Therapist and counseling center effects on international students’ counseling outcome: A mixed methods study.

Abstract

We employed a convergent mixed methods design to examine therapist and counseling center effects on international student clients' (ISCs) counseling outcomes. Using the Center for Collegiate Mental Health (CCMH) data set (2015-2017), we conducted a three-level hierarchical linear model with clients (N = 85,110) nested in therapists (N = 1,267), and therapists nested in counseling centers (N = 111), with clients' international status predicting distress (DI) in their last sessions while controlling for initial DI. Compared to domestic students, the average last session DI was significantly higher among ISCs. Random effects were significant, suggesting that some therapists and centers were more effective in their work with ISCs than others. When the proportion of ISCs seen was accounted into the model, we found a cross-level interaction in which the last session DI differences between ISCs and domestic students were significant for centers seeing a small percentage of ISCs but not for centers with large percentages of ISCs in the caseload. Grounded theory analysis of qualitative data from 11 therapists with international backgrounds revealed therapist and center factors that converged with our quantitative findings. Participants reported adhering to general clinical frameworks when working with ISCs given the lack of training on international competence (which may help explain the effectiveness gap), but also noted nuanced culturally-informed components that likely contribute to more effectively working with ISCs. Findings around center effects were complemented by qualitative results emphasizing systemic representation and engagement with diversity, creative outreach efforts, and administrative/leadership support. Implications for practice and research are discussed. Public Significance StatementInternational student clients reported worse distress outcomes at the end of therapy than domestic students at college counseling centers. This difference varied across therapists and counseling centers and was significant for centers that saw a small percentage of international students but not for centers with a large percentage of international students in the caseload. We identified both challenges and culturally-informed approaches among therapists and centers that contribute to differential counseling outcomes among international students.

Center effects, therapist effects, and international student clients’ drop out from psychotherapy.

“…However, researchers have yet to explore if drop out is more likely at different centers (i.e., a center effect) and if these therapist effects hold true for specific populations like ISCs. are both differentially effective at treating ISCs (Keum et al, 2021). ISCs in these data also utilized psychotherapy services at lower rates when compared to USCs.…”

“…The results contribute to the growing body of literature demonstrating that therapists have an effect on outcomes in college counseling centers (e.g., Owen et al, 2012; Xiao, Castonguay, et al, 2017) and that these effects may vary for specific client identities (e.g., REM students, Hayes et al, 2016). Moreover, our work is further situated in the literature about international students’ mental health in university/college counseling centers (e.g., Kawamoto et al, 2018; Keum et al, 2021). We provided the first evidence drawn from a national data set (i.e., United States) that ISCs are not more likely to drop out than USCs but that therapists are differentially effective in preventing the likelihood of drop out for ISCs.…”

“…We also found no difference with our outcome (i.e., drop out) between groups in our study (ISCs and USCs) but that therapists play a statistically significant role in preventing drop out and that this effect varies in magnitude by student status. This trend is echoed in qualitative data drawn from mixed-methods research in which therapists described needing to work expediently and flexibly to prevent ISCs from dropping out of treatment (Keum et al, 2021) and supported by multilevel modeling suggesting that therapists are differentially effective with respect to distress outcomes among ISCs. The therapist random slope in our data suggests the magnitude of drop out effect varies by student status (ISC or USC) across therapists, which can be taken to mean that some therapists are better than others at sustaining treatment attendance for ISCs and, conversely, some therapists are worse than others.…”

“…Researchers have found that therapists are differentially effective in reducing REM clients’ distress in university/college counseling centers (Hayes et al, 2016) and that university/college counseling center therapists have an overall effect on drop out (Owen et al, 2012; Xiao, Castonguay, et al, 2017; Xiao, Hayes, et al, 2017). Moreover, prior research has demonstrated that (a) ISCs utilize fewer clinical sessions than USCs, and (b) therapists and centers are differentially effective with respect to ISCs’ distress reduction (Keum et al, 2021). These factors suggest, in a large data archive of naturalistically collected data, that predicting drop out calls for the need to control variables like clients’ distress and the amount of treatment received (i.e., total sessions attended).…”

“…These therapist and center effects may extend to other treatment outcomes such as drop out for international student clients (ISCs). Recent mixed-methods research with international students currently in psychotherapy demonstrated that (a) ISCs used fewer services compared to domestic U.S. student clients (USCs) and (b) therapists believed they approach working with ISCs differently to, in part, mitigate ISCs from dropping out of treatment early (Keum et al, 2021). Others have similarly described concerns that ISCs utilize fewer services compared to USCs (e.g., Nilsson et al, 2004; Yakushko et al, 2008) and posed that ISCs may be at greater risk to drop out of therapy (Keum et al, 2021).…”