Effectiveness of Cognitive Behavioral Group Intervention on Acculturation

Abstract

Objective:

This study examined the effectiveness of group cognitive behavioral intervention (CBI) in improving mental health and promoting postmigration growth for Mainland university students in Hong Kong.

Methods:

Thirty-six Mainland students with mild-to-moderate levels of psychological distress have completed a 8-session CBI group. Various mental health measures have been administered at the pre-, post-, and 3-month follow-up tests.

Results:

The levels of psychological distress, acculturative stress, and negative emotions and negative thoughts of the participants were significantly reduced, while their positive emotions and postmigration growth were significantly increased upon completion of the CBI group. The positive effects were maintained at 3-month follow-up.

Conclusions:

CBI group appears to be an effective intervention approach for improving the mental health and promoting postmigration growth for Mainland university students in Hong Kong. Implications for social work practices when engaging with Chinese international students were provided.

Keywords

cognitive behavioral intervention mental health acculturation Chinese international students

As the hub of higher education in the East Asia region, Hong Kong has been actively seeking to internationalize its universities by increasing the number of nonlocal students, especially those from Mainland China, since its handover to China in 1997. Mainland student enrollment in local Hong Kong universities has increased 11.9 times since 1997 (from 953 in 1997 to 11,374 in 2013), and its percentage of the total student enrollment has rapidly increased from 1.4% in 1997 to 12% in 2013 (University Grant Council, 2015). The admission quota set by the universities in Hong Kong for nonlocal students will be increased to 20% in the near future to further encourage the internationalization of local higher education. Thus, Mainland students have become a nonnegligible student group in Hong Kong universities. However, as a subgroup of international students, few studies have focused on this particular group of students.

Acculturative Stress and Mental Health of International Students

Compared with local students, international students are more likely to experience psychological distress (Furnham & Trezise, 1983) due to the various adjustment issues they experience in a new culture, such as host language deficiencies, demanding academic work, limited social networks and social interaction with the local community, and cultural differences (Pan, Yue, & Chan, 2010; Zeng, 2006). A moderate level of acculturative stress has been reported for Chinese international students in Australia (He, Lopez, & Leigh, 2012), and 11.6% of the international students enrolled in an American university were found to experience sufficient acculturative stress that would warrant concern (Chavajay & Skowronek, 2008). Similarly, a recent study found that 21% of Chinese international students surveyed showed a high level of psychological distress during their studies in the United States (Wang et al., 2012). A high level of stress often puts students at risk of developing mental health problems (Ying & Liese, 1991). A systematic review has suggested that approximately 15–25% of international students suffer from various mental health problems (Church, 1982). Some students may also have minor psychiatric issues, such as depression, anxiety, obsessive–compulsiveness, perfectionist tendencies, and somatic complaints (Chataway & Berry, 1989; Khawaja & Dempsey, 2007; Oei & Notowidjojo, 1990). In addition, most students may experience a variety of negative emotions, such as homesickness, loneliness, worry, tiredness, and sadness as well as having a sense of alienation, disorientation, and hopelessness (Nilsson, Berkel, Flores, & Lucas, 2004; Sam & Eide, 1991; Zheng & Berry, 1991). Thus, international students are a population group of concern for their mental health issues.

Psychosocial Intervention for International Students

It has been seldom addressed in literature on how psychosocial approaches can help international students cope with and alleviate acculturative stress as well as improve their mental health. A systematic review has indicated “a shortage of empirically tested interventions that seek to decrease acculturative stress and aid adaptation of international students” (Smith & Khawaja, 2011, p. 708). The current few intervention studies on international students mainly aim at improving their sociocultural adaptation (e.g., Mak, Westwood, Barker, & Ishiyama, 1998; Sakurai, McCall-Wolf, & Kasjima, 2010) and offering practical and academic assistance (e.g., Arthur & Popadiuk, 2010; Baik & Greig, 2009), but no attempt has been made to evaluate the effectiveness of these interventions in facilitating psychological adaptation and improving their mental health (Smith & Khawaja, 2011), except for one study which found that group assertiveness training leads to lower negative affect (NA) for international students (Tavakoli, Lumley, Hijazi, Slavin-Spenny, & Parris, 2009). In addition, intercultural training is typically predominated by cognitive and behavioral components with the central goal of developing intercultural competency and communication skills for migrants to help them interact effectively and appropriately with members from different cultures (Wiseman, 2003). However, affective goals are in fact the most important element and therefore should be adequately represented in intercultural training programs (Wawra, 2009). Aside from the teaching of social norms and communication skills in the host culture at the cognitive and behavioral levels, intercultural training should also focus on managing the emotional challenges of performing these norms in real social interactions (Morris, Savani, Mor, & Cho, 2014). Therefore, holistic intervention that includes cognitive, behavioral, and affective elements is essential to facilitating the cross-cultural adaptation of international students (Smith & Khawaja, 2011) and accommodating their unique needs in acculturation.

Justification for the Use of Cognitive Behavioral Therapy (CBT) in Working With Chinese International Students

CBT has been widely recognized as an effective prevention and intervention approach for improving the mental health outcomes and reducing emotional distress of various populations. Meta-analysis studies have shown that in comparison with other intervention approaches, CBT is the most effective in promoting the mental health of university students (Conley, Durlak, & Dickson, 2013), particularly in reducing depressive/anxiety symptoms or preventing depression/anxiety (Christensen, Pallister, Smale, Hickie, & Calear, 2010). Specifically, a number of empirical evidence have demonstrated that CBT, in various forms, is effective for nonclinical groups of university students in significantly reducing psychological distress and perceived stress (Deckro et al., 2002), NA (Kenardy, McCafferty, & Rosa, 2003), test anxiety (Neuderth, Jabs, & Schmidtke, 2009), perfectionism (Arpin-Cribbie, Irvine, & Ritvo, 2012), anxiety sensitivity and negative automatic thoughts (Radhu, Daskalakis, Arpin-Cribbie, Irvine, & Ritvo, 2012), and developing a more optimistic explanatory style (Seligman, Schulman, & Tryon, 2007), reducing anxiety-related cognitions (Kenardy et al., 2003), having a purpose in life and gaining self-acceptance (Ruini, Belaise, Brombin, Caffo, & Fava, 2006), and self-efficacy to cope with depression (Oikawa & Sakamoto, 2007). The beneficial effects were sustained at the 4-week (Kearns, Forbes, & Gardiner, 2007), 6-month (Tomba et al., 2010), and 18-month follow-ups (Peden, Rayens, Hall, & Beebe, 2001). In addition, cognitive behavioral group intervention is preferred in university setting for the following reasons. (1) No differences between individual and group treatment for depression were found by meta-analysis study (Cuijpers, Straten, Warmerdam, & Smits, 2008). (2) Group intervention may facilitate to establish interdependence and develop trust rapidly among group members (Scheinfeld, Rochlen, & Buser, 2011). (3) Group intervention is cost-effective, given the insufficient counseling professionals in many universities, particularly in Asian, such as Hong Kong.

Although research on the application of CBT to immigrant groups is still in its early stage, a few studies have shown that CBT has similar effects for migrant groups in alleviating psychological distress and depressive symptoms and improving their quality of life (Choi et al., 2012; Piedra & Byoun, 2012; Renner & Berry, 2011; Shen, Alden, Sochting, & Tsang, 2006; Wong & Poon, 2010). Three- and 6-month maintenance effects were also reported (Piedra & Byoun, 2012; Wong, Poon, & Kwok, 2011). However, few studies have used CBT to work with international students. In addition, the existing research seldom tests the effectiveness of CBT on the outcome variables related to acculturation, such as acculturative stress and postmigration growth, which have been verified by recent acculturation research on international students, including mastery of the host language, improved interpersonal and communication skills, personal development, and academic success (Gu, Schweisfurth, & Day, 2010).

CBT is also a good fit for the Chinese culture because CBT shows a high conceptual compatibility with the common values of the Chinese culture (Hodges & Oei, 2007). First, as a well-structured and directive approach, CBT conforms with the directive counseling preference of Chinese people over nondirective approaches (Hodges & Oei, 2007; Lin, 2002). Second, teaching/learning skills and focusing on the “here and now” are consistent with the Chinese values of pragmatism and seeking direct solutions to problems (Hodges & Oei, 2007). Third, the shared responsibility between therapist and client as well as the emphasis on homework meet the expectation in the Chinese culture that diligence is essential for gaining achievement (Hodges & Oei, 2007). Finally, the role of the therapist in CBT as an educator and expert, which corresponds to the great respect of the Chinese people for authority and expertise (Lin, 2002). In addition, the effectiveness of CBT for Chinese clients has been demonstrated by various empirical studies (e.g., Leung, Chiang, Chui, Mak, & Wong, 2011; Wong, 2009).

The cognitive characteristics of Chinese international students may fit well with CBT, which has a primary focus on cognitive reconstruction and behavioral modification as well as the interplay of cognition, behavior, and emotions (Beck, 2011). Chinese international students have some unique cognitive characteristics that are specific to the Chinese cultural belief system. Concern about face is one of the most popular beliefs in Chinese culture. Chinese people strive to gain the respect of others (He & Zhang, 2011), suppression their expression of distress and avoid violating social norms to save face (Chen & Mak, 2008; Liao & Bond, 2011). They also attempt to save face by overemphasizing hardwork and educational success (Sung, 2010). For example, Chinese culture holds that “the degree that you earn is the life that you lead” (Pearce & Lin, 2007, p. 27). However, these beliefs related to saving face are associated with distress (Mak, Chen, Lam, & Yiu, 2009) and negative emotions (Sung, 2010) for Chinese international students. In addition, compared to their Caucasian counterparts, Chinese students report a higher level of maladaptive perfectionism and demonstrate a maladaptive attribution style that leads them to attribute failure to internal factors, such as lack of ability and effort, and attribute success to external factors, such as luck (Anderson, 1999). These cultural beliefs presented in different domains of their overseas study, such as academic work, interpersonal relationships, career planning, and managing cultural differences, may be related to depression, loneliness (Anderson, 1999; Wei et al., 2007), and psychological distress (Wong, 2008). Chinese international students may benefit from the cognitive strategies of CBT, such as gaining different perspectives of their performance expectations and developing more realistic expectations for themselves (Rice, Choi, Zhang, Morero, & Anderson, 2012).

Cultural Adaptation of CBT to Chinese Clients

As a working approach developed for Caucasians in Western countries, cultural adaptation has been recommended for its applicability to different ethnic groups (Nicolas, Arntz, Hirsch, & Schmiedigen, 2009). Some cultural modifications have been made in CBT to better accommodate Chinese clients, including reframing skills in ways that promote respect and interpersonal harmony, modifying phrases and concepts for consistency with Chinese cultural values, and suggesting five strategies to cope with negative emotions (Choi et al., 2012; Wong, 2005). However, there are some challenges involved in applying CBT to Chinese clients, as what constitutes maladaptive cognitions across various cultural contexts have to be addressed (Rathod & Kingdon, 2009). An example is to determine ways to implement cognitive reconstruction strategies when dealing with culture-specific beliefs related to social relationships and cultural identity expected in a collectivist culture (Lin, 2002; Shen et al., 2006). Specific Chinese cultural beliefs, such as saving face and maintaining relationship harmony, should be addressed when working with Chinese clients. In this sense, CBT must be culturally and linguistically attuned to help Chinese clients learn cognitive and behavioral skills more effectively (Wong & Sun, 2006).

The Present Study

The objectives of this study are to test the effectiveness of group cognitive behavioral intervention (CBI) at both the cognitive and affective levels in a nonclinical sample of Mainland Chinese university students in Hong Kong. Three hypotheses were proposed as follows: (1) The participants in the CBI group would experience lower levels of psychological distress, acculturative stress, and NA and higher levels of positive affect (PA) and postmigration growth at posttest than at pretest; (2) the participants in the CBI group would have fewer negative automatic thoughts and more positive automatic thoughts at posttest than at pretest; and (3) the intervention effects would be maintained at the 3-month follow-up test.

Intervention Program

The intervention program was developed based on the CBT proposed by Beck (2011) and the CBT for Chinese clients by Wong (2005). The intervention consisted of 8 weekly sessions, with 3 hours for each session. The first two sessions focused on identifying the association between thought and emotional and physiological stress responses that Mainland students experience in Hong Kong. Sessions 3–4 focused on identifying their automatic thoughts and cognitive distortions, and challenging and replacing negative thoughts with more constructive ones, and identification of behavioral activation strategies (i.e., activity rescheduling). Sessions 5–7 consisted of working on the cognitive rules derived from their dysfunctional automatic thoughts. These sessions included identification of individual rules in academic work, peer relationships, career planning, family/romantic relationships, and language/cultural differences, review of past experiences related to these rules, and relaxation of these rules. Cognitive skills such as advantages and disadvantages analyze, pie chart, and cognitive continuum were applied in these sessions. The last session was the conclusion of the group, where individual progress was reviewed and ways to apply the learned skills for future life situations were discussed. Each session also included a mood check and homework review at the beginning of the session (except for the first session) and then a summary of the session, opportunity for feedback and homework assignment at the end (except for the last session). The whole process focused on the use of the examples provided by the participants themselves to demonstrate the cognitive and behavioral skills emphasized in CBT.

Credibility of Group Leaders

Two group leaders were involved in conducting the CBI groups. One is a certified cognitive behavioral practitioner trained at the Beck Institute in the United States. She is an experienced social worker with more than 10 years of practice experience and has run more than 100 CBI groups and training workshops for Chinese clients and trainees. The other is a registered social worker in Hong Kong with nearly 400 hours of CBI training and practice experience and a PhD degree in social work. The group leaders spoke the same language (i.e., Mandarin) as the students in the CBI group.

Fidelity of Intervention

To assess the degree of adherence to the CBI principles and procedures, an independent reviewer, who is a qualified university counselor with more than 5 years of CBI training and practice experience, was invited to conduct onsite evaluation of two to three sessions for each CBI group with the consent of the participants. The sessions were randomly selected by the reviewer who was given a session plan for the corresponding session and evaluated the degree to which the groups adhered to the session plan. The average adherence to the session plans was 90.6%.

Research Method

Participants and Recruitment

The participants in this study are Mainland students who are studying in Hong Kong universities. These students are nonlocal students from Mainland China who are admitted by the universities in Hong Kong and come to Hong Kong holding a student visa. Posters that outlined the objectives and procedures of the study were placed on the campus of seven Hong Kong universities to invite Mainland students for participation. All of the participants were screened at a pregroup interview conducted by the first author. The pregroup interview focused on the motivation of the individuals for taking part in the study, adjustment problems that they have encountered in Hong Kong, past history of mental health problems and suicidal ideation and attempts, and expectations toward the CBI group. By the end of the interview, qualified individuals were invited to fill in a questionnaire, which included the scales for the outcome measures. Students are eligible for inclusion in the study if they (1) have a General Health Questionnaire (GHQ)-12 score of 2–10 (0-0-1-1; i.e., mild-to-moderate levels of psychological distress) and (2) are willing to complete the entire study process. Students are excluded if they demonstrate any of the following conditions: (1) one psychosis (or more) or (2) severe depression as diagnosed by a psychiatrist or clinical psychologist with suicidal attempts/ideation in the past 3 months. The two exclusion criteria were set, as these clients may need medical treatment and/or immediate crisis intervention, which is beyond the capacity of this project and would be referred to professional mental health services. No participants in this project indicated that they had diagnosis of either psychosis or severe depression in the pregroup interview. Instead, a very few participants indicated that they had suicidal ideation in the past 3 months and we referred them to university student counseling services.

Research Design and Procedure

One-group pre–posttest design was adopted in this study due to the difficulties in recruiting participants for the control group. Ethical approval was granted from the institutional review board of the Hong Kong Baptist University before data collection. The participants took part in a eight-session CBI group on a weekly basis. Details are provided in the section on the intervention program. Participants completed the same set of questionnaire for the pretest in the pregroup interview, posttest within 1 week after the completion of the CBI group, and 3-month follow-up test. A flow diagram of the participants through each stage of the study is presented in Figure 1. Informed consent was obtained following the introduction of the study and after it was ascertained that the potential participants were eligible, a total of 64 participants were recruited for the study, while 15 were excluded due to ineligibility, thus resulting in 49 eligible participants. A total of 42 students completed the pretest and took part in one of the four separate CBI groups. Thirty-three and 29 participants completed the post- and 3-month follow-up tests, respectively. The average attendance rate was 61.9%.

Figure 1.
Flow diagram of the participants throughout the stages of the study.

Outcome Measure

GHQ-12

GHQ-12 is a widely used screening instrument for general psychological distress in both clinical and nonclinical settings (Goldberg & Williams, 1988). The Chinese version of the GHQ-12 (Ye, 2009) is adopted in this study. The 0-0-1-1 scoring method was used to determine the scale score (which ranged from 0 to 12), with a higher score indicating higher levels of psychological distress. The cut-off point of 1/2 for the Chinese population was used to detect participants at risk of developing mental health problems (Goldberg et al., 1997). Thus, those with a GHQ-12 score of 2 or above were identified as at-risk cases, and those with a GHQ-12 score of 1 or 0 were identified as not-at-risk cases. The internal consistency of the Cronbach’s α was reported to be .92 and .93 in Chinese immigrant groups (Chou, 2007).

Acculturative Stress Scale for Chinese Students (ASSCS)

The ASSCS was used to measure acculturative stress (Bai, 2012). It consists of 32 items with five subscales: Language Insufficiency, Social Isolation, Perceived Discrimination, Academic Pressure, and Guilt Toward Family. Some adaptations of the original ASSCS were made to fit the Hong Kong context. For example, a subscale of cultural difference from the Acculturative Hassles Scale for Chinese Students (Pan et al., 2010) was included. One item in this subscale was excluded due to low factor loading. Thus, the ASSCS comprised 35 items with six subscales. Other modifications included changing “U.S.” to “Hong Kong” (Items 2, 9, 10, 27, and 31), “English” to “English or Cantonese” (Items 8 and 13), “my people” to “Mainland students” (Items 17 and 22), “ethnicity” to “Mainland background” (Items 6 and 28), and “others” to “Hong Kong people” (Items 11 and 14). The responses were rated on a 4-point Likert-type scale (0 = never, 3 = always). The item scores were averaged as a scale score or subscale scores, with higher scores indicating higher levels of acculturative stress. The Cronbach’s α of the original ASSCS was .94, with the α of the subscales ranging from .83 to .92 (Bai, 2012). Criterion-related validity was demonstrated by its significant correlation with depression and life satisfaction (Bai, 2012).

Chinese Automatic Thoughts Questionnaire (CATQ)

A 14-item CATQ (Pan, Ye & Ng, 2016) is used to measure automatic thoughts in this study. It was adapted from a combined version of the 8-item ATQ (Netemeyer et al., 2002) and 10 positive items in the ATQ revised (Kendall, Howard, & Hays, 1989) for Chinese university students. The CATQ includes three subscales: Negative Thoughts, Positive Thoughts (emotional), and Positive Thoughts (cognitive). Sample items for the Negative Thought subscale (n = 6) are “I am worthless” and “I am no good.” Sample items for the two Positive Thought subscales are “No matter what happens, I know I’ll make it” and “I feel very happy.” Participants were asked to rate the frequency of each thought in the past week on a 5-point scale (1 = not at all, 5 = all the time). Item scores were averaged as the subscale scores for positive and negative thoughts, with higher scores indicating greater positive/negative thoughts. The Cronbach’s α of the CATQ was .83 for the total score and 0.85, 0.84, and 0.76 for the three subscale scores in a sample of Chinese university students in Hong Kong (Pan et al., 2015). Concurrent validity of the CATQ was demonstrated by its positive correlation with NA for the Negative Thought subscale, and its negative correlation with PA and life satisfaction for the two Positive Thought subscales (Pan et al., 2015).

Chinese Affect Scale (CAS)

The CAS is designed to measure trait and state affects for Chinese-speaking people (Hamid & Cheng, 1996). It consists of 20 items with two subscales: (10 items) and NA (10 items) Sample items are “happy,” “peaceful,” and “comfortable” for the PA subscale and “depressed,” “insecure,” and “tense” for the NA subscale. Participants were asked to rate the items on a 6-point Likert-type scale (1 = not at all, 6 = extremely). Items were averaged as subscale scores, with higher scores indicating higher levels of PA/NA. Good reliability and validity were reported (Hamid & Cheng, 1996).

Postmigration Growth Scale (PMGS)

PMGS is a scale designed to measure the personal growth of Chinese international students after migration (Pan, Wong, & Ye, 2013). It consists of 14 items with two subscales: Interpersonal Growth and Intrapersonal Growth. Sample items include (1) “My self-confidence in overcoming difficulty and coping with stress has improved”; (2) “I realize the importance of family to me, and cherish the relationship with my family”; and (3) “I am able to relate to others with a peaceful mind.” Participants were asked to rate the degree to which they experienced each item in the host society on a 6-point Likert-type scale (1 = not at all, 6 = a great deal). The mean score was calculated as the scale score, with higher scores indicating higher levels of postmigration growth. The Cronbach’s α was reported to be .93 for the total scale and .90 and .89 for the two subscales, respectively (Pan et al., 2013). Good concurrent validity was also demonstrated by its positive correlations with PA and life satisfaction and its negative correlation with NA (Pan et al., 2013).

Data Analysis

Prior to data analysis, the expectation–maximization algorithm was computed to replace missing data because this approach can mitigate the pitfalls of traditional techniques (Baraldi & Enders, 2010). One-way analysis of variance (ANOVA) was conducted to compare the pre-, post-, and follow-up test scores of the outcome variables, respectively. Post hoc testing with least significance difference was performed for pairwise comparison. The effect size was calculated by Cohen’s d to determine the size of the difference between the pre- and posttests, pre- and follow-up tests, and post- and follow-up tests of the outcome variables. χ² test was performed to compare the percentage of not-at-risk cases based on the GHQ-12 score at the pre-, post-, and follow-up tests. All of the statistical analyses were performed with SPSS 21.0 program.

Results

Descriptive Summary of Participant Demographics

The characteristics of the 36 participants who took part in this study are shown in Table 1. Fifty-eight percent (n = 21) are female and 42% (n = 15) are male. Fifty-six percent (n = 20) are studying at the Hong Kong Baptist University and the rest are from six other universities in Hong Kong. Forty-four percent (n = 16) are under the age of 23, 50% (n = 18) are in the age range of 24–30, and 5.6% (n = 2) are over 30 years. Fifty percent (n = 18) are studying in Master programs, 28% (n = 10) in bachelor programs, and 14% (n = 5) are in PhD program. In terms of their length of residence in Hong Kong, 50% (n = 18) have resided in Hong Kong for less than half a year, 31% (n = 11) for half a year to one year, 8.3% (n = 3) for 1–2 years, and 11% (n = 4) for more than 2 years. The vast majority (89%, n = 32) are single. The average attendance rate is 61.9%.

Table 1.
Demographics of Study Participants.

Variable n % Variable n %

Gender Marital status

Male 15 41.7 Single 32 88.9

Female 21 58.3 Married 4 11.1

University

HKBU 20 55.6 Length of residence in Hong Kong

CityU 5 13.9

HKU 2 5.6 <0.5 years 18 50.0

CUHK 4 11.1 0.5–1 years 11 30.6

PolyU 2 5.6 1–2 years 3 8.3

OpenU 2 12.5 >2 years 4 11.1

LU 1 2.8

Age Degree

<23 years 16 44.4 PhD 5 13.9

24–30 years 18 50.0 Master 18 50.0

31–35 years 2 5.6 Bachelor 10 27.8

Other 3 8.3

Total 36 100 Total 36 100

Note. HKBU = Hong Kong Baptist University; CityU = City University of Hong Kong; HKU = The University of Hong Kong; CUHK = The Chinese University of Hong Kong; PolyU = The Hong Kong Polytechnic University; OpenU = Open University of Hong Kong; LU = Lingnan University.

Comparison of Outcome Measures Among Pre-, Post-, and 3-Month Follow-Up Tests

The results of the one-way ANOVA are presented in Table 2 to show the effectiveness of the cognitive behavioral group intervention on the outcome variables for these Mainland Chinese university students in Hong Kong. Significant changes are found in psychological distress, F(2, 95) = 18.52, p < .001, acculturative stress, F(2, 95) = 8.94, p < .001, positive emotions, F(2, 95) = 4.17, p < .005, negative emotions, F(2, 95) = 5.70, p < .01, negative thoughts, F(2, 95) = 7.93, p < .001, and postmigration growth, F(2, 95) = 3.37, p < .005, at the pre-, post-, and 3-month follow-up tests. The results of the pairwise comparison and changes between the pre-, post-, and 3-month follow-up test scores are presented in Table 3 and Figures 2 –4. As expected, the level of psychological distress is substantially decreased from the pretest (M = 5.17, SD = 2.85) to the posttest (M = 1.70, SD = 2.20, p < .001) and the follow-up test (M = 2.36, SD = 2.39, p < .001). Similarly, the posttest score (M = 0.95, SD = 0.37) and follow-up test score (M = 0.87, SD = 0.31) of acculturative stress are significantly lower than its pretest score (M = 1.21, SD = 0.35, p ₁ < .05, p ₂ < .001). The pairwise comparisons also indicates significant differences between the pre and posttest scores and between the pretest and follow-up test scores for the measures of positive and negative emotions, negative thoughts, and postmigration growth, but not for positive thoughts (see Table 3). The effect size of Cohen’s d ranges from 0.47 to 1.36 for the variables with significant changes (see Table 3), which shows medium to large differences for the comparisons (Cohen, 1992). These results suggest that the participants continue to maintain significant improvement in mental health outcomes and reduced their negative thoughts not only after the immediate completion of the cognitive behavioral group intervention but also at the 3-month follow-up.

Table 2.
Results of ANOVA on the Comparison of Pre-, Post-, and 3-Month Follow-Up Tests on Outcome Measures.

Outcome Measure Pretest (n = 36) Posttest (n = 33) Follow-Up Test (n = 29) F p

M SD M SD M SD

Psychological distress 5.17 2.85 1.70 2.20 2.36 2.39 18.52* .000

Acculturative stress 1.21 0.35 0.95 0.37 0.87 0.31 8.94* .000

Positive emotions 3.30 0.70 3.79 0.80 3.72 0.82 4.17* .018

Negative emotions 3.41 0.85 2.88 0.86 2.78 0.73 5.70 .005

Positive thoughts 2.55 0.78 2.72 0.71 2.66 0.83 0.44 .649

Negative thoughts 2.21 0.74 1.72 0.56 1.69 0.42 7.93* .001

Postmigration growth 3.99 0.80 4.35 0.72 4.41 0.60 3.37* .039

Note. ANOVA = analysis of variance.

p < .05. p < .01. p < .001.

Table 3.
LSD Post Hoc Pairwise Comparison on Outcome Measures.

Variable Pairwise Comparison

T ₁ − T ₂ Cohen’s d T ₁ − T ₃ Cohen’s d T ₂ − T ₃ Cohen’s d

Psychological distress 3.47* 1.36 2.81* 1.07 –0.66 –0.29

Acculturative stress 0.26* 0.72 0.35* 1.03 0.09 0.23

Positive emotion –0.49 –0.65 –0.42* –0.55 –0.07 0.09

Negative emotion 0.53 0.62 0.63 0.80 –0.10 0.13

Positive thought –0.17 –0.23 –0.11 –0.14 0.05 0.08

Negative thoughts 0.49* 0.75 0.52* 0.86 0.03 0.06

Postmigration growth –0.36* 0.47 –0.42* –0.59 –0.06 –0.09

Note. LSD = least significance difference; T ₁ = pretest; T ₂ = posttest; T ₃ = 3-month follow-up test.

p < .05. p < .01. p < .001.

Figure 2.
Changes in psychological distress, acculturative stress, and postmigration growth in pre-, post-, and 3-month follow-up tests.

Figure 3.
Changes in positive and negative emotions at pre-, post-, and 3-month follow-up tests.

Figure 4.
Changes in positive and negative thoughts at pre-, post-, and 3-month follow-up tests.

The percentage of at-risk and not-at-risk cases at the pre-, post-, and 3-month follow-up tests based on GHQ-12 is presented in Table 4. According to the cut-off point of 1/2 of GHQ-12 for the Chinese population (Goldberg et al., 1997), 62.5% and 50.0% of the participants could be considered as not-at-risk cases at the post- and 3-month follow-up tests. The χ² test showed a significant difference of the percentage of at-risk and not-at-risk cases at the three time points (x ² = 35.99, df = 6, p < .001). This indicates that the at-risk cases for mental health problems significantly decreased immediately upon completion of the cognitive behavioral group intervention and at the 3-month follow-up.

Table 4.
Percentage of Not-At-Risk Cases at Pre-, Post-, and Follow-Up Tests Based on GHQ-12 Score.

GHQ-12 score Pretest Posttest Follow-Up Test

0–1 (not-at-risk case) 0 62.5 50.0

2–6 74.3 34.4 46.4

7–9 17.1 3.1 3.6

10–12 8.6 0 0

Total 100 100 100

Note. GHQ = General Health Questionnaire.

Discussion and Application to Practice

To the best of our knowledge, this is pioneering to apply CBI to Chinese international students. Consistent with previous findings on CBT for university students, this study has provided preliminary data to demonstrate that the levels of acculturative stress, psychological distress, negative thoughts, and emotions were reduced, and the levels of positive emotions and postmigration growth were increased for Mainland Chinese university students in Hong Kong after joining a CBI group. These positive effects are sustained for at least 3 months. These evidences suggest that group CBI might an effective prevention and intervention approach, not only to help international students manage their acculturative stress and improve their mental health, but also to provide a promising platform to facilitate their positive changes in the process of overseas study.

The positive effects of group CBI for Mainland Chinese students in Hong Kong suggest that this intervention approach fits well with the cognitive characteristics, cultural background, and acculturation context of this particular group of students. Unlike the Hong Kong Chinese clients in a local study (Wong, Sun, Tse, & Wong, 2002) who had difficulties in examining the cognitive factors related to their problems, Mainland students in this study were able to easily identify the negative cognitions associated with their psychological distress caused by their cross-cultural adaptation problems, once they realized the interplay of cognition, emotion, behavior, and physiological responses. In this sense, it is easy for the group leaders to address their negative cognitions and positive effects are therefore achieved. Consistent with the literature, maladaptive perfectionism is also observed among the Chinese students in the CBI group in this study. Many students are concerned about making mistakes and being looked down upon due to loss of face, which is associated with their behavioral responses, such as striving for perfection; overpreparation for academic work, such as presentations; and setting high standards for success. Similar, internal attribution for failure is also obvious in these Chinese students. For example, some students have the belief that “(they) got a poor grade on the exam because (they) had not put in enough effort in (their) study.” Others said that “(they) would be laughed at in group discussions because of (their) poor Cantonese with a Mandarin accent.” By using cognitive reconstruction and behavioral modification, these Chinese students are able to create realistic standards and expectations for themselves, others, and the world as well as attribute failure to both internal and external factors, which may improve their well-being and resilience (Mak, Ng, & Wong, 2011; Zhang et al., 2014). In addition, CBI is able to help Mainland student to make sense of the acculturative stressors that they experience in Hong Kong. For example, their experience with a variety of adjustment problems is reframed in the CBI group as a normal process that almost every student experiences in overseas study. Sense-making coping is found to promote the postmigration growth of Chinese international students (Pan, 2015).

The positive effects may be also related to the specific CBI skills used in this study for working with Chinese international students. First, Chinese people are reluctant to express emotional vulnerability due to loss of face (Chen & Mak, 2008), but the Mainland students in this study are willing to share their psychological distress in a group setting, which may facilitate the normalization of stress, negative emotions, and experience of cognitive distortions. In addition, implementation of CBI in a group setting can provide alternative perspectives from other group members to students. Second, the cognitive skills of self-talk and development of positive statements work very well for Chinese students. These skills are taught to the students in four of the eight sessions in this study. It is particularly useful to help Mainland students make sense of and find benefit from various adjustment problems that they experience in Hong Kong, as these two dimensions of meaning-focused coping are found to have a strong association with positive psychological adaptation outcomes (e.g., Affleck & Tennen, 1996; Pan, 2011). For example, the Mainland students in this study are given assistance in reframing group discussion in Cantonese as a good opportunity to learn the host language with local Hong Kong students. Third, the format of mini-lecture as well as provision and discussion of case studies in the CBI groups suit these Mainland Chinese students who are accustomed to learning new things through lectures and demonstrations. Fourth, the use of drawing is also helpful for demonstrating ways to develop different perspectives on stressful life events in a simple and visual way. Finally, reviewing their past experience may help Chinese students to understand and modify their dysfunctional rules in a more easy and ready way.

However, no significant change has been found in terms of positive thoughts. This may be related to the greater focus on identifying negative thoughts and challenging these thoughts, and less emphasis on promoting positive thoughts in the CBI groups. Like positive and negative emotions (Fiske & Taylor, 1984), positive and negative thoughts may not be two end points of a continuum; instead, they might be two different dimensions, which need further empirical testing. In this sense, the reduction of negative thoughts may not necessarily imply the presence of positive thoughts. Thus, more emphasis should be placed on working with positive thoughts in CBI with Chinese international students.

Although the number of Mainland university students in Hong Kong has rapidly increased in recent years, there are still some difficulties in the recruitment of participants for this project. This is consistent with the recruitment difficulties reported by other studies on CBT for Chinese immigrants (e.g., Shen et al., 2006). One difficulty that we encountered is that we did not have a good platform to approach Mainland students to inform them about this program. We had to invite students through campus posters, which could be removed or covered by other posters. Another challenge is the high stigmatization of mental health problems and shame factor in the help-seeking process for Chinese clients (Hsu et al., 2008). Many Chinese students are reluctant to seek professional help even when they are highly stressed. With these challenges, we had difficulties in recruiting a sufficient number of participants for randomization in this project. In addition, the attendance rate (61.9%) in this project is lower than that of other local studies in Hong Kong (85–90%; Wong et al., 2002; Wong, 2008). Many students found it difficult to commit to 8 weeks with 3 hours for each session for various reasons. The time of the day/week that the group was implemented may also have affected their attendance, especially during exams when the attendance rate was low.

This study contributes to the current CBT literature in several ways. First, few CBT studies have targeted international student populations. This study provides some preliminary empirical evidence to support the efficacy of the group CBI approach for working with Chinese international students to help them cope with acculturative stress and improve their mental health in cross-cultural adaptation. Second, most of the CBT studies have used psychopathological outcome indicators, such as depressive and anxiety symptoms. In this study, we have not only used measures of negative psychological functioning, such as acculturative stress, psychological distress, NA, and negative thoughts, but also included the assessment of positive psychological functioning, such as PA and postmigration growth. Finally, the CBI approach in this project is specifically designed for Chinese international students, particularly for Mainland students in Hong Kong, which accommodate their cultural background and respond to their acculturative needs.

However, there are several limitations that should be kept in mind. First, this study is not a randomized controlled trial with a control group. Future research should include a control or comparison group to compare the effects on various mental health measures between groups with and without group CBI. Second, as a pilot study, this study has a relatively small sample size. A larger sample size is recommended for future research to further test the effectiveness of group CBI for Mainland students in Hong Kong. Third, no follow-up qualitative study has been conducted to explore the therapeutic factors in group CBI to help us understand the factors that are helpful for Chinese university students. Fourth, the cognitive variable measured in this study is only at the level of automatic thought. More cognitive outcomes of intermediate beliefs such as perfectionism and attribution style should be assessed in future research. Finally, the participants of this study are Mainland university students in Hong Kong. More evaluation studies could be conducted in the future to test the effectiveness of group CBI for Chinese international students in other countries or regions.

With the rapid increasing number of Chinese international students who are enrolled in universities throughout the world in recent years, this study provides some practical implications for working with this particular group of students. First, due to its positive effects, the application of the CBI approach, particularly in a group setting, is highly recommended to prevent the various mental health problems of Chinese international students. Second, it is also recommended that CBI is implemented in a class setting for Chinese international students to ensure participant recruitment and attendance rate. Third, more positive elements should be introduced into CBI when working with Chinese international students to facilitate their changes of positive dimensions of outcome indicators, such as positive thoughts and positive emotions. For example, more emphasis could be placed on the identification and enhancement of positive thoughts in CBI; on how clients have managed to cope with stress by identification and reinforcement of their own strengths and past successful experiences. Third, we also recommend the inclusion of more behavioral activities in CBI, such as warm-up and board games or adventure-based activities, so that students can engage in behaviors or new experiences that challenge their dysfunctional thoughts. Fourth, it is also useful to create new experiences by behavioral experiments with Chinese students. For example, social workers can help Chinese international students to broaden their perspectives on exam failure by inviting them to ask other students in their class who have failed the same examination and find out how they understand and attribute their failure. By doing so, students would be able to obtain diverse perspectives on and understand a variety of contributing factors to failure and success. Finally, it is highly recommended for host universities to hire social workers or counselors with similar language and cultural backgrounds to work with the diversity found in the population of international students.

Variable	n	%	Variable	n	%
Gender			Marital status
Male	15	41.7	Single	32	88.9
Female	21	58.3	Married	4	11.1
University
HKBU	20	55.6	Length of residence in Hong Kong
CityU	5	13.9
HKU	2	5.6	<0.5 years	18	50.0
CUHK	4	11.1	0.5–1 years	11	30.6
PolyU	2	5.6	1–2 years	3	8.3
OpenU	2	12.5	>2 years	4	11.1
LU	1	2.8
Age			Degree
<23 years	16	44.4	PhD	5	13.9
24–30 years	18	50.0	Master	18	50.0
31–35 years	2	5.6	Bachelor	10	27.8
			Other	3	8.3
Total	36	100	Total	36	100

Outcome Measure	Pretest (n = 36)	Posttest (n = 33)	Follow-Up Test (n = 29)	F	p
Psychological distress	5.17	2.85	1.70	2.20	2.36	2.39	18.52***	.000
Acculturative stress	1.21	0.35	0.95	0.37	0.87	0.31	8.94***	.000
Positive emotions	3.30	0.70	3.79	0.80	3.72	0.82	4.17*	.018
Negative emotions	3.41	0.85	2.88	0.86	2.78	0.73	5.70**	.005
Positive thoughts	2.55	0.78	2.72	0.71	2.66	0.83	0.44	.649
Negative thoughts	2.21	0.74	1.72	0.56	1.69	0.42	7.93***	.001
Postmigration growth	3.99	0.80	4.35	0.72	4.41	0.60	3.37*	.039

Variable	Pairwise Comparison
Psychological distress	3.47***	1.36	2.81***	1.07	–0.66	–0.29
Acculturative stress	0.26*	0.72	0.35***	1.03	0.09	0.23
Positive emotion	–0.49**	–0.65	–0.42*	–0.55	–0.07	0.09
Negative emotion	0.53**	0.62	0.63**	0.80	–0.10	0.13
Positive thought	–0.17	–0.23	–0.11	–0.14	0.05	0.08
Negative thoughts	0.49***	0.75	0.52***	0.86	0.03	0.06
Postmigration growth	–0.36*	0.47	–0.42*	–0.59	–0.06	–0.09

GHQ-12 score	Pretest	Posttest	Follow-Up Test
0–1 (not-at-risk case)	0	62.5	50.0
2–6	74.3	34.4	46.4
7–9	17.1	3.1	3.6
10–12	8.6	0	0
Total	100	100	100

Footnotes

Acknowledgments

The authors would like to thank Prof. Daniel Fu Keung Wong for his permission of using the Chinese CBT work sheets in this project and Miss Veron Man Shan Chan for running the CBT groups for this project.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was financially supported by the Faculty Research Grant in Hong Kong Baptist University.

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Variable	Pairwise Comparison
Variable	T ₁ − T ₂	Cohen’s d	T ₁ − T ₃	Cohen’s d	T ₂ − T ₃	Cohen’s d
Psychological distress	3.47***	1.36	2.81***	1.07	–0.66	–0.29
Acculturative stress	0.26*	0.72	0.35***	1.03	0.09	0.23
Positive emotion	–0.49**	–0.65	–0.42*	–0.55	–0.07	0.09
Negative emotion	0.53**	0.62	0.63**	0.80	–0.10	0.13
Positive thought	–0.17	–0.23	–0.11	–0.14	0.05	0.08
Negative thoughts	0.49***	0.75	0.52***	0.86	0.03	0.06
Postmigration growth	–0.36*	0.47	–0.42*	–0.59	–0.06	–0.09