the effectiveness of ACT among Chinese population for a depression intervention, there is a potential that ACT could help Chinese international students who face unique stressors and challenges alleviate associated stress. However, the ACT intervention used in this study was generic instead of being tailored to address college Chinese international students’ specific stressors. In addition, while this study compared CBT and ACT, there was no control group to rule out changes related to other non-treatment related factors.
Finally, in Australia, Smith and Khawaja (2014) designed an experiential cognitive behavioral therapy called STAR (strengths, transitions, adjustments, and resilience) for international college students. STAR consisted of four weekly sessions and each session was 2 hours. During the sessions, participants were encouraged to engage in discussion of acculturative stress among international students, how to make local friends, depression and anxiety and positive coping strategies, and psychological health help-seeking. To evaluate STAR, 16 students 8 completed outcome measures at pre-treatment, post-treatment, and one month follow up. Results showed that participants reported significant post-treatment improvements in psychological adaptation as measured by modified Student Adjustment Strain (ISAS) (pre-post, p = .021, d
= .9), as well as belief in the ability to obtain social support (p = .045, d = .8), problem-focused coping (p = .029, d = .86) and reduced unpleasant thoughts and emotions (p = .023, d = 1) as measured by Coping and Self-efficacy Scale. However, none of the improvements were significant at one month post-treatment. The researchers also reported that the participants stated that they learned new approaches to problem solving and coping, received information concerning mental health access, and enjoyed making friends and exchanging experiences.
There are some significant limitations of Smith and Khawaja study. First, the study lacked power in the results due to the small sample size (n=13), and no significant improvement was found at follow-up assessments. Second, there was no control group. Third, the results showed that psychological distress was not associated with the intervention. Finally, while studies have showed that language deficiency is a major obstacle that international students encounter when they seek mental health services (Blignault, et al, 2008; Lu, et al, 2014), this intervention was not provided in the participants’ primary language to minimize the effect of language difficulty.
In summary, the aforementioned studies indicate that there is a limited number of studies evaluating the effects of interventions for Chinese international students attending Western universities and colleges. Further, there are several research design limitations (no control group, small sample sizes, generic interventions, non-native language therapist) that adversely affect the internal validity, construct validity, and generalizability of findings. However, there are some promising findings in this literature. First, there is evidence that structured interventions can 9 confer improvements in the wellbeing of Chinese international students. Second, ACT has been shown to be helpful in reducing psychological distress of Chinese students and international students.
As noted above, two studies provided evidence for the effectiveness of ACT in reducing psychological distress among Asian college students (Muto et al, 2011; Zhao et al, 2013).
However, both studies were limited because one (Muto et al., 2011) used a workbook intervention that was not customized to meet the needs of international students. In addition, the authors acknowledged that there were significant limitations associated with using a self-help book rather than in-person therapy sessions. Similarly, Zou et al. (2013) did not use an ACT intervention that was specifically tailored for Chinese college students. Additionally, this study was conducted in China, so it did not provide specific information about the effectiveness of
ACT for Chinese international students who are struggling with different types of stressors relative to Chinese students in China.
Despite the limitations of the above cited studies, they do provide evidence that ACT has the potential to yield positive effects for Chinese international students. In addition, there are other studies that suggest ACT could be an effective intervention approach for alleviating stress associated with college life. For example, two studies conducted by Levin et al., (2014) and
Danitz et al., (2016) demonstrated that ACT was helpful in reducing distress among domestic college students in the USA. Moreover, Scent and Boes (2014) reported that two 90-minute ACT workshops delivered one week apart helped increase college students’ psychological flexibility and decrease their academic procrastination. Similarly, Glick and Orsillo (2015) found that an acceptance-based behavioral therapy was effective in reducing academic procrastination, typically for college students who highly value academic success. Additionally, Wang, Heppner, 10
Fu, Zhao, and Chuang (2012) reported that acceptance was associated with better cross cultural adjustment among Asian students. Finally, Hayes (2002) elaborated the parallels between
Buddhism and ACT in areas of concepts and practice, such as the understanding of human suffering, mindfulness, and values-aligned living. Since China hosts the largest population of
Buddhists and Buddhism has been influencing Chinese culture and values since it was first introduced to China about 2000 years ago (The Pew Forum on Religion & Public Life, 2012), there is a potential for ACT to be a culturally relevant and well accepted intervention for people with Chinese culture background including Chinese international students.
This study has two specific aims. The first is to identify specific stressors experienced by
Chinese international students using a focus group format. The second aim is to use focus group data and information gathered from the literature review to adapt and pilot an ACT intervention for Chinese international students.
11
STUDY 1: EXPLORING STRESSORS FACED BY CHINESE INTERNATIONAL
STUDENTS USING FOCUS GROUPS
Specific Aims: this focus group study was conducted with the aims to (a) gather information on unique acculturation experiences and stressors experienced by Chinese international students, (b) develop a measure of acculturation stress, and (c) adapt a culturally relevant ACT intervention using focus group data.
Methods Participants
Nineteen volunteers (6 males and 13 females) were recruited and 5 focus groups were conducted (see table 1). Their mean age was 24.63 (SD = 3.59, Range 18-30). The average length of residence in United States was 23.26 months (SD = 20.00, Range 2.00-70.00). There were 7 undergraduate students and 12 graduate students, and the participants were enrolled in different years and departments. Ten participants (52.63%) received some level of scholarship or assistantships from the university and 9 participants (47.37%) were funded by family support.
Fourteen (73.68%) participants were from major cities in China (Shanghai, Beijing, Shantou,
Qingdao, Luoyang) or provincial capital cities (Taiyuan, Harbin, Zhengzhou), and 5 (21.05%) were from smaller cities (it is worth noting that even the smallest city which the participants are from has over 2,200,000 population).
Procedures
Chinese international students who were enrolled at a small Midwestern University were invited to participate in focus groups via email. Participants were required to be above 18 years of age and identified as Chinese citizens currently studying in American colleges. The focus groups were held at the departmental psychology clinic. Participants sat in a circle during 12 meetings, and refreshments (coffee and donuts) were offered to create a relaxed atmosphere. The principal researcher, who is also an international student from China, was the moderator for all the sessions. Previous studies showed that Chinese students felt more comfortable communicating in Chinese (Li, & Tse, 2015). Therefore, all the focus groups were conducted in
Chinese to facilitate the expression of the participants’ opinions, emotions, attitudes and beliefs.
Each session started with reading and signing an informed consent. After that, the moderator emphasized the limits of confidentiality for the study. Next, a structured set of questions inquiring about the challenges associated with attending college in the USA were discussed during each group (see Table 2). The focus groups were semi-structured, and the moderator followed a focus group protocol when conducting the sessions (see Appendix B). The moderator also monitored the group discussion and participants’ interaction to ensure that participants had an equal chance of expressing opinions. The focus groups were approximately two-hours long. Each group was comprised of 2-5 participants. The focus groups were audio recorded.
Analysis and Results
Three judges who were fluent in both Mandarin and English (two graduate students, one college instructor) listened to the focus group recordings and were instructed to “generate unique participant responses to each question independently”. For example, “I have so heavy course load” in response to the question of “major challenges you have encountered as Chinese international students?” and “I live in this country but I do not feel as a part of it” in response to
“what are the types of thoughts you have, both in words and images, when you are stressed?”
This method generated a list of over 200 comments. Some comments overlapped because similar 13 concerns were reported by more than one participant. The principle investigator deleted the overlapping comments which resulted in a list of 176 distinct items. These comments were then translated into English.
A free card sort method was used to identify themes. Three additional judges (two professors, and one graduate student) were instructed to “read through the comments and form content categories/themes based on your own judgements.” Content categories that were formed by at least 2 judges were kept. Categories that were similar but had different wording from judges were blended into a single category by the principle investigator. For example, categories
“friendship with Americans”, “friendship with Chinese”, “friendship concerns”, “social relationship”, and “social relation” were blended to form the category “social difficulty”. This method resulted in a total of ten categories: loneliness, academic stress, social difficulty, transportation, financial burden, family distance, health care, language barrier, food preferences, and future concerns. Each category had between 4 and 27 comments. Comments that were not assigned to any category by the judges were kept for the next step of sorting.
Closed card sorting was then used. All of the comments were examined by another three judges (psychological graduate students) and these new judges were asked to assign each comment into one of the 10 previously identified categories. Only comments that were grouped into the same content category by at least two judges were kept for further analysis. With this method, 90 comments were retained.
Next, the two authors of this study worked collaboratively to make sure that each comment contained only a single construct. For example, the comment “I cannot talk to my parents about my stress because I don't think they understand my stress” was broken down to 14 two items include “I cannot talk to my parents about my stress”, “I don't think my parents understand my stress”. Additionally, the authors reworded the comments so that they could all be rated on a frequency scale that ranged from 1 (never) to 7 (always). For example, the original comment “I want to quit school” was reworded to “I think about quitting attending college in the
United States”. This method generated a total number of 103 items.
The final card sort was conducted on the 103-item measure. Two additional judges
(undergraduate research assistants) were instructed to assign all 103 items into one and only one of the ten identified content categories. The interrater reliability of rater assignment into the 10 categories was 85.58%. The 103 items in this new measure can be found in Appendix C, Table
C1.
Finally, 103 items were translated into Mandarin by the primary investigator of this study for research use with Chinese international students who prefer reading in Chinese. (See
Appendix C, Table C2).
Discussion
The focus groups yielded 103 items that fell into 10 categories of major unique stressors experienced by Chinese international students. These items comprise the Unique Stress for
Chinese International Students Questionnaire (USCIS).
One other researcher (Bai, 2016) study developed a stress measure for Chinese international students named the Acculturative Stress Scale for Chinese college students in the
United States (ASSCS). Bai created the scale using items from existing scales, literature review, and information generated from interviews with eight Chinese students. A 72-item ASSCS was 15 originally generated with this method and it had nine domains included academic pressure, language deficiency, cultural differences, social interaction, perceived discrimination, financial concerns, safety and health, feelings toward families, and others. Bai performed an exploratory factor analysis on the ASSCS using data collected from 267 students in the United States. The factor analysis yielded a five-factor solution with 32 items. The five factors were Language
Insufficiency, Social Isolation, Perceived Discrimination, Academic Pressure, Guilt towards
Family.
Compared to the ASSCS, the USCIS covers not only the domains discussed in ASSCS, but also a wider range of stressors faced by Chinese international students, such as unfamiliarity with the health care system, transportation difficulties, concerns for future, and family distance.
The USCIS is most likely unique and more specific because item generation was derived from
Chinese international students in the USA during in-depth focus group discussions with a total of nineteen students. The stressors presented in the USCIS can better inform interventions for
Chinese international students because of its breadth and specificity. Yet admittedly, the USCIS has not been validated with a large pool of responders, which could change the number of items or group the items in ways that differ from the card-sorted categories. Therefore, future validation studies need to be conducted.
Limitations
One of the limitations of this study is related to language. Many translations occurred during the measure development process and the ways that English speaking American researchers perceive a comment may differ from persons from a different culture. For example, a
Chinese student might perceive the struggle with making friends to be a “language barrier” while 16 an American researcher might label it as a “social difficulty.” However, the label of social difficulty might mask the true stressor which is language because the student may have no difficulty making friends in China. Another limitation is that this study was conducted in a small
Midwestern city, where the perceived struggles may be different from the ones experienced by
Chinese students in larger urban areas where transportation, food, social opportunities are more accessible. 17
STUDY 2: A PILOT STUDY-FEASIBILITY AND OUTCOME OF AN ACT
INTERVENTION FOR CHINESE INTERNATIONAL STUDENTS
Specific Aims: this pilot study was conducted with the aims to a) preliminarily evaluate the psychometric characteristics and convergent validity of the newly developed measure of acculturative stress, the Unique Stress for Chinese International Students Questionnaire
(USCIS); b) evaluate relationships between USCIS and acceptance, defusion, and symptoms; and c) evaluate the feasibility, acceptability, and preliminary effectiveness of a newly developed
ACT intervention specifically for Chinese international students.
Methods
Participants
A total of 34 participants were recruited for the study. However, 4 were dropped because they were familiar with the primary investigator from extracurricular activities for Chinese
International Students. Of the 30 participants, 13 were assigned to the ACT treatment group and
17 were assigned to the control group. A majority of the participants were female (63%) and the mean age was 23.73 years old (SD = 3.3 years, Range: 19 to 31 years of age). Approximately half (47%) were undergraduate students while the other half (53%) were graduate students. The participants came from diverse regions in China with 17% from tier one cities (Beijing,
Shanghai, Guangzhou and Shenzhen), 4% from tier two cities (Tianjin, Nanjing, Hangzhou,
Suzhou, Wuhan, Xi an, Shenyang, Chengdu and Chongqing), 24% from tier three cities (Jinan,
Hefei, Dalian, Harbin, Changsha, Zhengzhou, Shijiazhuang, Fuzhou, Taiyuan, Urumqi and
Qingdao), 10% from tier four cities (Kunming, Guiyang, Nanchang, Lanzhou, Yinchuan,
Nanning, Xining, Changchun, Hohhot, Baoding, Ningbo, Datong, Xiamen, Weihai, Shantou
Lhasa and Haikou), and 45% from tier five cities (all other smaller cities). One person did not 18 give their hometown city. The average length of residence in United States was 32.33 months
(SD = 24.86, Range: 1 to 72 months of residency).
A small number (3) of participants reported they had had experience with some type of stress management intervention while the remainder (27) reported no prior experience with any type of stress management intervention. Three (10%) participants reported mild stress (DASS-21 stress score > 14), 24% reported mild and moderate anxiety (DASS anxiety score > 8), 13% reported mild depression (DASS depression score > 10) and 60% reported more than minimal physical complaints (PHQ-15 score > 4).
A majority of the participants (63%) described themselves as Atheist. Yet, 17 (47%) of the Atheists reported they attended Christian events or gatherings during their residency in the
United States. In a question assessing the associations that have reached out to welcome participants, a majority (63.3%, 19) identified Christian groups. Table 4 provides a summary of participant demographic characteristics.
Procedures
Participants were recruited via email. Participants were all over 18 years old and identified as a Chinese international student (holds Chinese citizenship and speaks Mandarin as his/her primary language). The assessment package was distributed to the potential participants one week prior to the date of the first intervention session via email. The assessment package contained a brief description of the current study and the informed consent form. After obtaining informed consent, participants were invited to complete the assessment survey online using
Qualtrics.
Participants were then randomly assigned into either a treatment group or a control group by the website http://www.randomizer.org/. Participants in the treatment group were notified 19 with the dates and times for the ACT intervention after completing the survey. Participants in the treatment group received two, two-hour, intervention sessions spaced one week apart.
Participants in the control group did not participate in any intervention but were offered an opportunity to receive the intervention at a later time after all data was collected.
A second assessment package was sent to the treatment group and control group participants via email at the conclusion of the ACT intervention. All participants were given a week after the intervention to complete the second assessment package. Two reminder emails were sent to participants who had not completed the survey at the end of the first week and the end of the second week. The second assessment package contained the same measures as the first package with the exception of demographics. Participants in both conditions, with the exception of the last intervention group, completed the pre and post-treatment surveys at varying times between mid-October and late November of 2017. The last intervention group was conducted in early May. Participants in both conditions received a 10-dollar Amazon Giftcard to compensate them for participation.
Measures
Demographic Questionnaire. A demographic questionnaire was used to collect information on participants’ gender, age, degree in progress, length of time in the United States, financial support, relationship status, English language proficiency as indicated by Test of
English as a Foreign Language (TOEFL) score and/or International English Language Testing
System (IELTS) score, and previous experience with stress management workshop (Appendix
D).
Acceptance and Action Questionnaire-II. The Chinese version of the AAQ-II was used as a process measure of acceptance. The AAQ-II is a 7-item self-report scale that assesses 20 psychological flexibility (Bond, Hayes, Baer, et al., 2011; Cao, Ji, & Zhu, 2013). Normed on
1749 Chinese college students, the Chinese version AAQ-II demonstrates excellent internal consistency (Cronbach’s α=0.88) and good test-retest reliability (Cronbach’s α=0.80) (Cao, Ji, &
Zhu, 2013). Additionally, the Chinese version AAQ-II showed adequate criterion and convergent validities (r = 0.26 - 0.69, p < 0.01), as well as incremental validity (∆R2 = 0.07 - 0.13, p <
0.001) (Cao, Ji, & Zhu, 2013). Sample items from the Chinese version AAQ-II include “my painful experiences and memories make it difficult for me to live a life that I would value
” and “it seems like most people are handling their lives better than I am ”. Consistent with the items on the original AAQ-II, the items on Chinese version AAQ-II were arranged on a 7 point Likert scale from 1 (never true
) to 7 (always true ), where higher scores are associated with greater psychological inflexibility and increased experiential avoidance (See appendix E). The internal consistency of the Chinese version AAQ-II for this sample was .854, which is consistent with the literature.
Depression, Anxiety, and Stress Scale-21. The Chinese version of the DASS-21 was developed from the original English version of DASS-21. It is an instrument that consists of 21- items assessing current symptoms (over the past week) of depression, anxiety, and stress
(Lovibond, & Lovibond, 1995b; Moussa, Lovibond, & Laube, 2001). Taouk and colleagues
(2001)’ Chinese version of DASS-21 has been validated to use among Chinese college population (Wang, Shi, et al., 2016; Gong, Xie., Xu, & Luo, 2010). This measure possesses good internal consistency. The depression scale, anxiety scale, and stress scale have Cronbach’s α that ranged from 0.76 to 0.83, and the total DASS scale has Cronbach’s α that ranged from 0.89 to
0 .92 across two validation studies normed on over 3000 domestic college students in China 21
(Wang, Shi, et al., 2016; Gong, Xie., Xu, & Luo, 2010). The internal consistencies of the three different scales of the Chinese version DASS-21 for this sample were ranged from .649 to .833, which were consistent with the literature. This version also showed moderate test-retest reliability (.39-.46 for each subscale, .46 for the total DASS-21) (Wang, Shi, et al., 2016). In this study, the three subscales were analyzed separately to evaluate different domains of psychological distress.
Sample items on the DASS-21 include “I couldn’t seem to experience any positive feelings at all ” and “I found it difficult to work up the initiative to do things ”. The 21 items are evenly divided into the three categories (depression, anxiety and stress) with 7 items measuring each category. All the items are rated on a 4-point severity/frequency scale from 0 (did not apply to me at all ) to 3 (applied to me very much, or most of the time ) (See appendix F).
Patient Health Questionnaire Chinese Version. Instead of expressing distress with negative affect and emotions, Chinese people who have collectivistic values and background tend to present distress with somatic symptoms (Zaroff, Davis, Chio, & Madhavan, 2012), which put barriers for clinician to detect signs of mental issues. Therefore, we decided to use a somatic symptom checklist to evaluate aspects of mental health in this study.
The Chinese version PHQ-15 was originally translated from the questionnaire developed by Kroenke and colleagues in 2002 (Qian, Ren, Yu, He, & Li, 2014) and then modified to be more culturally sensitive (Lee, Ma, & Tsang, 2011; Zhang, Fritzsche, Liu, Wang, Huang, Wang,
& Leonhart, 2016). This measure assesses the severity of fifteen somatic symptoms (such as back pain, headache, and trouble sleeping) over the past four weeks, on a 3-point Likert scale 22 rated from 0 (“not bothered at all” ) to 2 (“bothered a lot” ). Normed on 1329 inpatients in a tertiary hospital in China, the Chinese version PHQ-15 has good internal consistency (Cronbach’s alpha = 0.83) and good test-retest reliability (r = 0.75, p<0.01) (Qian,
Ren, Yu, He, & Li, 2014; Zhang, Fritzsche, Liu, Wang, Huang, Wang, & Leonhart, 2016) (See appendix G). The internal consistency of the Chinese version PHQ-15 for this sample was .826, which is consistent with the literature.
Unique Stress for Chinese International Students Questionnaire. As described in
Study 1, this was used to measure the unique stressors reported by Chinese international students
(Appendix C).
Cognitive Fusion Questionnaire. A Chinese version of the newest 7-item Cognitive
Fusion Questionnaire was used as a measure of cognitive fusion, it describes the extent to which a person fuses with their thoughts, beliefs, and memories (Zhang, Ji, Li, Guo, &Zhu, 2014;
Gillanders, et al., 2014). This version of the cognitive fusion scale is based on a 9-item Chinese version that was adapted from the 13-item Cognitive Fusion Questionnaire by Gillanders and colleagues (2010), and translated to Mandarin by Zhang and colleagues (2014). Two of the items in the 9-item Chinese version were deleted by Gillanders, et al., (2014), because further exploratory factor analysis (EFA) showed that these items accounted for little percentage of variance. Additionally, some wording modifications were made by the principal investigator to make the meaning of the items more consistent with the original English version. This Chinese version of Cognitive Fusion Questionnaire has not been tested on a Chinese population yet.
This 7-item scale assesses cognitive fusion on a 7-point Likert scale rated from 1 (never true ) to 7 (always true ), where the higher the scores the higher the levels 23 of cognitive fusion. Sample items include “my thoughts cause me distress or emotional pain
” and “I get caught up in my thought that I am unable to do the things that I most want to do ” (See appendix
H). The internal consistency of the Chinese version CFQ for this sample was .969.
Treatment Conditions/Protocol Development
A Chinese international student specific Acceptance and Commitment Therapy intervention was developed and piloted for this study. The Chinese ACT protocol was developed and revised from a well-established ACT protocol that was initially developed by researchers in the UK to alleviate worksite-related stress (Bond & Bunce, 2000) and revised by the Bowling
Green State University Mindful Behavior Therapy and Psychophysiology Lab (MAPLab) to incorporate additional metaphors and adapt the language.
The MAPLab protocol was piloted with two groups of undergraduate research students and graduate students, and then reviewed by Bond to confirm the consistency with the original version. It has been subsequently piloted with different samples including international students, firefighters, and nursing home residents. The MAPLab protocol has used in a randomized control trial study with mental health case managers and high school teachers (McCarren, O’Brien,
Bannon, & Delaney, 2014) and the researchers reported that participants experienced the ACT intervention as a supportive and task-focused intervention. The MAPLab protocol was also currently used to treat work stress and prevent injury, assault, and abuse for nurses and nursing aides. The ACT intervention contains basic components (mindfulness training, defusion training, valued living exercises, and committed action) that have been found to be helpful for relieving stress (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). 24
To create the new protocol for Chinese international students, the MAPLab protocol was adapted by incorporating topics, techniques, and metaphors that more directly address the unique stressors identified by Chinese international students in the focus groups. For example, the ten categories of stressors for Chinese international students identified from the focus group study were presented to the participants in the intervention. Additionally, ACT metaphors that were not culturally sensitive were discarded and replaced by more workable metaphors. For example,
“Bob the Bum” metaphor was replaced by “birds in the Backyard” since having parties and inviting people over are not common activities experienced by Chinese international students in their own culture. And the “lie detector” metaphor was modified in accordance with a Chinese professor’s comment on it being perceived as “violent”. Specifically, instead of saying “a gun is connected to the lie detector and if you lie you will be shot in the head”, we would say “you will feel a gentle but unpleasant electric shock every time you lie, do you think you will get shock?
Can you fool the machine?” In addition, the new ACT protocol invites the therapist to utilize more self-disclose in session. We envisioned self-disclosure as a culturally sensitive therapeutic strategy when working with Chinese population for the following three reasons. First, the
Chinese “acquaintance culture” indicates that Chinese people generally feel more comfortable socially when they have knowledge of the person they interact with (Zhao, Yang, Yang, Hou,
Zhang, & Ji, 2011). Second, the Chinese “reciprocal culture ( )” could lead to Chinese clients’ expectation of reciprocal information exchanges with the therapist, which might not be intuitive for therapists trained to engage only “minimal” self-disclose. Third, self-disclosure regarding therapists’ personal experiences in acculturation and stress coping can be helpful for students who face similar problems (Sue, & Sue, 2012). 25
Since limited language proficiency has been identified as one of the major barriers for international students to seek help from mental health professionals (Blignault, et al, 2008; Lu, et al, 2014), the intervention was conducted in Mandarin to reduce language difficulty. Therefore, the new protocol was fully translated by the principal investigator into Mandarin. In addition, one bilingual professor in psychology and two bilingual doctoral students proofread the protocol and their feedback was adapted to finalize the protocol. This newly developed ACT protocol consisted of two two-hour workshops spaced one week apart and were run in groups of 3 to 5 participants (see Appendix I)
Therapist. Huanzhen Xu, the principal investigator, delivered the interventions.
Huanzhen Xu attended intensive ACT training, ACT experiential workshops, read ACT therapist guides and articles, and met with a board certified clinical supervisor prior to and after each session to discuss treatment material and progress.
Treatment Group. Four treatment groups were conducted. A total of 10 participants attended and competed the intervention. All of their post-treatment surveys were completed within one week after the final intervention session.
Control Group. Participants who were randomly assigned to control groups completed surveys at the same time points as the treatment group. At the conclusion of the study, they were offered an opportunity to participate in the ACT intervention. Out of the 17 persons assigned to the control group, 17 completed the pretreatment survey and 4 completed the posttreatment survey.
Treatment Integrity Checks
All treatment sessions were audio taped. An undergraduate research assistant listened to each audiotape and indicated whether the key items contained in the ACT protocol were 26 presented and discussed in sessions using a therapy integrity checklist, which can be found in
Appendix J.
Analysis Plan
All analyses were conducted using SPSS Version 23.0 and Microsoft Excel. Mean scores, standard deviations, and internal consistencies were calculated for all of the self-report questionnaires. To evaluate the convergent and predictive validities of the USCIS, the correlations between it and other measures were calculated. Paired sample t-tests and reliable change index (RCI) scores were used to assess differences between pre-treatment and post- treatment. Given the small sample size, standard deviation, and reliability coefficients from validation studies were used to calculate RCIs for each measure. The formulas for calculating
RCI and standard difference are provided below.
2 RC = X2 – X1 Sdiff = √2(SE) SE = SD√(1-r) Sdiff
In the above formulas, X2 is the post-treatment score, and X1 is pre-treatment score. The standard difference (Sdiff) is the square root of the standard error of measurement (SE) squared and multiplied by two. The standard error of measurement is the standard deviation multiplied by the square root of 1 minus the reliability coefficient for a particular measure. If the RCI was 1.96 or greater, the difference is classified as “statistically reliable,” and if the RCI was less than 1.96, then it is classified as “not statistically reliable.”
Results
Psychometric Characteristics of New Measure
The overall internal consistency of the measure was 0.962. Individual subscale internal consistency ranged from 0.707 to 0.954 (detailed results see Table 5). 27
Convergent Validity
To assess the convergent validity of the USCIS, we computed Pearson correlations with other self-report measures of clinical symptoms and psychological distress of depression, anxiety, and stress (See Table 6). Results showed that the total USCIS was significantly and positively correlated with depression, anxiety, and stress (depression: r = .60, p < 0.01; anxiety: r
= .58, p < .01; stress: r = .77, p < 0.01) but not physical symptoms. Among the ten USCIS subscales, depression and stress were correlated individually with all USCIS subscales
(depression r = .369 - .569, p < .05; stress r = .384- .726, p < .05) with the exception of Health
Care and Food. Anxiety was positively correlated with a majority of USCIS subscales, including
Loneliness, Academic Stress, Social Difficulty, Transportation Difficulty, Financial Burden, and
Language Barrier (r = .38-617, p < .05). In addition, the subscale Health Care System
Familiarity was significantly correlated with physical symptoms (r = .388, p < .05).
Correlations with Acceptance and Cognitive Fusion
The results showed that the total USCIS was significantly correlated with measures of psychological inflexibility (AAQ-II: r = .59, p < .01, CFQ: r = .68, p < .01). Among the subscales, Transportation, Food and Future Concerns were not significantly correlated with either acceptance or cognitive fusion. In addition, Family Distance was not significantly correlated with cognitive fusion and Health Care was not significantly correlated with acceptance. Other than the exceptions described above, the USCIS subscales were significantly correlated with both acceptance and cognitive fusion scores (correlations ranged from 37 to .63 with all p < .05). Detailed results of the correlations can be found in table 7. 28
Intervention Results
Participants who were randomly assigned to the treatment group were not significantly different from control group participants on any demographic variables (for details please see
Table 8). However, significant differences were observed for depression, USCIS transportation difficulty, and total USCIS, which indicated that the participants in treatment groups were experiencing higher levels of distress relative to control group participants at baseline. Ten out of
13 participants assigned to the treatment group attended the first intervention session. All 10 of these participants attended the second intervention session and completed the following post- intervention survey. Thus, there was no attrition. Four out 17 participants from the control group completed the second survey. Figure 1 presents a (CONSORT) flow chart detailing enrollment and attrition rates for each condition.
Due to the small sample size and limited number of participants in the control group, it was not possible to conduct meaningful between 2 x 2 analyses. Therefore, within subject analyses were conducted to evaluate treatment outcomes for the treatment and control groups separately. In addition, RCIs were used to test the effect of the intervention at a single subject level for the treatment group participants. Statistical analyses were performed using SPSS statistics version 24.
Treatment Feasibility and Acceptability. A treatment integrity check showed that the intervention covered 89.29% of the proposed protocol. As session attendance is used as a behavioral measure of feasibility and acceptability, no attrition in the treatment group indicated excellent feasibility and acceptability of the intervention. Qualitative observations indicated that all ten participants appeared to be engaged and actively participated in the sessions. All ten participants who attended the intervention sessions completed the post-treatment survey 29 demonstrating a 100% completion rate once they attended the ACT intervention. At the end of the intervention, several participants expressed appreciation for having an opportunity to discuss their difficulties and to connect with others who shared similar experiences. Eight participants reported that they learned “a different way” to evaluate and cope with their stress. In addition, all
10 participants in the treatment groups reported no prior therapy experience (the three participants who reported past stress management experience happened to drop out of this study) and many of them shared that they would consider pursuing therapy in the future when needed given that “now we know what that is like.”
Group Level Evaluation of Outcomes. Paired-sample t-tests were conducted to evaluate the impact of the intervention on participants’ scores on various measures. None of the pre to post changes were significant. These findings remained consistent after applying a bootstrap method to eliminate the potential adverse effects of outliners (see Table 9).
To further analyze the effect of the intervention, one-way repeated measures ANOVAs were used to calculate effect sizes. Results indicated that partial eta squared ranged from .001 to .283 for tested measures. To be specific, a medium effect size was observed for the AAQ-II
(η2=.108) and stress (η2=.117), while a small effect size was observed for anxiety (η2=.036) and depression (η2=.033). For the USCIS, analyses yielded a partial eta square of .283 for the subscale Financial Burden, which corresponds to a large effect size. In addition, partial eta squared for all other USCIS subscales, except Food Dissatisfaction, were shown to be above .012
(above small effect size).
An examination of individual level data indicated that the two participants in the last
ACT intervention group differed from other participants in the direction and magnitude of pre to post differences. Further, there appeared to be no significant differences at the baseline between 30 these two participants and the others. The timing of the intervention differed substantially for these two participants as well. Specifically, their intervention ended the week before finals week and their post-treatment measure completion occurred during finals week. In contrast, the other groups were run earlier in the semester and post treatment measurement occurred well before finals week.
Because of the difference in intervention timing, we ran another paired sample t-test without the data points from the two participants (participant 8 and 9) in the group that completed the post treatment measures during finals week. With these two participants omitted, statistically significant decreases in stress (t = 2.858, p = .02), depression (t = 3.55, p = .009), and
USCIS subscale Financial Burden (t = 2.46, p = .04) were observed. The results also showed a near significant reduction of anxiety (t = 2.46, p = .058), which became statistically significant in the expected direction with bootstrapping (t = 2.26, p = .05). Finally, there were trends for changes in the expected direction for the USCIS subscale loneliness (t = 1.91, p = .10 two- tail, .05 one-tail) and social difficulty scale (t = 1.62, p = .15 two-tail, .075 one-tail).
One-way repeated ANOVAs using data from the eight participants indicated partial eta squared (η2) values that ranged from .42 to .64 for depression, anxiety and stress which correspond to large effect sizes. The total USCIS demonstrated a large effect size (η2 = .24).
Further, the USCIS subscales loneliness, social difficulty, financial burden, and language barrier demonstrated large pre to post effect sizes (η2 = .24 - .46). For detailed results please see Table
10.
Paired-sample t-tests were also conducted to evaluate pre to post differences for the control group participants. None of the pre to post-treatment changes were significant (see Table 31
11). One-way repeated measures ANOVAs were used to calculate effect sizes. Results indicated that partial eta squared ranged from zero to .59 for tested measures.
Single-Subject Evaluation of Outcomes. Reliable change scores by construct are presented on Tables 12 – 28. It should be noted that the test-retest reliability of the USCIS could not be established given the preliminary nature of this study. Therefore, we used the internal consistency to calculate RCI when advised to use test-retest reliability. As a result, the RCI scores calculated for the total USCIS and its subscales should be interpreted with cautions.
Statistically significant change occurred on acceptance and cognitive fusion for three participants, yet not all changes occurred in the expected direction (Tables 12 &13). A couple of participants endorsed significant decreases on depression, anxiety, stress, and clinical symptoms, and these results were consistent with research hypothesis (Tables 14-17). On USCIS and its subscales, a number of participants reported statistically reliable changes in the expected directions. For example, participant 3 reported significant decreases in both the total USCIS scale and nine out of the ten subscales (total RCI=-12.28, subscale RCI ranged from -8.46 to -
2.78). Similarly, participant 7 reported significant decreases in both the total scale and eight out of the ten subscales (total RCI=-7.01, subscales RCI ranged from-6.96 to -2.10). reliable decreases also were observed for Participant 4 on the total USCIS scale (RCI=-3.36) and four subscales (RCI ranged from -5.35 to -2.32). However, results also detected reliable changes in the unexpected direction for two participants on the total USCIS scale (participant 6: RCI=2.47, participant 9: RCI=7.77) (Tables 18-28). 32
Discussion
Summary of Findings
This pilot study was conducted with the aims to preliminarily evaluate the psychometric characteristics and convergent validity of the newly developed Unique Stress for Chinese
International Students Questionnaire (USCIS), evaluate relationships between USCIS and acceptance, cognitive defusion, and symptoms, as well as evaluate the feasibility, acceptability, and preliminary effectiveness of a newly developed ACT intervention specifically for Chinese international students.
Results indicated that the total USCIS and its subscales demonstrated excellent internal consistency as well as good convergent validity with measures of psychological distress.
Moreover, psychological flexibility measured by acceptance and cognitive fusion was shown to be correlated in the expected directions with the USCIS total scale.
As for the intervention outcome study, results using data from ten participants suggested no statistically significant differences in self-report measures from pre- to post-treatment. However, with the exclusion of two participants from a group that was conducted during finals week, significant decreases in anxiety, depression, stress, and the USCIS subscale financial burden were observed, with near significant reductions in USCIS subscales loneliness and social difficulty being reported as well. Moreover, analysis on an individual level demonstrated significant changes on tested measures among several participants in the predicted directions.
Qualitative feedback from treatment participants suggested positive experience of the ACT intervention, which was also evidenced by the extremely low (zero) attrition rate.
In summary, results demonstrated that the USCIS has sound internal consistency and convergent validity. Results also indicated good feasibility and acceptability of the newly 33 developed ACT intervention. Finally, there was evidence of effectiveness in reducing psychological distress and acculturative stress among Chinese international students.
Implications
The USCIS is one of the first measures devoted to assessing acculturative stress experienced among Chinese international students. It was developed with first-hand data from in-depth focus group discussions and is in Chinese language. The domains of stress highlighted in the measure include the ones suggested by literature, such as language barrier, academic stress, social difficulty, loneliness, and adaptation to the new environment, as well as the newly discovered dimensions such as family distance, unfamiliarity with U.S. health care, future concerns, and transportation difficulty.
Among the ten domains, academic stress and social difficulty appeared to be the most prominent stressors reported by the treatment group participants. Difference in food preference was commonly identified by participants of this study as a life aspect difficult to adapt to, yet results showed that it was not significantly correlated with psychological distress. While graduate student participants tended to discuss stress associated with financial burden, family distance, and future concerns, younger and undergraduate participants inclined to bring up issues related to social relationships and inconvenience of transportation. Our preliminary psychometrics testing showed that the USCIS measure is significantly correlated with depression, anxiety, and stress. We envision this measure to be used as a screening tool for identifying Chinese international students who express acculturation-related psychological distress.
Among participants who completed the first survey, we noticed that a majority described themselves as “Atheist”. Yet, around half of the self-identified atheist students had attended 34
Christian events or gatherings during their residency in the United States. These participants explained that their primary reason for attending was that they enjoyed the social opportunities provided by the religious activities. Thus, it appears that religious organizations provide important opportunities for Chinese international students to socialize and find a sense of community while living in a foreign country. However, an atheist student who attends Christian events and gatherings might experience pressure to convert to Christianity. The impact of the interaction between this conversion pressure and the search for social support is an important area for future research.
In our intervention study, the ACT protocol demonstrated effectiveness in reducing a number of distress-related dimensions, including depression, anxiety, stress, and acculturative stress. Participants from the treatment groups reported that the knowledge from ACT was insightful and helpful. Though none of the treatment group participants had prior experience with mental health services, many of them shared that they felt more comfortable and open to seeking support in the future after the intervention.
During intervention sessions when mindfulness was introduced, participants generally made the connection to Buddhism, as Buddhism is one the three major religions in China (Yao, 2010) and mindfulness is an essential Buddhist practice. Moreover, when the ACT concept “creative hopelessness” was discussed in sessions with Chinese participants, there seemed to be a common knowledge shared by the groups that “sufferings are to be accepted,” which indicated their understanding of an important teaching from Buddhism regarding the ubiquity of human suffering (Hayes, 2002). There are clear parallels between Buddhism and the mindfulness component in ACT (Hayes, 2002), and it is possible that knowledge of one could promote learning of the other. ACT possesses the potential to be a culturally relevant intervention for 35 people who demonstrate understanding of Buddhism, and future studies are encouraged to examine the role the knowledge of Buddhism plays in the learning of ACT.
This study answered the call for academic and clinical commitment to enhancing the lives of young people of culturally diverse backgrounds (Chen, et al,. 2013). A strength of both the
USCIS and the newly developed ACT intervention is their cultural competence, as the entire protocol and measures used were in Chinese language. Given that language difficulty is listed as one of the top challenges in day to day living among international students and one of the most prominent barriers to accessing mental health services, removal of this communicative obstacle could be extremely helpful in mental health care.
Among participants who completed the baseline survey, none had previously sought for or received mental health services. A study with almost 2,000,000 Chinese participants showed that over fifty percent of Chinese adults with a long-standing mental disorder had never used any mental health services (Li, Du, Chen, Song, & Zheng, 2013). The barrier for Chinese students to seek out help from mental health professionals was centered around mental health illiteracy and stigmatization (Chen, et al, 2015). From a study with 211 untreated Chinese patients who met criteria for DSM-IV disorders, researchers found that 92% of them perceived a low need for treatment (Lee, Guo, Tsang, He, Huang, Liu, … Kessler, 2010). The Chinese cultural value “do not reveal family wound to outsiders ( )” forebodes the impractical expectation for
Chinese people to actively request support.
It is beyond the scope of this study to examine Chinese people’s cultural views on mental health and their barriers to accessing mental health services. Due to these unique cultural challenges shared among Chinese people, treatment outcome studies may experience difficulty in recruitment. The methodology of recruitment commonly used in American universities requires 36 voluntary involvement initiated from the participants’ end. However, the relatively low mental health literary and stigmatization of mental illness and treatment often lead to unawareness of available services and reluctance to receive such services. Therefore, innovative strategies for care engagement are required when working with people from diverse backgrounds.
Several authors (Chen, 1999; Overzat, 2011) contend that good intent is not enough, and proactive actions need to be initiated by mental health services in higher education to reach out to this culturally specific student population. With this consensus, mental health professionals’ responsibility to reach out and the importance of extending support to students with culturally diverse backgrounds were highlighted in diversity counseling studies (Corey, 2009; Arredondo,
Toporek, Brown, Jones, Locke, Sanchez, Stadler, 1996; Chen, 2003). Because the same barriers faced by Chinese people in accessing mental health services exist in studies focusing on intervention processes, we experienced significant difficulty in recruiting participants for our intervention study. Future studies are recommended to employ innovative and more culturally sensitive methods when it comes to recruiting.
Additionally, while there is already a cultural predisposition for Asian people to underutilize mental health services, there is also a shortage in the available professional help.
Chinese participants from our study shared feelings of disconnection and exclusion from mental health services, as there is a lack of multi-cultural representation and personnel who speak their first language. Their perception is not wrong, as data from the American Psychological
Association showed that Asians are the smallest racial minority in the Clinical Psychology workforce (4%) (APA Center for Workforce Studies, 2018). Further, it is unlikely that many of the Asian psychologists are bilingual or international. As noted in the introduction, Chinese international students comprise approximately 32% of all international students in American 37 universities, which is over 3% of the total student population (Institute of International
Education, 2016). Thus, there is a clear and increasing need for bilingual and culturally competent mental health professionals for Chinese international students.
Limitations
The primary purposes of this study were to create a new measure to assess acculturation stress and a new ACT protocol specifically for Chinese international students. Combined with the difficulty of recruiting Chinese international student participants in a small mid-western city, we made this intervention accessible to all interested Chinese international students with no further inclusion criterions. Future studies are recommended to test the effectiveness of the new
ACT intervention with a clinically distressed sample.
Events outside of the intervention or between repeated measures of the dependent variable may affect participants' treatment outcomes. In retrospect, the difference in the time points when the intervention groups were conducted appeared to have had an impact on the divergent treatment outcomes. As discussed in the results section, while there were no significant differences between participants from the last intervention group and the previous four intervention groups at baseline measures, the last group demonstrated a similar response pattern in the post-treatment measures that was inconsistent with the pattern demonstrated by the previous groups. As noted in the method section, the last intervention group was conducted in early May of 2018, while the other groups were finished before the end of November in 2017.
The difficulty in recruiting subjects and the changes in the primary investigator’s availability ultimately led to this long interval between groups. It is worth noting that the last intervention group was conducted during the finals weeks. To be specific, the pre-treatment surveys were filled out during the third from the last (final) week, the two-session intervention was conducted 38 across the following two-week span, and the post treatment surveys were filled out during the finals week. However, the early groups were all conducted during regular weeks in the semester.
Research showed that stress levels and negative affect were significantly higher during final weeks than mid-semester weeks for college students (Crandall, Preisler, & Aussprung, 1992;
Trueba, 2015). Moreover, participants were less likely to show improvement in psychological intervention if they had more current stressful life events (McDermut, Miller, & Brown, 2001).
The noticeable difference in response patterns between the last group and the other groups, together with the significantly different results from data analysis after excluding the last group, we hypothesized that the history effect related to final exams might have affected the last group’s response to the intervention.
Another methodology challenge we experienced was the high attrition rate in the control group. While all participants in the treatment group finished the intervention and post-treatment survey, 13 out of 17 participants in the control group failed to complete the second survey despite receiving two reminders to do so. Several factors might have contributed to the high attrition rate found in the control group. First, the survey was very lengthy (USCIS alone had 103 items and the entire survey had a total of 153 items). Bai (2016)’s study with Chinese international students reported the similar challenge, where the results showed a 52% dropout rate for completing a survey of 102 items. In our study, we obtained baseline data from all seventeen control group participants. Yet, the difficulty arose when they were asked to complete another survey of the same length again.
Second, control group participants received no therapist contact and minimal contact from the authors. Chinese people tend to be more interpersonal ( ) and private. Without personal encouragement and reassurance, they may be reluctant to complete a long and 39 personally revealing survey. Future studies are recommended to clarify to what extent therapist contact is necessary for Chinese individuals to engage in an intervention study.
Third, more graduate students were randomly assigned to control group, which could be indicative of the high drop-out rate. Graduate students reportedly face the challenge associated with time planning and management (Canna, 2003). With their heavy commitments to academic studies and potential family responsibilities in mind, it is possible that they ceased to see a need to continue investing additional time into filling out a 153-item survey. Not to mention that the lack of rewards for completing the survey (10 dollars Amazon giftcard) might be viewed as
“limiting professional effectiveness” (Amon, 2017). They might find it not helpful and therefore did not see a need to continue investing additional time into the surveys.
Due to the small sample size in the control group, between-group comparisons at post- treatment were not conducted. Without control group comparisons, it is difficult to rule out several threats to the internal validity such as history, maturation, and regression toward the mean (Schmiedek, 2016). From a construct validity perspective, it is possible that there were elements to our intervention that may have promoted changes that were unrelated to the specific
ACT components. For instance, it is possible that the basic clinical skills the therapist demonstrated in session, such as supportive listening and rapport building, were effective enough to elicit a change (Sommers-Flanagan, & Sommers-Flanagan, 2015). In addition, the group therapy format introduces several therapeutic factors, such as universality, altruism, and socializing techniques developing (Yalom & Leszcz, 2005). These unique features of group therapy might have contributed to the significant outcomes in this study. 40
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APPENDIX A: TABLES Table 1 Focus Group Participant Characteristics Group # 01 02 03 04 05 Total Total N 3 5 4 5 2 19 Gender Female 3 3 2 3 2 13 Male 0 2 2 2 0 6 Education level Graduate 3 5 4 0 0 12 Undergraduate 0 0 0 5 2 7 Residence Length 22 21.2 26 27.6 14 23.26
Note. #=number. Residence length=the average residence length in month(s) 50
Table 2 Focus Group Questions
o What are the major challenges you have encountered as Chinese international students? o Have those challenges exerted some level of stress on you and how serious you think the stress is? o What sorts of physical symptoms did you experience once you arrived in the U.S.? o What changes do you noticed in your body when you are stressed? o What are the types of thoughts you have, both in words and images, when you are stressed? o What coping strategies you use to manage stress? Have they been helpful? o What do you know about the mental health services at BGSU? o What are the barriers for accessing mental health services to help with stress? o What would be a better way to communicate mental health information with Chinese international students? o Would you be interested in participating in a workshop aimed at reducing your stress? o What components should be in a workshop for Chinese students experiencing stress? o What organizations have reached out to you to assist with stress since you arrived in the USA? (eg., campus clubs, volunteer center, religious groups, etc.) Have they been helpful? 51
Table 3 Demographics of the Judges Judge group 1 Judge group 2 Judge group 3 Judge group 4 Total N 3 3 3 2 Bilingual 3 0 0 0 Ethnicity Chinese American American American Gender Female 3 1 2 1 Male 0 2 1 1 Professions Professors 0 2 0 0 graduate students 1 1 3 0 undergraduates 0 0 0 2 Others 2 0 0 0 Tasks given Listen to focus Read through Assign comments Assign the 103 group comments and into the 10 items into the recordings; generate stress categories given; 10 categories. Generate categories; Leave out the comments Assign ones that do not comments into belong to any categories categories Notes. Others in professions=bilingual persons working in education field. 52
Table 4 Participants’ Characteristics (N=30) Variable M (SD) Age (years) 23.7 (3.3) Residency Length (Months) 32.3 (SD=24.9) (24.9) n % Gender Female 19 (63.3) Male 11 (36.7) Others 0 (0) Degree in Progress Undergraduate 14 (46.7) Graduate 16 (53.3) Relationship Status Married 2 (6.7) In a relationship 10 (33.3) Single 18 (60)
Religion Christianity 5 (16.7) Buddhism 4 (13.3) Taoism 2 (6.7) Atheism 19 (63.3) Attending Religious Events Never 5 (16.7) Seldom 14 (46.7) Sometimes 7 (23.3) Often 3 (10) Always 1 (3.3) Financial Resources Parents 22 (73.3) Scholarship (stipend) 6 (20) Self 2 (6.7) 53
Table 5 Internal Consistency of the Overall New Measure and its Subscales Cronbach’s Alpha N of Items USCIS-total .962 103 Loneliness .916 13 Academic Stress .954 26 Social Difficulty .922 16 Transportation .912 7 Financial Burden .729 2 Family Distance .707 11 Health Care .883 10 Language Barrier .854 6 Food .902 10 Future Concerns .901 2 54
Table 6 Correlations with Depression, Anxiety, Stress, and Symptoms
Measure 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1.Depression - .450* .615** -.184 .561** .424* .612** .418* .569** .397* -.039 .497** .070 .369* .599** 2.Anxiety - .757** .338 .617** .380* .431* .482** .387* .292 .074 .545** .202 .149 .575** 3.Stress - .294 .726** .633** .549** .384* .524** .544** .277 .745** .064 .487** .770** 4.Symptoms - .200 .325 .159 .025 .128 .179 .388* .279 .085 .198 .321 5.Loneliness - .432* .675** .519** .414* .667** .145 .449* .127 .288 .767** 6.Academic Stress - .552** .217 .565** .526** .333 .468** -.045 .688** .783** 7.Social Difficulty - .280 .443* .446* .194 .634** .118 .443* .790** 8.Transportation - .327 .212 .225 .292 .456* .024 .568** 9.Financial Burden - .456* .306 .484** .022 .416* .635** 10.Family Distance - .243 .260 -.077 .443* .646** 11.Health Care - .531** .184 .259 .502** 12.Language Barrier - .058 .405* .691** 13.Food - .077 .299 14.Future Concerns - .596** 15.USCIS Total - Notes. N=30, *p<.05, **p<.01 55
Table 7 Correlations with Acceptance and Cognitive Fusion Measure 1 2 3 4 5 6 7 8 9 10 11 12 13
1.AAQ - .686** .608** .431* .486** .127 .464** .457* .311 .629** .021 .320 .592**
2.CFQ - .611** .448* .581** .347 .440* .299 .373* .702** .164 .349 .675**
3.Loneliness - .432* .675** .519** .414* .667** .145 .449* .127 .288 .767**
4.Academic Stress - .552** .217 .565** .526** .333 .468** -.045 .688** .783**
5.Social Difficulty - .280 .443* .446* .194 .634** .118 .443* .790**
6.Transportation - .327 .212 .225 .292 .456* .024 .568**
7.Financial Burden - .456* .306 .484** .022 .416* .635**
8.Family Distance - .243 .260 -.077 .443* .646**
9.Health Care - .531** .184 .259 .502**
10.Language Barrier - .058 .405* .691**
11.Food - .077 .299
12.Future Concerns - .596**
13.USCIS Total -
Notes. N=30, *p<.05, **p<.01 56
Table 8 Demographics of Treatment Condition (N=13) and Control condition (N=17) and Their Baseline Scores on Measures Treatment Control Mean SD Mean SD Age (years) 23.23 2.98 24.12 3.57 Residency Length (Months) 31.31 27.96 33.12 23.00 AAQ 22.31 6.43 17.82 7.82 CFQ 30.92 12.61 25.47 13.35 Depression 5.38 4.37 1.71 1.45 Anxiety 5.77 3.75 3.53 2.65 Stress 7.69 4.55 5.18 3.76 PHQ 7.54 4.46 7.18 6.16 USCIS-total 400.08 87.54 334.88 75.92 n % n % Gender Male 4 (30.8) 7 (41.2) Female 9 (69.2) 10 (58.8) Degree in Progress Undergraduate 8 (61.5) 7 (41.2) Graduate 5 (38.5) 10 (58.8) Relationship status Married 0 (0) 2 (11.8) In a relationship 5 (38.5) 5 (29.4) Single 8 (61.5) 10 (58.8) Religion Christianity 1 (7.7) 4 (23.6) Buddhism 3 (23.1) 1 (5.9) Taoism 0 (0) 2 (11.8) Atheism 9 (69.2) 10 (58.8) Financial resources Parents 11 (84.6) 10 (58.8) Scholarship (stipend) 2 (15.4) 4 (23.5) Self 0 (0) 2 (11.8) 57
Table 9 Means, Standard Deviations, and Within Group Analysis for Outcome Measures for Treatment Groups (N=10) Pre Post Mean SD Mean SD t F p (2- p after Partial Effect tailed) bootstrap η2 Size AAQ 22.4 6.42 24.4 8.30 -1.04 1.091 .32 .32 .108 M CFQ 32.8 10.66 32.3 14.78 .12 .01 .91 .91 .001 / Stress 7.8 4.05 6.1 4.58 1.092 1.19 .30 .28 .117 M Anxiety 6.1 3.93 5.3 4.81 .576 .33 .58 .57 .036 S Depression 5.3 4.27 4.4 5.125 .55 .30 .60 .60 .033 S PHQ 7.4 4.79 6.6 6.26 .48 .23 .65 .64 .025 S Loneliness 45.5 14.63 43.3 17.62 .42 .18 .68 .67 .019 S Academic Stress 99.4 23.84 93.9 42.45 .51 .261 .62 .60 .028 S Social Difficulty 68.2 19.70 60.6 25.95 .87 .75 .41 .47 .077 S Transportation 29.2 14.67 27.6 16.26 .64 .41 .54 .56 .044 S Financial Burden 9.9 3.81 7.6 4.48 1.88 3.55 .09 .13 .283 L Family Distance 43.9 7.87 41.2 15.29 .56 .31 .59 .59 .033 S Health care 38 14.75 35.8 20.04 .34 .114 .74 .73 .012 S Language Barriers 25.8 7.87 23.5 12.34 .59 .345 .57 .61 .037 S Food 36.4 17.37 37 17.85 -.14 .021 .89 .88 .002 / Future concerns 6.4 4.20 5.9 3.70 .48 .233 .64 .60 .025 S USCIS total 402.7 58.11 376.3 159.13 .646 .417 .54 .56 .044 S Notes. S=small effect size, M=medium effect size, L=large effect size, / = smaller than small effect size 58
Table 10 Means, Standard Deviations, and Within Group Analysis for Outcome Measures for Treatment Groups (N=8) Pre Post Mean SD Mean SD t F p (2- p after Partial Effect tailed) bootstrap η2 Size AAQ 21.64 6.91 21.5 6.35 .08 .006 .94 .93 .001 / CFQ 33.38 10.62 29.38 15.15 .90 .81 .40 .43 .104 M Stress 8.25 4.33 4.75 3.62 2.86 8.17 .02 .03 .54 L Anxiety 7.13 3.56 4.75 4.71 2.26 5.11 .058 .05 .42 L Depression 5.75 4.53 2.75 2.82 3.55 12.6 .01 .01 .64 L PHQ 7.13 5.22 4.88 4.97 1.37 1.87 .21 .21 .21 M Loneliness 46.25 16.32 38.13 14.93 1.91 3.66 .10 .10 .34 L Academic Stress 97.50 27.65 84.00 36.52 1.19 1.41 .27 .27 .17 M Social Difficulty 69.25 22.17 54.75 24.79 1.62 2.62 .15 .18 .27 L Transportation 28.75 15.08 25.38 16.34 1.22 1.48 .26 .31 .17 M Financial Burden 9.75 4.23 6.5 4.21 2.46 6.07 .04 .10 .46 L Family Distance 43.75 8.21 37.63 13.24 1.16 1.35 .28 .28 .16 M Health care 35.13 15.06 30.63 18.22 .57 .32 .59 .57 .04 S Language Barriers 26.75 8.48 21.25 12.44 1.47 2.15 .19 .21 .24 L Food 34.38 18.55 33.25 16.77 .22 .05 .83 .82 .01 S Future concerns 5.63 4.17 4.88 2.64 .59 .35 .57 .55 .05 S USCIS total 397.13 58.24 336.38 138.04 1.49 2.22 .18 .22 .24 L Notes. S=small effect size, M=medium effect size, L=large effect size, / = smaller than small effect size 59
Table 11 Means, Standard Deviations, and Within Group Analysis for Outcome Measures for Control Groups (N=4) Pre Post Mean SD Mean SD t F p (2-tailed) Partial η2 Effect Size AAQ 18.25 7.23 22.00 10.03 -2.09 4.36 .128 .59 L CFQ 23.75 14.64 27.25 12.76 -.57 .33 .607 .10 M Stress 4.75 3.30 5.25 3.10 -.78 .60 .495 .17 M Anxiety 4.00 2.94 3.75 2.22 .04 .20 .854 .01 S Depression 1.25 .96 2.75 2.75 1.29 1.13 .339 .30 L PHQ 10.75 8.42 9.00 7.26 4.20 2.05 .133 .58 L Loneliness 30.25 13.20 28.50 17.97 .32 .10 .770 .03 S Academic Stress 68.25 26.49 70.75 31.32 .94 .88 .417 .23 M Social Difficulty 46.25 20.65 43.25 21.78 -.79 .62 .488 .17 M Transportation 14.00 6.58 15.00 8.16 -.40 .16 .714 .05 S Financial Burden 5.5 .58 5.75 2.63 .16 .03 .882 .01 S Family Distance 30.25 8.02 33.25 9.50 -1.04 1.08 .375 .27 L Health care 29.50 10.02 36.50 11.85 2.01 4.03 .138 .57 L Language Barriers 19.50 11.62 21.75 9.74 -.94 .88 .417 .23 L Food 36.25 7.80 36.50 10.88 .06 .00 .953 .00 / Future concerns 3.00 2.00 3.75 2.87 -1.57 2.46 .215 .45 L USCIS total 282.75 87.72 295.00 105.23 .72 .52 .52 .15 M Notes. S=small effect size, M=medium effect size, L=large effect size, / = smaller than small effect size 60
Table 12 RCI Scores for AAQ Participant pre post Change RCI 1 27 30 3 0.63 2 18 16 -2 -0.42 3 17 17 0 0 4 32 25 -7 -1.48 5 17 24 7 1.48 6 30 27 -3 -0.63 7 14 11 -3 -0.63 8 28 37 9 1.90 9 23 35 12 2.54* 10 18 22 4 0.85 Notes. *=statistically reliable change 61
Table 13 RCI Scores for CFQ Participant pre post Change RCI 1 43 42 -1 -0.09 2 28 18 -10 -0.94 3 40 11 -29 -2.72* 4 44 36 -8 -0.75 5 35 47 12 1.13 6 35 35 0 0 7 11 7 -4 -0.38 8 20 41 21 1.97* 9 41 47 6 0.56 10 31 39 8 0.75 Notes. *=statistically reliable change 62
Table 14 RCI Scores for Stress Participant pre post Change RCI 1 12 2 -10 -2.27* 2 6 5 -1 -0.23 3 2 1 -1 -0.23 4 15 9 -6 -1.36 5 7 8 1 0.23 6 12 9 -3 -0.68 7 5 0 -5 -1.13 8 4 8 4 0.91 9 8 15 7 1.59 10 7 4 -3 -0.68 Notes. *=statistically reliable change 63
Table 15 RCI Scores for Anxiety Participant pre post Change RCI 1 9 2 -7 -1.98* 2 7 4 -3 -0.85 3 2 1 -1 -0.28 4 8 7 -1 -0.28 5 12 15 3 0.85 6 10 5 -5 -1.41 7 2 0 -2 -0.57 8 0 3 3 0.85 9 4 12 8 2.26* 10 7 4 -3 -0.85 Notes. *=statistically reliable change 64
Table 16 RCI Scores for Depression Participant pre post Change RCI 1 4 0 -4 -1.03 2 10 7 -3 -0.77 3 3 0 -3 -0.77 4 10 5 -5 -1.29 5 1 1 0 0 6 13 6 -7 -1.80 7 3 1 -2 -0.51 8 1 5 4 1.03 9 6 17 11 2.82* 10 2 2 0 0 Notes. *=statistically reliable change 65
Table 17 RCI Scores for Clinical Symptoms (PHQ) Participant pre post Change RCI 1 8 2 -6 -1.57 2 3 5 2 0.52 3 11 0 -11 -2.88* 4 0 2 2 0.52 5 12 13 1 0.26 6 3 4 1 0.26 7 5 1 -4 -1.05 8 6 8 2 0.52 9 11 19 8 2.10* 10 15 12 -3 -0.79 Notes. *=statistically reliable change 66
Table 18 RCI Scores for USCIS Subscale Loneliness Participant pre post Change RCI 1 65 55 -10 -1.54 2 71 44 -27 -4.17* 3 35 17 -18 -2.78* 4 52 37 -15 -2.32* 5 45 45 0 0 6 46 50 4 0.62 7 22 14 -8 -1.24 8 38 55 17 2.63* 9 47 73 26 4.01* 10 34 43 9 1.39 Notes. *=statistically reliable change 67
Table 19 RCI Scores for USCIS Subscale Academic Stress Participant pre post Change RCI 1 62 72 10 1.16 2 85 95 10 1.16 3 74 26 -48 -5.58* 4 138 92 -46 -5.35* 5 74 75 1 0.12 6 126 148 22 2.56 7 115 55 -60 -6.97* 8 91 94 3 0.35 9 123 172 49 5.69* 10 106 109 3 0.35 Notes. *=statistically reliable change 68
Table 20 RCI Scores for USCIS Subscale Social Difficulty Participant pre post Change RCI 1 66 61 -5 -0.64 2 98 64 -34 -4.33* 3 80 16 -64 -8.15* 4 95 76 -19 -2.42* 5 43 44 1 0.13 6 79 92 13 1.66 7 45 28 -17 -2.17* 8 66 70 4 0.51 9 62 98 36 4.59* 10 48 57 9 1.15 Notes. *=statistically reliable change 69
Table 21 RCI Scores for USCIS Subscale Transportation Participant pre post Change RCI 1 45 42 -3 -0.54 2 36 28 -8 -1.44 3 27 7 -20 -3.59* 4 14 11 -3 -0.54 5 38 37 -1 -0.18 6 47 49 2 0.36 7 7 7 0 0 8 18 24 6 1.08 9 44 49 5 0.90 10 16 22 6 1.08 Notes. *=statistically reliable change 70
Table 22 RCI Scores for USCIS Subscale Financial Burden Participant pre post Change RCI 1 2 2 0 0 2 10 8 -2 -0.70 3 13 2 -11 -3.84* 4 14 10 -4 -1.40 5 11 9 -2 -0.70 6 14 13 -1 -0.35 7 8 2 -6 -2.10* 8 9 10 1 0.35 9 12 14 2 0.70 10 6 6 0 0 Notes. *=statistically reliable change 71
Table 23 RCI Scores for USCIS Subscale Family Distance Participant pre post Change RCI 1 50 45 -5 -0.63 2 45 31 -14 -1.75 3 40 13 -27 -3.38* 4 54 53 -1 -0.13 5 37 50 13 1.63 6 37 44 7 0.88 7 54 28 -26 -3.25* 8 38 42 4 0.50 9 51 69 18 2.25* 10 33 37 4 0.50 Notes. *=statistically reliable change 72
Table 24 RCI Scores for USCIS Subscale Health Care Participant pre post Change RCI 1 34 37 3 0.450 2 10 28 18 2.99* 3 61 10 -51 -8.46* 4 31 33 2 0.33 5 29 24 -5 -0.83 6 50 70 20 3.32* 7 33 15 -18 -2.99* 8 45 46 1 0.17 9 54 67 13 2.16* 10 33 28 -5 -0.83 Notes. *=statistically reliable change 73
Table 25 RCI Scores for USCIS Subscale Language Barrier Participant pre post Change RCI 1 31 31 0 0 2 18 24 6 1.28 3 33 6 -27 -5.76* 4 39 33 -6 -1.28 5 18 7 -11 -2.35* 6 34 36 2 0.43 7 18 8 -10 -2.13* 8 25 26 1 0.21 9 19 39 20 4.27* 10 23 25 2 0.43 Notes. *=statistically reliable change 74
Table 26 RCI Scores for USCIS Subscale Food Dissatisfaction Participant pre post Change RCI 1 47 49 2 0.32 2 14 30 16 2.58* 3 33 10 -23 -3.71* 4 14 31 17 2.74* 5 61 56 -5 -0.81 6 57 47 -10 -1.61 7 25 12 -13 -2.10* 8 36 39 3 0.48 9 53 65 12 1.93 10 24 31 7 1.13 Notes. *=statistically reliable change 75
Table 27 RCI Scores for USCIS Subscale Future Concern Participant pre post Change RCI 1 3 5 2 1.26 2 2 6 4 2.51* 3 2 2 0 0 4 14 10 -4 -2.51* 5 4 6 2 1.26 6 4 3 -1 -0.63 7 9 2 -7 -4.39* 8 7 6 -1 -0.63 9 12 14 2 1.26 10 7 5 -2 -1.26 Notes. *=statistically reliable change 76
Table 28 RCI Scores for USCIS Total Participant pre post Change RCI 1 405 399 -6 -0.26 2 389 358 -31 -1.32 3 398 109 -289 -12.28* 4 465 386 -79 -3.36* 5 360 353 -7 -0.30 6 494 552 58 2.47* 7 336 171 -165 -7.01* 8 373 412 39 1.66 9 477 660 183 7.77* 10 330 363 33 1.40 Notes. *=statistically reliable change 77
APPENDIX B: FOCUS GROUP PROTOCOL
Chinese International Students Focus Group Protocol Moderator Script [CAPITAL TEXT] = instructions that should NOT be read aloud. [M] = Moderator [WELCOME]
[M]: Welcome everyone! Thank you so much for taking time out of your busy schedules to join us today. Today we want to talk to you about your role as Chinese international students in the U.S. We will ask you about the challenges and stressors that Chinese international students experience. Specific questions will be addressed on coping strategies used, physical symptoms observed, and ideas about available health services, and so on. I will also ask you to give suggestions on how to improve mental health services for Chinese students. Your honest opinions are very important to us!
Let’s start with a few house-keeping items. First, please write your name on the name tent at your seat.
[GIVE PARTICIPANTS TIME TO CREATE NAME TENTS; MODERATOR SHOULD CREATE THE NAME TENT AS WELL].
Second, please read through the consent form at your seat. This is a document that describes the nature of your participation in this study. It is very important that you understand the nature of participation and your rights as a participant. So please read the document thoroughly. Feel free to ask any questions about the informed consent document or this study in general. Once you have finished reading, you can indicate consent to participate by signing both copies of the informed consent form. The second copy is for you to keep. Once you finish signing both copies, please pass one of them to the front of the table.
[GIVE PARTICIPANTS TIME TO SIGN INFORM CONSENT FORMS. BE AVAILABLE TO ASNWER QUESTIONS. ONCE ALL SIGNED CONSENT FORMS ARE PASSED IN, PROCEED WITH INTRODUCTIONS].
[INTRODUCTIONS + GROUND RULES] [M]: Now we are ready to begin! We would like to start by getting to know each other. We will go around the table, each stating your name, your major, your year in school, and how many years you have been studying abroad. Let’s begin with me, and then go from there. [BEGINNING WITH MODERATOR, HAVE EACH PERSON INTRODUCE THEMSELVES.]
[M]: Next, I’d like to lay out a few ground for the rest of our meeting. Ground rule #1: What is said in this room is confidential. We ask that you do not share opinions expressed in this meeting with persons outside of this room, and the researchers will do the same. You should feel comfortable stating your honest opinions, because your opinions will not be shared with anyone outside of the research team. We are audio taping this session, but that is 78 only because we want to capture everything that you have to say. We will not identify anyone’s name in any report or publication or report based on this study. Ground rule #2: Respectfully participate. Every person’s experiences and opinions are important. Speak up when you agree or disagree, but please do so in a respectful manner. Ground rule #3: We want you to do the talking today. We want to hear from everyone today, so we may call on you if we haven’t heard from you in a while. Does anyone have any questions regarding the ground rules for today’s meeting? [ANSWER QUESTIONS, SHOULD THEY ARISE. THE MODERATOR SHOULD TEAR AND POST THE SHEET OF RULES ON THE WALL WHERE THEY ARE VISIBLE TO PARTICIPANTS. THE SHEET OF RULES SHOULD BE PREPARED BEFORE EACH SESSION.]
[THE LIMIT OF CONFIDENTIALITY] [M]: I know that we have talked about the confidentiality issue in the ground rule #1 [POINT TO THE RULE #1 ON THE SHEET]. However, I cannot guarantee that the information discussed here remain confidential given the nature of the focus group. I cannot guarantee that participants would not talk outside this room. Therefore, I would like to invite you to disclose information only when you feel comfortable sharing within the context of the focus group setting
[FOCUS GROUP QUESTIONS] [M]: Now we can move on to our questions regarding your experience as overseas. You are free to talk in either Chinese or English, whichever language that you think that would best express your opinions. Let’s begin! [AS PARTICIPANTS ANSWER EACH QUESTION, THE MODERATOR SHOULD WRITE DOWN MAJOR THEMES ON THE FLIP CHART, TEARING OFF AND POSTING PAGES WHENEVER SPACE BECOMES LIMITED.]
1. What are the major challenges you have encountered as Chinese international students? 2. Have those challenges exerted some level of stress on you and how serious you think the stress is? 3. What sorts of physical symptoms did you experience once you arrived in the U.S.? 4. What changes do you noticed in your body when you are stressed? 5. What are the types of thoughts you have, both in words and images, when you are stressed? 6. What coping strategies you use to manage stress? Have they been helpful? 7. What do you know about the mental health services at BGSU? 8. What are the barriers for accessing mental health services to help with stress? 9. What would be a better way to communicate mental health information with Chinese international students? 10. Would you be interested in participating in a workshop aimed at reducing your stress? 11. What components should be in a workshop for Chinese students experiencing stress? 12. What organizations have reached out to you to assist with stress since you arrived in the USA? (eg., campus clubs, volunteer center, religious groups, etc.) 79
[M]: Thank you so much for your input on those questions. This brings us to our last question. It is a “catch-all” question to make sure that we didn’t miss any important opinions today. Is there anything that you felt we missed in our questions today? Did we miss any important aspect of your lives in the U.S. that has been generating stress?
[CONCLUSION] [M]: This brings us to the end of today’s session. We greatly appreciate you taking the time out of your schedule to join us today and for your thoughtful responses. Should you have any questions regarding your participation today, please contact me or Dr. William O’Brien. Both of our contact information is listed on your copy of the informed consent form. Thank you! 80
APPENDIX C: THE USCIS Table C1 Unique Stress for Chinese international Students Questionnaire (USCIS) Never Almost Seldom Sometimes Often Almost Always Never always 1 2 3 4 5 6 7
1. I feel that my holidays and weekends are lonely 1 2 3 4 5 6 7
2. I feel that my holidays and weekends are boring 1 2 3 4 5 6 7
3. I feel far away from my family 1 2 3 4 5 6 7
4. I feel far away from my cultures 1 2 3 4 5 6 7
5. I have feelings of not being filial 1 2 3 4 5 6 7
6. I cannot talk to my parents about stress 1 2 3 4 5 6 7
7. My parents do not seem to understand my stress 1 2 3 4 5 6 7
8. My parents do not seem to know how to help me feel better 1 2 3 4 5 6 7
9. I feel alone here 1 2 3 4 5 6 7
10. I feel that there are no other Chinese students who I can rely on 1 2 3 4 5 6 7
11. I feel like I have no one to rely on 1 2 3 4 5 6 7
12. I feel that no one would know if something bad happened to me 1 2 3 4 5 6 7
13. I feel insecure living alone 1 2 3 4 5 6 7 14. I had to breakup with my significant other because we are so far apart 1 2 3 4 5 6 7
15. I feel helpless 1 2 3 4 5 6 7
16. I feel there is nobody I am close with 1 2 3 4 5 6 7
17. I feel insecure 1 2 3 4 5 6 7
18. I feel lonely 1 2 3 4 5 6 7
19. I feel bored 1 2 3 4 5 6 7
20. I fail to achieve academic plans 1 2 3 4 5 6 7
21. My academic workload is heavy 1 2 3 4 5 6 7 81
22. I feel that there are not opportunities to hangout and socialize 1 2 3 4 5 6 7 23. I feel that I have too much reading 1 2 3 4 5 6 7
24. I feel that I have extra obligations as a graduate assistant 1 2 3 4 5 6 7
25. I have very high academic stress 1 2 3 4 5 6 7
26. I feel that my academic stress now is much higher than in China 1 2 3 4 5 6 7
27. I cannot get the grades that I want even though I put a lot of time 1 2 3 4 5 6 7 and effort
28. I think that my time and effort in classes does not pay off 1 2 3 4 5 6 7
29. I feel frustrated about my grades 1 2 3 4 5 6 7
30. I feel upset about my grades 1 2 3 4 5 6 7
31. I do not get good enough grades 1 2 3 4 5 6 7
32. I wake up at night thinking of unfinished projects 1 2 3 4 5 6 7
33. I cry when I think about my unfinished projects 1 2 3 4 5 6 7
34. My American classmates get much higher grades with less effort 1 2 3 4 5 6 7
35. I get low grades on papers even though I spend so much time on 1 2 3 4 5 6 7 writing
36. American professors have little compassion for my struggles 1 2 3 4 5 6 7
37. American students have little compassion for my struggles 1 2 3 4 5 6 7
38. My professors do not know how to teach Chinese students 1 2 3 4 5 6 7 effectively
39. My professors ignore me 1 2 3 4 5 6 7
40. I think about all of the tuition I have paid 1 2 3 4 5 6 7
41. I care about my academic success 1 2 3 4 5 6 7
42. I feel exhausted from studying 1 2 3 4 5 6 7
43. I think about quitting attending college in the United States 1 2 3 4 5 6 7
44. I feel that I have more pressure than the other American students 1 2 3 4 5 6 7
45. I am not included in class discussions 1 2 3 4 5 6 7 82
46. American students avoid talking with me 1 2 3 4 5 6 7
47. American students know my English is not good 1 2 3 4 5 6 7
48. There are few Chinese here to make friends with 1 2 3 4 5 6 7
49. It is hard to find good Chinese friends 1 2 3 4 5 6 7
50. I cannot find good friends 1 2 3 4 5 6 7
51. I feel that being friends with Americans is not fun 1 2 3 4 5 6 7
52. I feel so different from Americans 1 2 3 4 5 6 7
53. I cannot form deep friendships with Americans 1 2 3 4 5 6 7
54. it is hard to find commonalities with Americans 1 2 3 4 5 6 7
55. I find it hard to merge with American culture 1 2 3 4 5 6 7
56. I feel uncomfortable to hanging out with Americans 1 2 3 4 5 6 7 57. It is hard to make friends with Americans outside of class or work setting 1 2 3 4 5 6 7
58. I do not have good relationships with my classmates 1 2 3 4 5 6 7 59. I feel my classmates and I do not make plans to hangout after school 1 2 3 4 5 6 7
60. I feel that I do not enjoy making friends as much as I used to 1 2 3 4 5 6 7
61. I feel that making friends with Americans is stressful 1 2 3 4 5 6 7
62. Transportation is not convenient 1 2 3 4 5 6 7 63. I have no vehicle to go around. 1 2 3 4 5 6 7
64. I do not have friends or family to help me with transportation 1 2 3 4 5 6 7
65. It is hard to access stores. 1 2 3 4 5 6 7
66. Everything is America is spread out 1 2 3 4 5 6 7
67. There is not enough convenient public transportation 1 2 3 4 5 6 7
68. It is not easy for Chinese students to pass the driving test 1 2 3 4 5 6 7
69. I feel stress because I depend on parents’ financial support 1 2 3 4 5 6 7
70. I am stressed because I cannot get financial aid and loans 1 2 3 4 5 6 7 83
71. I express my down feelings to my family 1 2 3 4 5 6 7
72. I feel that my parents do not understand my problems in the US 1 2 3 4 5 6 7
73. I feel I would make my parents worry if I talk to them about my 1 2 3 4 5 6 7 problems
74. I cannot do things for my parents because of the distance. 1 2 3 4 5 6 7
75. I feel bad because I cannot help my parents 1 2 3 4 5 6 7
76. I think that health services in clinics and hospitals is shockingly 1 2 3 4 5 6 7 expensive
77. I think that health insurance is very expensive 1 2 3 4 5 6 7
78. I use the health services 1 2 3 4 5 6 7
79. I feel the medical professionals do not seem to be very 1 2 3 4 5 6 7 professional
80. I feel like a lab rat when I visit the health care center 1 2 3 4 5 6 7
81. I think the health services are not convenient 1 2 3 4 5 6 7
82. If I am ill, I feel the treatment is not available in a timely 1 2 3 4 5 6 7 manner.
83. I think it takes too long to see a doctor for an illness 1 2 3 4 5 6 7
84. I do not go to the health care center even when I am ill 1 2 3 4 5 6 7
85. I tolerate the illness until I can no longer tolerate it. 1 2 3 4 5 6 7
86. Speaking English is tiring for me 1 2 3 4 5 6 7
87. It is not comfortable for me to talk in English 1 2 3 4 5 6 7
88. I think that my English is not good enough. 1 2 3 4 5 6 7
89. I feel that the English I learned in China did not serve me well 1 2 3 4 5 6 7 for daily communication in the USA
90. When it comes to counseling, I feel that I cannot communicate 1 2 3 4 5 6 7 well with American counselors
91. I feel stressed if I cannot express myself well with American 1 2 3 4 5 6 7 therapists
92. The food here is unfamiliar to me 1 2 3 4 5 6 7 84
93. I do not know how to order food at restaurants 1 2 3 4 5 6 7
94. I prefer to eat at home 1 2 3 4 5 6 7
95. I go to the same restaurants if I go out to eat 1 2 3 4 5 6 7
96. I order the same things if I go to non-Chinese restaurants 1 2 3 4 5 6 7
97. The food here is not tasty 1 2 3 4 5 6 7
98. I have much less variety in foods I can eat in the US. 1 2 3 4 5 6 7
99. The food here is very high in calories 1 2 3 4 5 6 7
100. The food here is very sweet 1 2 3 4 5 6 7
101. I am not used to the food here. 1 2 3 4 5 6 7
102. I do not have a plan for the future after I graduate 1 2 3 4 5 6 7 103. I do not have anyone who can give me advice about the future. 1 2 3 4 5 6 7 85
Table C2 (The USCIS Chinese Version)
1 2 3 4 5 6 7
1. 1 2 3 4 5 6 7
2. 1 2 3 4 5 6 7
3. 1 2 3 4 5 6 7
4. 1 2 3 4 5 6 7
5. 1 2 3 4 5 6 7
6. 1 2 3 4 5 6 7
7. 1 2 3 4 5 6 7
8. 1 2 3 4 5 6 7
9. 1 2 3 4 5 6 7
10. 1 2 3 4 5 6 7
11. 1 2 3 4 5 6 7
12. 1 2 3 4 5 6 7
13. 1 2 3 4 5 6 7
14. 1 2 3 4 5 6 7
15. 1 2 3 4 5 6 7
16. 1 2 3 4 5 6 7
17. 1 2 3 4 5 6 7 86
18. 1 2 3 4 5 6 7
19. 1 2 3 4 5 6 7
20. 1 2 3 4 5 6 7
21. 1 2 3 4 5 6 7
22. 1 2 3 4 5 6 7
23. 1 2 3 4 5 6 7
24. 1 2 3 4 5 6 7
25. 1 2 3 4 5 6 7
26. 1 2 3 4 5 6 7
27. 1 2 3 4 5 6 7
28. 1 2 3 4 5 6 7
29. 1 2 3 4 5 6 7
30. 1 2 3 4 5 6 7
31. 1 2 3 4 5 6 7
32. 1 2 3 4 5 6 7
33. 1 2 3 4 5 6 7
34. 1 2 3 4 5 6 7
35. 1 2 3 4 5 6 7 87
36. 1 2 3 4 5 6 7
37. 1 2 3 4 5 6 7
38. 1 2 3 4 5 6 7
39. 1 2 3 4 5 6 7
40. 1 2 3 4 5 6 7
41. 1 2 3 4 5 6 7
42. 1 2 3 4 5 6 7
43. 1 2 3 4 5 6 7
44. 1 2 3 4 5 6 7
45. 1 2 3 4 5 6 7
46. 1 2 3 4 5 6 7
47. 1 2 3 4 5 6 7
48. 1 2 3 4 5 6 7
49. 1 2 3 4 5 6 7
50. 1 2 3 4 5 6 7
51. 1 2 3 4 5 6 7
52. 1 2 3 4 5 6 7
53. 1 2 3 4 5 6 7
54. 1 2 3 4 5 6 7
55. 1 2 3 4 5 6 7 88
56. 1 2 3 4 5 6 7
57. 1 2 3 4 5 6 7
58. 1 2 3 4 5 6 7
59. 1 2 3 4 5 6 7
60. 1 2 3 4 5 6 7
61. 1 2 3 4 5 6 7
62. 1 2 3 4 5 6 7
63. 1 2 3 4 5 6 7
64. 1 2 3 4 5 6 7
65. 1 2 3 4 5 6 7
66. 1 2 3 4 5 6 7
67. 1 2 3 4 5 6 7
68. 1 2 3 4 5 6 7
69. 1 2 3 4 5 6 7
70. 1 2 3 4 5 6 7
71. 1 2 3 4 5 6 7
72. 1 2 3 4 5 6 7
73. 1 2 3 4 5 6 7
74. 1 2 3 4 5 6 7
75. 1 2 3 4 5 6 7 89
76. 1 2 3 4 5 6 7
77. 1 2 3 4 5 6 7
78. 1 2 3 4 5 6 7
79. 1 2 3 4 5 6 7
80. 1 2 3 4 5 6 7
81. 1 2 3 4 5 6 7
82. 1 2 3 4 5 6 7
83. 1 2 3 4 5 6 7
84. 1 2 3 4 5 6 7
85. 1 2 3 4 5 6 7
86. 1 2 3 4 5 6 7
87. 1 2 3 4 5 6 7
88. 1 2 3 4 5 6 7
89. 1 2 3 4 5 6 7
90. 1 2 3 4 5 6 7
91. 1 2 3 4 5 6 7
92. 1 2 3 4 5 6 7 90
93. 1 2 3 4 5 6 7
94. 1 2 3 4 5 6 7
95. 1 2 3 4 5 6 7
96. 1 2 3 4 5 6 7
97. 1 2 3 4 5 6 7
98. 1 2 3 4 5 6 7
99. 1 2 3 4 5 6 7
100. 1 2 3 4 5 6 7
101. 1 2 3 4 5 6 7
102. 1 2 3 4 5 6 7
103. 1 2 3 4 5 6 7 91
APPENDIX D: DEMOGRAPHIC QUESTIONNAIRE The following questions ask for you to provide a wide range of information about yourself such as: gender, age, degree in progress, etc. As always, your responses to these questions will be kept completely confidential. We ask that you be as honest as possible throughout the survey.
Date: participant number (to be filled out by researcher): Email address:
l Age: l Gender: l Male l Female l Others:_____ l What is the city you grew up in: l What is your degree in progress? 1. Undergraduate 2. Master 3. Doctoral 4. Post-doctoral 5. Others:_____ l Length of time in the United States: ______month (s) l Financial support 1. Parents 2. Graduate stipend 3. Self 4. Others: _____ l Relationship status 1. Single 2. In a relationship 3. Married 4. Divorced 5. Separated 6. Widowed 7. Others: _____ l Your scores on Test of English as a Foreign Language (TOEFL) or International English Language Testing System (IELTS): l Your previous experience with stress management workshop: l Religion 1. Christian 2. Catholic 3. Buddhism 4. Taoism 5. Not religious 6. Others: _____ 92
APPENDIX E: ACCEPTANCE AND ACTION QUESTIONNAIRE II 1 2 3 4 5 6 7
」 a
1. 为 1 2 3 4 5 6 7 a
2. 1 2 3 4 5 6 7
3. c 1 2 3 4 5 6 7
4. 1 2 3 4 5 6 7
5. 1 2 3 4 5 6 7
6. 1 2 3 4 5 6 7
7. 之 中 1 2 3 4 5 6 7 93
APPENDIX F: DEPRESSION ANXIETY STRESS SCALE-21 b a T — S S c 两 aS
c 」 1 2 3 4
1. 」为 b 1 2 3 4 2. 1 2 3 4 3. c 1 2 3 4 4. 为 c c 1 2 3 4 5. 」为u — 1 2 3 4 6. 1 2 3 4 7. 乐 1 2 3 4 8. 」 1 2 3 4 9. e 1 2 3 4 10. y 1 2 3 4 11. c 1 2 3 4 12. 」为 1 2 3 4 13. p 1 2 3 4 14. 中 1 2 3 4 15. 1 2 3 4 16. 与 1 2 3 4 17. c y 1 2 3 4 18. 」 1 2 3 4 19. c 1 2 3 4 20. 1 2 3 4 21. 1 2 3 4 94
APPENDIX G: CHINESE VERSION PATIENT HEALTH QUESTIONNAIRE -15 — ( b 乏 」
0 1 2
0 1 2
不 0 1 2 ( d 乏 0 1 2
) 0 1 2
0 1 2
0 1 2
, 两 0 1 2
- 」 0 1 2
c 0 1 2
乏 0 1 2
（ 0 1 2
c 0 1 2
( 0 1 2
) 乏 0 1 2 95
APPENDIX H: CHINESE VERSION COGNITIVE FUSION QUESTIONNAIRE
1 2 3 4 5 6 7 c c c r两
1. 1 2 3 4 5 6 7 2. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 4. r 1 2 3 4 5 6 7 5. t 1 2 3 4 5 6 7 6. 」 1 2 3 4 5 6 7
7. b 1 2 3 4 5 6 7 96
APPENDIX I: NEWLY DEVELOPED ACCEPTANCE AND COMMITMENT THERAPY PROTOCOL
Acceptance and Commitment Therapy for Chinese International Students
Mindful Behavior Therapy and Psychophysiology Lab (MAPLab) Bowling Green State University Overview of Acceptance and Commitment Therapy Intervention Components
______Session 1 • Discuss and develop rules about confidentiality and levels of disclosure • Discuss symptoms or signs of acculturative stress or stress in general • Discuss ways individuals have tried to control feelings of stress and level of success • Discuss control agenda and why it does not work within the body • Introduce willingness and acceptance as alternative to control • Identifying stress buttons • Homework
Session 2 • Discuss homework assignment • Review acceptance as alternative to control • Introduce cognitive defusion • Discuss self as context • Discuss values/Clarify values • Discuss value based actions/Fill out Values Assessment Ratings Form • Public pledge to committed value based action
______97
Session 1 – Week 1
Introduction l Welcome the participants l Importance of this study. l Acculturative stress is common among Chinese international students l We have conducted focus groups in the past, and identified unique stressors for this population. l Therapist (myself) as a Chinese international student have experienced some challenges myself. l We are here to help and be present for you as a person to assist and also to learn.
-Overview of sessions • Program consists of 2, 2 hour sessions (Today and next ______) • We ask two things of you o 1. Please come to both sessions o 2. Please do not talk to other Chinese international students about this program (Explain some aspect of contamination of treatment) • Introduce idea of workability: o Maybe you have ways of handling stress that work just fine. In this case, we are trying to add some other tools to your toolbox. We are offering these as suggestions.
- Group Get to Know Each Other • Before we begin, we would like to take a moment to go through introductions. We know you may know each other, but if you could just humor us. • Leader introduce herself first.
------Confidentiality
• We commit to keeping the content of these workshops private. o We will not disclose and ask you do the same o Please only discuss your own experiences with others
• We commit to showing up psychologically when we are willing(optional) o Being engaged and present – this is different from disclosing o Again, we want to be really clear that this is optional. If you are not willing to be engaged and present with the material and your experience of it, that is your choice…. This brings us to the part that is not optional…
• We commit to creating a space for others to ‘show up’ psychologically (not optional)….all of the other commitments really fold into this one… 98
o Confidentiality. It is important, because trust in confidentiality makes it possible for people to feel willing to share themselves more fully. o Not Rescuing. We will listen to the experience of other people. We will not rescue people. If someone is struggling or having difficult feelings, we will allow space for this. Often we try to comfort people because we feel uncomfortable with pain. In this space, we will allow people to feel what they feel without trying to change it or comfort them in the moment.
• We Commit to the possibility that this workshop could be transformational and facilitate a powerful shift in the way you view and live your life.
“These commitments are so important that we ask that you use your time for other things if you cannot abide by them. If you are not prepared to make this sort of commitment at this time, that is completely fine. We will not evaluate or judge this decision; instead we can all appreciate your willingness to be honest about this. For the next few minutes take some time to reflect on whether you are ready to make this commitment with the group today. If you are not, please use this time to excuse yourself.” [pause - - allow time for people to leave] ------
What is acculturative stress? (examples written on white board)
Prompt for the acculturative stressors identified from the focus groups. “Before this, I have met with 20 Chinese international students and talk with them about the stressors they experience. Here, I would like to share what we discussed with you”
Loneliness Academic Stress Social Difficulty Difficulty with Transportation Financial Burden Distance from Family Lack of Familiarity of the Health Care System Language Barriers Food Concerns for Future
How do you respond to the stress? 99
Responses are noted on a whiteboard. After several people provide examples, make sure the following are covered: physical (e.g., sleep loss), mood (e.g., irritability), thinking (e.g., poor memory), and action signs (e.g., crying) of stress.
Appraisal
Event Response
Physical/ Emotional Reaction
“One way of looking at the stressors you described is illustrated here. It starts with some event. As you described (use participant examples such as class assignment, seeing some people go out and not inviting you, seeing the moon at night and thinking about how far away from home you are, seeing that its Saturday night and you are alone in your room or apartment, noting the professor not look at you, etc.). This event is appraised or evaluated by your mind. And that appraisal can affect the perceived importance of the event. It can make it seem bigger or smaller, right or wrong, good or bad, happy or sad. Our minds do this all the time and automatically. The emotional and physical reaction to the event are a result of the event and the appraisal. Sometimes, but very rarely its almost all the event itself (like a loud sound that startles you). Most of the time, the physical and emotional response is a result of the appraisal and many times is it almost 100% appraisal (provide an example from the group that demonstrates how appraisals affect response). Finally, the appraisal and the physical/emotional reaction then affect how you respond to the event. Importantly your response can be outside or overt (actions you take that affect others or the environment), inside or covert (actions you take that that affect your ways of thinking or feeling), or both.
In ACT, we focus on the appraisal process and how we may be able to work with that to change emotional and physical experiences. We also focus on changing the responses we make in the presence of thoughts and feelings.
What are your thoughts about this?”
Allow discussion. 100
• Kitchen sink metaphor • “Consider for a moment that you are a bathroom or kitchen sink. The sources of stress that we have just discussed are like taps that can pour water (or stress) into a sink, and the more taps that flow, the more water there is that is poured into the sink. Now, under most circumstances, the sink will become overwhelmed with water and overflow, causing damage. The goal of these stress management sessions is not to stop the water from flowing, but rather, to help you unplug your sinks so that the stress that you encounter will not overwhelm you.”
Beginning ACT
Since most people believe that distressing thoughts and feeling interfere with effective and enjoyable living, the participants have probably spent a great deal of effort trying to get rid of it. Examples of this effort are elicited from the participants. For example, they may have tried to avoid, change, justify, rationalize, deny, ignore, or tolerate. In order to elicit these examples, the trainer asks a question, such as,
• “How have you tried to deal with your (anxiety, unhappiness, worries [e.g., unwanted psychological content])?”
It is likely that the participants will respond to this question by listing a number of popular and culturally reinforced methods. These might include alcohol, relaxation training, religion, meditation, avoidance, social reassurance, distraction, positive thinking, analyzing the situation, and maybe even psychotherapeutic techniques that involve changing one’s beliefs. (WRITE THESE ON WHITE BOARD OR DISCUSS THEM OPENLY)
Question prompts asked in first intervention. Optional: “Why do we do this?” A: To avoid negative feelings. “What are the consequences?” Not in present moment (this leads to next section well)
Workability “And…how has that worked?” l Focuses on direct results: pay attention to your experience! What does it tell you? l It's not about what should work: our minds will say a lot of things about what should work. Eg., telling myself I'm a good person should make me feel like a good person. ; telling myself to feel better and count my blessings should make my bad feelings go away. But my experience might tell me something different. Elicit examples from the group members about things that they think should work, but really don't. l Note examples from your own life or examples of therapy or general observations. For example, the idea that a person may think themselves to be fat and never feel thin enough even when they are objectively thin and others tell them they are thin. Or, a person who feels insecure in a relationship may ask over and over “do you love me” to their partner. 101
And may text over and over. Or may check in over and over on their partner like “where are you?” “what are you doing?” The partner may tell the person, that their questions are not good for the relationship and may even become more distant. This, in turn causes the person to text more, ask more. This is an example of how sometimes the mind produces solutions that are not working and the evidence is there that it is not working (the statements from the partner) but the person keeps doing the same thing. The rules have not delivered the desired result. How have you noticed this in your own life?” l “Ask yourself: have your rules delivered? If you do what your mind tells you (if you follow your verbal constructions), are the consequences you actually experience in line with those rules?”
To determine how helpful their mind has been, the trainer asks how the participants’ favored experiential avoidance strategies have assisted them in altering the form of, frequency of, or susceptibility to their negative experiences. Note, the examples do not have to be only from the current acculturative experience, but from lifelong strategies for managing stress.
• “How have your control strategies changed your vulnerability to (negative experience)?”
Doctor Metaphor • “If you went to a doctor that was treating us for illness and he tried different drugs, increased/decreased dosages and nothing worked, would we still go to him? • Your mind tells you to go along with what it’s telling you • Which will you go with: Your mind or your experience? • Up until now the answer has been “your mind,” but just notice what your experience tells you about how it has worked.”
Conversations such as these are conducted with several members of the group, and it is always emphasized that listening to one’s mind is not always effective in relieving the effects of stress, worry, unhappiness, etc. (and it’s not even always effective in helping people to achieve the goals that they wish to accomplish.) After three of these conversations, the trainer speaks as follows:
Control is the Problem
• “We do what our minds tell us to do about our thoughts and feelings, but sometimes it does not seem to help. In fact, sometimes it can make it worse. • We can try so hard to control things, but there are some things that cannot be controlled.”
Polygraph metaphor: • “I had all of you hooked up to the best polygraph that’s ever been built. This is a perfect machine, the most sensitive ever made and will know if you are stressed or anxious 102
• So, I give you a task: All you have to do is stay relaxed. If you get the least bit anxious I will know it. • I want you to try hard and so does the machine, therefore it’s also hooked up to a gun. • If you just stay relaxed, the gun will not go off, but if you get nervous (and I’ll know it because you’re wired to this perfect machine) the gun will go off. • What would happen? WHY? • Here’s another way to think of what we’re talking about. If I hold a gun to your head and tell you to vacuum the floor, could you do it? • WHY? • Even if you are anxious or nervous, you can still control your behaviors. We would argue that your behaviors are always under your control, but your thoughts and emotions are not.
Love metaphor: • Pleasant thoughts can also not be controlled. Sometimes people tell others to “Just be happy!” or “if you are happy everything will fall into place”. But how hard is that sometimes to create positive emotions? • What if I asked you to fall deeply in love with the next person that walked into the room? • What would happen? WHY?
When you try to control, you are missing out in life
Monster Metaphor “Say now you’re in a tug of war with some huge monster that represents something you may struggle against sometimes (negative thoughts, feelings, etc). You’ve got one end of the rope, and the monster has the other end. In between you, there’s a huge bottomless pit. You’re pulling backward as hard as you can, but the monster keeps on pulling you ever closer to the pit. What’s the best thing to do in that situation?”
“Pulling harder comes naturally, but the harder you pull, the harder the monster pulls. You’re stuck. What do you need to do?
Dropping the rope means the monster’s still there, but you’re no longer tied up in a struggle with it. Now you can do something more useful.”
“What was this exercise like for everyone?” Ask for examples from the group. elicit examples for them to discuss. Eg. When you get invited to a party, you avoid going because you do not like what your mind would be telling you if you go, things like your English is bad, nobody likes to talk to you…
Willingness as an Alternate Strategy “We’ve seen how trying to control our thoughts, feelings, and other products of our mind is not a reliable or even helpful strategy for reducing our problems. But, what is the alternative?”
Pause. Discuss if somebody offers an answer. 103
1. “It’s willingness - willing to have an emotion or thought and not get rid of it, or alter it. If you are willing, then you can escape the inevitable consequences of control. 2. However, if you refuse to have an emotion or thought, usually you’ve got it. The control strategy doesn’t work and this strategy itself results in an increase in the events it is designed to prevent or avoid. 3. That is, the more you don’t want to be anxious, the more anxious you will probably become. 4. Willingness is NOT wanting – you do not have to want to have what you got (e.g. anxiety, depression) because isn’t it true that whether you want it or not you got it? 5. Willingness is NOT tolerating – Tolerance: “I will allow this to be here for NOW but it will be over and if I just bare it until it’s over everything will be okay””
Suffering vs. Excessive Suffering: l Suffering is the pain that we all experience in our lives as a function of living. Clean discomfort varies in level; it might be relatively low at times, as when we feel irritated at someone for putting us down, or it may be high, as when we have a major argument with our parents or we fail a course. l Life serves up painful events, and our painful reactions to them are natural and entirely acceptable. l It is when we are unwilling to accept these natural reactions- the clean discomfort-that we wind up with what we term excessive suffering. l Excessive suffering is emotional pain created by our efforts to control the normal, natural clean discomfort that we experience. That is, when we are trying to avoid, control, or get rid of the clean discomfort, a whole new set of painful feelings, emotions, and thoughts appear. l The excessive suffering is an unnecessary addition of pain on top of pain: fear of fear, guilt over guilt, shame over guilt, blame over fear, or blame over unhappiness. l Can the group brainstorm an example from your life as international students of how clean discomfort can be compounded by dirty discomfort? l This simple, additive process results in an increased likelihood that people will use control/avoidance strategies, and thus, carry on a vicious circle of trying to increase control and, therefore, increase pain. l Acceptance, or willingness, involves moving in the opposite direction: towards the pain, rather than away from it; towards the emotions, thoughts, and feelings that we dislike. Willingness helps clean out the dirty sufferings. This aligns with our strategy: we do not intend to change/alter what it is and how it is that you experience, we intend to monitor and modify how you react to it.
Quicksand metaphor: 1. “You walk in the desert and, suddenly, you step in quicksand. What do you do now? 2. What happens as you try to escape the quicksand. “how do you feel now” “what are the thoughts that come to your mind as you keep sinking?” 3. That will be hard because your mind is telling you to struggle but using this strategy is counterproductive. 4. Only by accepting the quicksand, spreading out your limbs, fully allowing yourself to get in contact with it, you would float up and be saved. What are your thoughts on this metaphor? 104
Sometimes it would be a better idea to accept and be willing to experience the things that you think bother you. “What happens when you start sinking in your anxiety?” p: you start to get entangled in those feelings and thoughts. “an alternative when anxiety hits is to let it be and not struggle with it.”
Willingness Exercise I: “Just Noticing” “Now, we are going to practice some acceptance strategies; strategies that encourage you to get into full contact with your bodily sensations, thoughts, and emotions, without struggling with them; without trying to control them; that is, without trying to make them go away or avoid them. Just like what you should do if you step in quicksand-- get fully in contact with what you are experiencing.”
Clouds in the Sky “I’d like each of you to sit comfortably and close your eyes while we do an exercise. I am going to ask you to “just notice” various things that happen inside your body and mind. Your goal in this exercise is to act as if you were watching a film or TV, that is, your goal is to “just notice” what is occurring in your body; it is not to change it, avoid it, or struggle with it in any way: it is just to notice it. Remember, you are watching a film or a TV; you are an audience member; you are not the director who controls what will be on the screen; your role is not that of the editor who takes away scenes that he or she thinks should not be seen or experienced; and your role is not that of the producer, who finances the film and decides whether or not it will appear at all. Rather, your job again is just “to notice” what is actually shown on screen, what your body and mind provide you with. Now, I’d like you to notice your breathing - see how your breath comes into your body, streams down into your lungs and goes back out of your body again. Remember, do not change how you are breathing, but just notice how you do it.
[This breathing observation continues for about 2 minutes. Meanwhile, the trainer says things like, “if you find your mind drifting away to other things just gently bring it back to just noticing your breathing”]
Now, I would like you to notice a bodily sensation that you may have right now. Maybe it’s a cramp, a tingling sensation, or a pleasant “warmth” in a muscle. Perhaps it may be in your legs, your arms, your neck, or your back. What I would like you to do is to focus on that bodily sensation, and without trying to stop it or alter it in any way, see whether the sensation stays the same or changes in any way. If it does change, just notice how it changes; if it does not change, notice that as well.”
[During the next two minutes or so, the trainer says things like “if you find your mind drifting away to other things, just gently bring it back to just noticing your bodily sensations.”]
“Now, I’d like you to imagine yourself walking through a quiet, comfortable valley that is green and lush. The temperature and amount of sunshine is just how you like it. As you are walking through this valley, you see a patch of green grass on a hill and you decide to climb up the hill. You find a perfect spot and sit down on the hill. While sitting there, I’d like you to look into the sky and notice how blue the sky is. I’d also like you to notice how a group of white, 105 fluffy clouds moves across the sky, gently passing overhead. On these clouds, I’d like you to place any thoughts that you have and let the clouds hold your thoughts. Maybe the clouds will carry your thoughts across the sky away from your sight, or maybe the clouds will remain still over your head. Do not try to control the clouds. If you worry about how quickly the clouds are moving across the sky, or if they are moving at all, take that thought and put it onto a cloud.”
[During the five minutes that this part of the exercise is down, the trainer says things like, “If you find this difficult to do, that’s all right just put that thought on a cloud. If your mind wanders from the clouds and the sky, just bring it gently back to the clouds and place another thought on a cloud. If you are wondering whether or not you are doing the exercise “correctly,” place that thought on a cloud and watch it in the sky. Don’t worry if one cloud is moving faster than another, just notice that they’re moving at their natural pace”] “Now, I would like you to picture this room in your mind, see where in the room you are sitting, and imagine what you will see when you open your eyes, and, when you are ready, open your eyes.” [The trainer then asks, “How was this exercise for you?” If it does not come up during the discussion, the trainer next asks, “How does this exercise relate to what we have been discussing?” As should be evident, this “just noticing” exercise begins to show the participants how they can view and watch their thoughts and bodily sensations without having to alter them or stop them. The trainer also notes that this exercise is useful to do when people start to feel stress. Now, let’s spend some time talking about our personal signs of stress.]
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Identifying “Stress Buttons” (Provide pieces of paper and pens) stressors The participants are now asked to list on a piece of paper the various “stress buttons” that they have. They are told that these are situations, thoughts, emotions, or sensations that cause them stress. For example, it may be that confused and inadequate feelings in class, situations they need to communicate in English, thoughts they have when they see the school tuitions, when they receive less than ideal grades, or shallow breathing trigger a stress reaction. Discuss with participants that these stress reactions typically elicit a feeling of unwillingness in most people. Ask participants what people do when they’re unwilling to have the negative feelings. If it doesn’t come up, explain that most people react by using control strategies. Before they start writing down these “stress buttons,” the participants are asked to share, with the group, examples of their own triggers, in order to model what is expected. After several people have identified some of their own stressors, questions are elicited, and then participants write down their own “stress buttons.”
Talk about the stressors identified from focus groups again.
Loneliness Academic Stress Social Difficulty Difficulty with Transportation Financial Burden Distance from Family 106
Lack of Familiarity of the Health Care System Language Barriers Food Concerns for Future
“Now that we know what elicits negative feelings in each of us, let’s practice being willing to experience negative feelings.”
Willingness Exercise II: Index Card Demonstration Leaders will have these in bag and demonstrate this activity until the participants understand.
Group members are divided into pairs, and one half of the pair volunteers to pick a difficult private experience with which he or she is willing to do something playful and interactive (Do not have to say it aloud). The other half of the pair is referred to as "Life" and assists the volunteer with the exercise. The volunteer is given a card (e.g., a 3 x 5 index card) on which to write the private experience (the stress buttons), which can be represented by a symbol instead of a word if he or she does not want it to be known to his or her partner. The pairs are asked to find a place in the room where they can have a little bit of space to interact. The facilitator says the following: “Volunteers, please hand your card to Life. Face each other standing about 1.5 meter apart. Life, hold the card up with one hand so that it's facing your partner. Volunteers, take a good look at the card: this is your pain. Notice your immediate reactions to it. I'm going to ask you to interact with it in a variety of ways. This exercise will be a little bit physical, so everyone should make sure to be careful. We don't want to add any new injuries to the pain you already have! First, I would like you to gently press your hand against the hand of Life, holding the card between your hands… Now, add a little pressure.… Put a little bit more pressure on… Notice what happens in your body as you try to push the pain away.… Notice all the effort this takes… Now back off the pressure… Go back to just holding the card between your hands… Tell me, has the card gone away?” “So, isn’t it true that you can have the thought as just a thought, and not have to struggle against it?”
[at this point, questions and comments are invited]
-Closing
“Next week, we are going to spend more time talking about how to move towards your values instead of struggling with thoughts.”
Ask the participants to carry their card in their pocket for the upcoming week.
Homework: For homework, participants are asked to do the following: • Notice, in the week between sessions, how cognitive avoidance, cognitive struggle, and a lack of awareness of what they are thinking (or cognitive fusion) interferes with life, when their “stress buttons” have been pressed. 107
• Spend at least 10 minutes each day doing the “just noticing” exercise. • The goal is not to determine if what you observe is truthful, but rather to simply observe. • Bring your stress buttons to the next session.
These two homework assignments are written down on paper and handed out to the participants at this time. Any questions regarding the homework are taken and answered.
Session II – Week 2
• Review: personal information and content discussed is confidential • Can leave any time, for any reason, without being reported to anyone • Discussion of homework: o Did you notice any times you were trying to control your thoughts/feelings? o Did you do any “paying attention on purpose”?
Review acceptance as alternative to control “willingness is to let go, to not try to control.” “control and avoidance would both limit your life.” (revisit Monster metaphor from session I briefly). Another metaphor could illustrate the same idea:
Birds metaphor “Say that now you have a huge and beautiful yard, and you have always loved flowers and plants. Therefore, you decided to build up your own garden. You plan to plants all kinds of flowers, and maybe build a pound too so you could have some goldfishes in there. One day, you got all the tools you need to start the work, and the weather is great. So you walked out there in your yard, but only to hear some loud noises. You looked up, and see so many random birds in the sky above your yard, and they are just yelling and flying around. You immediately get so annoyed. You might decide to fight with them, or you decided to work another day. But if you fight with them, they always come back, you end up fighting with them all day. If you think maybe tomorrow they would be gone. The next day, you see them again, and the next day, and then the next few days. Finally, you realize you cannot get rid of them, nor would they ever leave, they will always be around. Whenever you walk out there and start your work, they will be there. What would you do in this situation?” “Obviously, if you keep fighting with these birds, you would not ever have time to work on your garden. Or if you avoid going out there because you do not want to deal with the annoying birds, you would not ever achieve the plan to have this amazing garden. Either way, you are missing out and watching what you value (the garden in this case) drafting away.”
“what is the best you can do in this situation?” p: “accept the fact that those birds would be there and they are annoying. And still go out there and start working on the garden while having those birds in the background.” 108
“If you listen closely, these birds are actually trying to talk to you. They shout that ‘you are not good enough’ ‘you always give up anyways’ ‘oh just give up’ ‘you cannot accomplish it after all’. The birds are your pain, your struggles. What would you do? Is it possible that you accept the fact that the birds will be there, and you know you want to work on your yard and so you are going to?”
“What do you think about this exercise? Do you have any similar experiences?” (Try to lead participants to say that thoughts usually keep coming back – bum’s chums.)
“During this workshop, we’ve talked about being willing to experience our thoughts and feelings as they are, that is, thoughts and feelings, and not what they say they are (e.g. life-limiting stress, terrible things that must be avoided). If we focus on trying to control those thoughts and feelings, we are missing out in life. for most people, we understand it is hard sometimes to not to control, just like it is hard to resist not listening to our “mind” while we have been listening to it for years. therefore, now we’re going to spend some time talking about how to make it easier to be willing to face all of these negative thoughts and feelings and why willingness is important.”
Pen in the hand metaphor “We’re going to start with a little demonstration. Can I have a volunteer? [Approaches volunteer]. In order to demonstrate this valuable lesson to the group, I need to jab this pen in your hand. Would it be ok if I did that?”
P: No—that’s not ok.
“Let’s say that, by some miracle, you have the power to stop all the hunger in the world. Only you have this ability- to make sure that everyone in the world gets food. But, in order to make that happen, you have to be willing to let me put this pen in your hand. Would it be ok for me to jab this pen in your hand now?”
P: Yes....
“Why? Isn’t it interesting that we can be willing to say yes to the most painful or extraordinary circumstance if we are doing it for a purpose? And that’s what we’re going to spend more time talking about. We’ll practice willingness to experience unpleasant feelings and clarify our own personal values and purposes.”
Letting go of the struggle (1st strategy to facilitate acceptance)
“Based upon this concept of willingness, I would like you to consider a very important question: are you willing to feel, think, and experience the negative things you struggle with in order to live a life that you value? This question is the core of what we have been doing. It is a question that we can never stop asking ourselves, because willingness is not an outcome, it is a process. Willingness is a choice to do something.” 109
In our daily life, there are some “happiness traps” that we fall in: we believe we can only be happy if everything happens the way we want them to. Next, I would like to give some metaphor to illustrate the reasons why this way of thinking is a trap.
Faucet Metaphor “Say for some reason a plumber comes to your apartment and fixes the faucet but it is different from all of the other faucets you use. Instead of turning to the left (counter clockwise) to get the water to flow, you have to turn it to the right. Now, when you use this sink, you may find yourself forgetting this and starting out by turning to the left, but no water comes out and then you remember and have to turn it right. This may be frustrating and you may even curse or swear or get angry at the sink for not being “right” and making you do the “wrong” thing. A very stubborn person may even say I am not going to use this sink because I get so mad about it being “wrong” or broken.
However, the sink is simply a sink and the faucet is neither right or wrong, you just need to adjust your behavior for this particular sink. That’s all there is to it. Our anger, frustration, stubbornness comes not from the sink, but from judgements about right or wrong. And, all that one has to do is simple adjust behavior to match to way that the sink works.”
Now in life this sort of thing happens all the time. For example, in relationships I sometimes hear people describe feeling angry or upset with a friend who is not “reciprocal” enough. That is, they feel like to give a lot and receive less in return. And, it upsets them because the friend is “wrong” to not give back equal amounts. Sometimes, they stop being friends over this. The problem here is not about being reciprocal. The problem is that one person is applying the right wrong rule differently than the other. Perhaps it is possible to not apply the rule and still have the friendship. We do this all the time with cats as a pet. They are not at all reciprocal. They come and go and sometimes give affection and sometimes not. Many people even like that about cats. Suppose with a friend one does the same thing. Instead of calling the friend “wrong” one merely accepts them as a “cat friend?”
But l I’d like to talk about the word “but” for a moment. It’s a funny little word that can draw us into a struggle with our thoughts and feelings. l For example, “I want to be a good student but I always feel unmotivated to do school work.” In this example, we end up putting one set of private events (e.g. intention to be a good student) against another (e.g. feeling unmotivated). l “But” literally means what comes after the word “but” negates or contradicts what comes before it. So, in our example, we are saying that being unmotivated negates intention to be a good student. As you can see, “but” is literally a call to fight. It pulls us into the war zone with our own thoughts and feelings. l Is it true that those things are REALLY opposites? Do you really no longer care about your school work when you feel unmotivated? l So, I’d like everyone to be aware of this when you use the word “but” and then substitute it for the word, “and”. This switch may make you more sensitive to one of the ways that language can pull us into a struggle with our thoughts and feelings, creating more stress. 110
What are people’s thoughts on all of this? All events have good and bad, one cannot separate the parts.
Self-As-Context Exercise (2nd strategy to facilitate acceptance)
“Think of your thoughts and feelings as chess pieces on a chessboard. Think of the white pieces as the thoughts and feelings you want (e.g., "confidence", “happiness”, “self-esteem”), and the black pieces as the thoughts and feelings you don't want (e.g., “anxiety”, “fear”, “self-doubt”, “hopelessness”). If you prefer, you can think of the black pieces as the desired thoughts and feelings, and the white pieces as the undesired ones.
One thing we humans do is try to defeat the black pieces. We want to get rid of our negative thoughts and feelings. So we go to war. At difficult times in our lives, it looks like we’re losing—the black pieces knock most of the white pieces off the board. At other times it may look like we are winning. We knock many of the black pieces off the board.
But look closely at your experience. What happens when you knock those black pieces off the board? Do they stay off forever, or do they come back sooner or later? Or do you find sometimes that new black pieces take the place of some of the old ones? It’s like a war that rages forever, with no end in sight.
The problem is, when we wage this war, we wage it against ourselves. When we battle the black pieces, we battle a part of our experience, a part of ourselves. We literally set up a situation where, in order to get on with life, large parts of our actual experience must disappear forever. This war carries a heavy cost. We can become absorbed with our internal struggles, and disconnected from the outside world and the things in life that matter most to us. We can become so absorbed with our internal struggles that we don't "see" the outside world.
But what if it’s possible to let go of the fight? What if you are the chessboard in this metaphor? Regardless of how the war between the black pieces and white pieces turns out, is the chessboard affected or damaged in any way? Or is the chessboard simply an arena where match after match can play itself out—and the board remains solid and intact, ready for whatever comes next. In the picture above, you could imagine the man lifting his head up and walking in any direction he wants to, regardless of what the chess pieces above are doing. Similarly, you are simply an arena where the thoughts and feelings appear. What if you could focus your energy on doing what you want, and carrying the positive and negative thoughts with you?
Remember, there is a distinction between your thoughts and your observer self. Think of the observer as being the chess-board—as being you. Think of your thoughts and feelings as being the chess pieces. The chess board carries the pieces, but it is not equal to the pieces. Similarly, you carry your difficult thoughts, you observe those thoughts, but you are not equivalent to those thoughts.”
(OPTIONAL) 111
House Metaphor You are ever changing like a house. The furniture may change, the paint may change, things inside will change.
Sky Metaphor Changing like the sky – always different kinds of weather, hurricanes, tornados, snow storm, sunshine, may be night time or day time.
What were people’s experiences of this exercise? [T: try to reinforce participants’ experiences of the observer. Ask participants’ about their experience with the observer]
Cognitive Defusion-The “Milk, Milk, Milk” Exercise (3rd strategy to facilitate acceptance) T: Let’s do another exercise. I’m going to ask you to say a word. Then you tell me what comes to mind. I want you to say the word, “milk.” Say it once. P: Milk T: What came to mind when you said milk?
[Listen for responses; prompt participants to talk about their experience of milk—prompt for the psychological experience of milk. For example: • Did any of you imagine what milk looks like? If so, ask participant to elaborate. • Could anyone taste milk? If so, ask participant to describe this. o Could anyone imagine what a gulp of milk is like? • Did anyone think of any sounds associated with milk? Ask participants to elaborate ]
Right, when you said the word milk, you could…see it, taste it… (use participants description of milk. Example: …you could almost see it and taste it…you can imagine what it might feel like to drink a glass. Cold, creamy, coats your mouth, goes glug, glug when you drink it. )
Let’s see if this fits: what shot through your mind were things about actual milk, and your experience with it, and all of that happened when we just said and thought the word “milk.” Incredible isn’t it? We weren’t looking at or drinking any milk. Yet we were able to experience milk psychologically. You and I were seeing it, tasting it, feeling it, and all these experiences were prompted by the word milk- not the actual thing.
Now, here is the little exercise, if you’re willing to try it. It’s a little silly, but I am going to do it with you so we can all be silly together. What I am going to ask you to do is to say the word “milk” out loud, rapidly, over and over again and then notice what happens. Are you willing to give it a try? Let’s go. Say “milk” over and over again. [Trainer periodically interjects comments like: “As fast as you can until I tell you to stop. Faster! Keep going faster! Do this for enough time that you cannot hear the word milk anymore]
OK, now stop. Did you notice what happened to the psychological aspects of milk that were here a few minutes ago?
[Solicit participant responses] 112
Right, the creamy, cold, gluggy stuff [or use participants descriptions from above] just went away. The first time you said it, it was as if “milk” were really meaningful; it was almost solid. But, when you said it again and again, you begin to lose the meaning and the words milk, milk, milk were reduced to sounds. So, when you say things to yourself, in addition to any meaning behind those words, isn’t it also true that these words are just words? The words are just smoke; there isn’t anything solid to them.
For example, consider the words, “I feel so stressed.” Just the word stress can evoke the psychological experience of stress. But, isn’t it also true that you can say “stress, stress, stress, stress,” just like “milk, milk, milk.” What’s the difference? When you have a thought or feeling, it looks as though its more than what you’ve experienced it to be. It creates an illusion that it is what it says it is. But, no matter what the words are, they are just that: words. They are just symbols we experience.
Of course, they’re related to things; it’s not that the words are meaningless or will ever be meaningless, I don’t mean that.
What I mean is that when the illusion shows up, looking solid, you are not actually experiencing the real thing, that is, thinking “stress” is not the same thing as experiencing stress; saying milk isn’t the same as taking a sip of milk. In both cases, you are having a thought. Isn’t it possible to accept the thought as just a thought? Saying the word “milk” or “stress” doesn’t mean that milk or stress are near you. So, the problem isn’t the word stress, the problem is that you think the word is real, that you think it is not just an illusion, and so you struggle against it, even when you only just hear the word.
(Maybe use the word “FEELINGS” for the second part of the exercise)
THE MASTERS YOU SERVE (Commitment, Purpose driven)
“Ok, now that we’ve talked a lot about willingness to accept our unpleasant thoughts and feelings, let’s talk more about the purpose of doing so. As we talked about earlier with the pen exercise, it is easier to accept unpleasant feelings if doing so for a purpose. We call this purpose our values, or what we want to stand for. To live a valued life is to act in the service of what you value. The question is: What do you want your life to be about? Your experience and your current psychological dilemmas have probably shown you that living in the service of pain reduction is no way to live at all. So for example, for me, I value education. I am willing to accept the negative thoughts that came along with this process and there are a lot – not good enough, not smart enough, other people can do it better, mistakes, this is too hard, I can’t take this anymore, etc.
Understand that you have the power to live a valued life right now, without anything in your immediate environment changing, can be a scary place. If you can really be about whatever you choose, how do you know what you want to do? Well right now, at this very moment, you have all the tools you need to make meaningful and inspiring life choices for yourself. It’s just a 113 matter of choosing a direction and figuring out what you want your life to be about, what is important to you.”
(OPTIONAL) ATTENDING YOUR OWN FUNERAL Option to REFLECT TO SELVES if the group seems unwilling to write.
We’re going to now do an exercise that helps people answer this question. Some find this exercise hard, and you’re more than welcome to not participate at any time. When people die, what is left behind is what they stood for. Think of someone who is no longer alive but whose life you look up to and admire. Think of your heroes. Now see if it isn’t true that what they stood for is now, after their passing, most important. [Elicit personal examples. Chairman Mao]. What’s important is not their material possessions or their inner doubts. The values reflected in their lives are what is important.
If you could live your life so that it is consistent with what you would choose to have it be about from here until it is over, what would be evident? That is, what would be clear about the kind of life you led? The question is not about what you’ve done or expect to do. We ask this question in the form of what you would hope those close to you will see. If your life could be about anything; if it were just between you and your heart; if no one would laugh or say it is impossible; if you were bold about your innermost aspirations, what would you want to be about? And to be that – so powerfully- that it was evident to those around you? Take a moment now to settle in and become fully part of this experience. Keep in mind that if you are willing to do this exercise, it can be a powerful and emotional experience. It is not about “facing your death.” It is about facing your life. Part of what often prevents people from embracing a valued life is that any value carries with it knowledge of how finite our lives are. Avoiding that knowledge means you can’t really, fully be about anything, and see if that’s not too high a price to pay. this is your only life. It is not a rehearsal for another life where you will really live to the fullest and pursue your dreams. This is it. Knowing this, it can be difficult to realize that your life is limited to several decades and you have only one chance to live your life to the fullest with meaning and purpose. Now close your eyes and settle into yourself. Notice your breathing. - - - - [Meditation instruction] Now, imagine, that you’ve died, but by some miraculous circumstance you are able to witness your own funeral in spirit form. Think about where it would be and what it would be like. Take a few minutes to visualize a clear picture of your future funeral service. Imagine that a family member or friend is there who has been asked to stand up and say a few words about what you stood for in your life; about what you cared about; about the path you took. In a moment, I’ll have you write this eulogy in two ways. 1.if you keep living the way you are living now, without moving towards the directions you want your life to present) To prepare, take a moment to notice what you are afraid might be said if the struggle you are currently engaged in continues to dominate your life, or even grows. Suppose you back off from what you really want to stand for, and instead, continue to live your life in the margins, whatever that means for you. Picture your family member or friend. What might he or she say? 114
Now, suppose you could see inside this person’s head in that moment. If no censoring was going on, no play-acting, and this person’s thoughts were visible to you, what else would be said (this time privately to himself or herself) that might not have been said publicly. [Optional: Write it down, word for word.] what is this person thinking about you: about what you stand for, what your strengths are, what you mean to him or her, and the role you play in his or her life.
Allow ~ 3 mins Prompt: Remember, you will NOT be asked to share this, so use this opportunity to be bold and explore what else might be said.
That eulogy was a description of what you fear, and perhaps a description of where your past path has been leading you. If you didn’t like writing what you wrote, channel that pain into the next process. Now, close your eyes and settle back into yourself. Notice the position of your body. Notice your breath as you inhale…exhale. Your eulogy doesn’t have to be like that. Imagine that from here forward you’ll live your life connected to that which you most value. This doesn’t mean that all of your goals will be magically attained; it means the direction you are taking in your life is evident, clear, and manifest (slower) Now, imagine who’s at your funeral. Certainly, your spouse, children, and closest friends would be there. Perhaps people from work, class, or church (to the extent possible facilitator should personalize this list). There are no limits. If you have old friends or have lost contact with people whom you would like to see there, don’t worry about it. They can all make it to this imagined service. Think of all of the important people in your life and place them in that space. Look at them. See their faces. Watch them watching your funeral.
(2.if you live a life you value). Now imagine that someone (you can pick which one) gives a eulogy about you that reflects what all of these people might see if your life had been true to your innermost values. Imagine what you would most want to have manifest in your life. This is not a test. You won’t be judged on this and no one else need ever know what you are thinking. While you get a clear idea about this, take a few minutes and think about what you would want to hear in your eulogy about how you lived your life. Be bold! This is not a prediction. This is not self-praise. Let these words reflect the meaning you would most like to create, the purposes you would most like to reveal about the time you spent on this planet. Picture your family member or friend preparing to speak about you. What might he or she say? [Optional: Write it down, word for word:]
Allow ~4 minutes Prompt: not shared
[Optional: Set your pencils down. It’s okay if you are not finished.] Besides the strangeness of watching your own funeral, what else came up for you in this exercise? [Allow participants to discuss their experiences] If you really reached for it, you might see inside the words you wrote something of what is already inside you. Can you see some of that which you want to make happen in your life? The way you would want to be remembered once your life is over should give you a very good idea about what you value now. We don’t know what anyone would say at your funeral, 115 but we do know that your actions today can make a profound difference in how your life works from here. It is not your [insert client relevant concerns here - - i.e. examples of thoughts, feelings, bodily sensations] that your loved ones will remember you by, but the choices you make and the actions you take each day of your life. Couldn’t that begin today? Couldn’t that begin now? Let’s see if we can use this method of looking back at your life to dig out what you hold dear, one more time. [co-facilitator: distribute tombstone worksheet] Let’s try to distill all of this down to a shorter version. When people are buried, an epitaph is often written. They say things like, “Here lies Sue, She loved her family with all her heart.” If this headstone was yours, what inscription would you like to see on it? How would you most like your life to be characterized? Again, this is neither a description nor a prediction; it is a hope; an aspiration; a wish. What would you like your life to stand for? Think about it for a moment, and see if you can distill your innermost values into a short epitaph and write it out on your tombstone. Allow ~2minutes.
Letting go of the struggle, in order to achieve your values and goals
1. Now I’d like each of you to think about something you really value where there might be a discrepancy between that value and how you are currently living your life. 2. So you could value being a good student, but feel as though you are not living up to what you think a good student should be. You could value other family relationships, work, health, recreation, being a good citizen or spirituality. Take a few minutes to do this.
3. Now, if you are willing, I would like to go around the room and ask you each to share one thing that you value, what you have been doing that is inconsistent with this value, what engaging in your struggle has cost you -– whatever form it takes for you -how has it interfered in your life.
4. Then, I would like you each to commit publicly to let go of the struggle and instead commit to do something else, something consistent with your valued path. I only want you to make such a commitment, if you are really prepared to choose to give up this struggle, to allow yourself to have experiences, even difficult ones, in the service of creating a valued life. 5. If you are willing, we share this one at a time and support one another until everyone has had the opportunity. For this public commitment ceremony, you can use the following structure to help you.
[facilitator discusses each of the 5 aspects of the presentation of values….give explanations to clarify what is being solicited…for instance for the “I am going to ___” line say something like, “Take a minute right now to think of some concrete action, something you can do in the next week in the service of this value…it doesn’t have to be the only thing you do, or the perfect thing, just pick one thing that you can commit to doing.” ]
[Facilitator should be prepared to coach committed action related to acculturative stressors as well. With some stressors it would be better to use acceptance, while with others, problem 116 solving could be a committed action (i.e., procrastinating, social engagement, etc.). Workability should be the deciding factor as to whether the participants should accept or commit to problem solve. You can even point out that committed action to problem solve will involve acceptance (i.e. noticing and accepting the experience of anxiety over talking to American students and even professors).] Committed action in session Solicit willingness…
Facilitators start with committed action
What I value is ______What I have been doing is______What it has cost me is______I’m through with that. I am going to ______(clear, concrete, specific)
[prompt that the committed action should be something that can be completed in the next one week]
Closing Remind of confidentiality… Also remind people to respect the fact that others may not want to discuss what happened during the workshop even with other workshop participants. To honor this, be sure to ask permission before following up with anyone about things that you learned about them in this context. Handouts: 1 Identifying “Stress Buttons” Stress buttons are the situations, thoughts, emotions, or sensations that cause you stress. List the various “stress buttons” that you have. 2 Homework (session 1) o In the week between sessions, notice how cognitive avoidance, cognitive struggle, and a lack of awareness of what you are thinking (or cognitive fusion) promotes stress, when your “stress buttons” have been pressed. o Spend at least 10 minutes each day doing the “just noticing” exercise. 3 Write-Your-Own Epitaph “What Do I Want My Life To Stand For?” An Experiential Life Enhancement Exercise 117
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APPENDIX J: INTEGRITY CHECKLIST Session 1 • Discuss and develop rules about confidentiality and levels of disclosure • Discuss symptoms or signs of acculturative stress or stress in general ü The functional analysis graph • Discuss ways individuals have tried to control feelings of stress and level of success (how do you respond to the stress) ü Kitchen sink metaphor • Discuss control agenda and its workability ü Doctor metaphor ü Polygraph metaphor ü Love metaphor ü Monster metaphor • Introduce willingness and acceptance as an alternative to control ü Clean and dirty sufferings ü Quicksand metaphor ü Mindfulness exercise-cloud in the sky • Identifying stress buttons ü Index card demonstration • Homework ü Identify personalized “stress button” ü 10 minute “mindfulness” every day. ü Reminder of bringing “stress button” to next session Session 2 • Discuss homework assignment • Review acceptance as alternative to control ü Birds in the backyard metaphor • Introduce values and other strategies to facilitate acceptance ü “pen in hand” metaphor ü letting go struggles, faucet metaphor, ü mindfulness of language, “BUT” metaphor ü Discuss self as context with chess board metaphor ü cognitive defusion, “milk” exercise • Discuss values and commitments ü “attending your own funeral” exercise ü writing eulogy ü writing epitaph • Discuss value-based actions • Public pledge to committed value-based action • Closing ü Confidentiality 136
APPENDIX K: CONSORT FLOW CHART
Enrolled (N=30)
Randomized to intervention Randomized to control (n=13) (n=17)
Completed first intervention (n=10) Completed post-intervention survey Completed second intervention (n=10) (n=4) Completed post-intervention survey (n=10) figure 1. CONSORT flow chart detailing random assignment and attrition