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.