‘Lifting the shell’: expressions of emotion and cross-cultural struggle in international students

Rebekah Callow 1
  • 1 , Norwich
Rebekah Callow
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  • Norwich
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  • Rebekah Callow based in Norwich and works for Friends International, supporting international students and equipping those working with them.
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Abstract

Research has shown that while humans around the world hold various emotions in common with one another – sadness, happiness, fear and anger – the expression of these emotions can look different depending on the culture. This article explores the different expressions of ‘struggle’ that arise when a person experiences ‘culture shock’ or ‘culture stress’ due to life in a cross-cultural context. The article argues that in the increasingly international context of higher education, urgent attention needs to be given to these different cultural expressions of struggle, in order to better understand students’ experiences and provide effective coping strategies. Richard Lewis's cultural model is developed for use in this context.

Seperti katak dibawah tempurung – Like a frog under a coconut shell.

(a Malay proverb)

Culture, for all its shadow and light, is essential and intimate to humanity. And like any intimacy, no one ‘from outside’ can ever fully share it, and no one ‘from inside’ can ever fully describe it. Such is human culture.1

Introduction: interpreting need and defining terms

A distraught face looked back at me as I opened the door. ‘I’ve lost my knitting!’ Forty-five minutes late for our meeting together, my Chinese friend looked incredibly upset. Linda had been meeting up with one of our volunteer team to learn how to knit, and a few East Asian students had joined in. The students would go away and practice, sometimes drawing in the expertise of their host families to help out. It connected cultures naturally, and significant conversations developed. What I learnt later was that they had been learning how to knit a baby's jumper. Linda said to me that she didn’t feel ready to have a child yet, but as they had learnt how to knit they had discussed their hopes for the future when they would return home, and all the students expressed a desire to start a family. Out of these discussions Linda had decided to knit a baby jumper and it was this little jumper – nearly finished – that she had lost.

Days earlier Linda had been asked about her future hopes in a volunteer team meeting. Linda hadn’t read the expressions in the faces of the group as they prepared to respond, despite the fact that Linda knew each member of the group well, and had spent a lot of time with them over the year. Her response had been lighthearted. However, in the knitting group, gathered around a communal, creative activity, with people from a similar cultural background, she was better able to read the expressions of those around her and make a connection with her own vulnerabilities and desires. This led to her being able to express herself more openly.

Meanwhile, back at the lost jumper. After an exhaustive search and much prayer on her part, the knitting wasn’t found. Linda had to deal with the disappointment of losing something precious to her; something that she had formed over weeks and months, that she had put much work and heart into. She wrestled through the experience of ‘prayers unanswered’, along with a nagging fear that it somehow even symbolised a possible end to her future hopes for a family back home.

These questions of ‘return’ for international students are very significant struggles: once hopes and ambitions of studying in the UK have been achieved, what do students return home to? It can lead to nervous and even superstitious feelings about the future projected into present reality.

This example from my work illustrates one of the reasons for the focus of this article: that of communicating and understanding emotions across cultural spectra. International students, by the very nature of crossing cultural boundaries and stepping well out of their comfort zones, are perhaps most likely to face feeling low because of the strains of cross-cultural adaptation. This has been defined as ‘culture shock’ or ‘culture stress’. Merriam-Webster's dictionary defines culture shock as ‘a feeling of confusion, doubt, or nervousness caused by being in a place (such as a foreign country) that is very different from what you are used to’.2 I prefer to use the term ‘culture stress’, because it gives a more accurate picture of an ongoing struggle, rather than a fleeting shock that passes in a single moment. Culture stress includes various stages, where a person responds to a new culture, sometimes described as ‘fun, fright, flight/fight, fit’.3 For every person these stages will take different lengths of time, some people taking months to work through each stage, others taking much shorter periods of time. When people experience the fight and flight/fight stages, the emotions can be very marked indeed, even if they had been expecting them – which many students are not – sometimes to the extent that others may think that the student is suffering from depression.

The complicated nature of depression and diagnosis thereof has been covered extensively by many authors and practitioners. It is a contentious topic and there are many opinions and theories about its diagnosis and treatment.4 In 2012, Professor George Christodoulou wrote an article for World Mental Health day where he names the difference between struggle and depression as being ‘between an “adaptive” and a “dysfunctional” response to an adverse life event’. He notes, however, that this distinction ‘is sometimes difficult’ to spot.5 When working with students who are battling through culture stress, where a new culture feels alien to them, these ‘adaptive’ struggles are to be anticipated and those walking alongside students need to be ready to spot the symptoms and listen through the process. Students can sometimes feel that they will not move through this difficult time and it can be hard for them to realise that even an intense struggle through culture stress will pass over time. In my own context, the fact that the majority of students I meet come to study for one-year Masters courses means that some students do not move through this painful adjustment before they return back home again.

While the focus of this article is not on depression, it has been helpful to look into research about it in order to gain greater clarity about expressions of depression in different cultures, but also to see how culture stress could perhaps be misconstrued as depression. I have also looked into material covering different communication styles, wondering whether there is a connection between a cultural style of communication and a more cultural response to struggle and depression. The World Health Organization estimates that 350 million people are affected by depression worldwide,6 which points to the growing global awareness of depression, but also to the challenge of how to spot, diagnose and treat it. While recognising the complexities within this topic, I have found it useful to focus on the World Health Organization's definition of depression as a helpful guide to work from in this article:

a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration. Moreover, depression often comes with symptoms of anxiety. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities.7

This heightened awareness of depression among the medical profession is helpful for the millions of sufferers who need to be heard and treated appropriately. In my own work I have seen how culture stress has led to depression, and it is important that those ministering to international students are aware of this reality and know how to enable students to seek help where necessary. However, culture stress and indeed depression may look different, depending on each culture, and support may be more usefully received in a variety of ways.8

This article, therefore, comes out of a desire to look more deeply at experiences of struggle that many international students face and express when they come to study in the UK – or indeed with reverse culture shock when they return back home.9 Part of my role in working in international student ministry is providing support for students coming from all over the world, but before being able to support others, it is useful to understand how struggle might be expressed in different cultures and whether there are different cultural responses to it.

Surviving in different cultures

A body of research exists that shows that humans around the world hold various emotions in common with one another – amusement, anger, fear and sadness.10 While this research shows that sadness occurs across cultures, in 2014 Andrea Horn, Catalina Cañizares and Yvonne Gómez focused on depression and showed that the concepts and ways in which depression is expressed have been found to vary. Furthermore, it is not just a case of recognising that one culture may show depression through physical symptoms and another through emotional expressions,11 it is also that different cultures have such an unseen influence on human behaviour that feelings of sadness may be shown in a completely opposite way to the one we expected, making it harder for someone of one culture to see sadness or depression in a person of another culture. An example of this was found in Japanese participants smiling when experiencing distress when they were with someone of higher status, but expressing as much negativity as their American peers when they were alone.12 It is also interesting to note that along with expressions of depression looking different across cultures, so the treatments also vary and some have argued that the Western model of psychotherapy does not fit comfortably within all cultures.13 Michael Bond, drawing from 20 years of experience as a psychologist and his observations of Chinese culture, wrote Beyond the Chinese Face, in which he concluded:

The psychotherapeutic process as practised in the West is extremely verbal, focused on the self and on the disclosure of personal information, change orientated, and non-directive . . . As such, it is simply not compatible with Chinese culture.14

Bond quotes a Chinese adage, that ‘problems within the family should not be discussed outside the family’,15 illustrating a practical outworking of a particular aspect of collectivist Chinese culture rather than a contemporary, Western, individualistic one. He describes the way in which ‘discussions with close friends, self-discipline, physical cures . . . are simply more attractive than talk therapy with stranger-professionals’.16 Although the World Health Organization attests to depression being ‘a common mental disorder’, some international students continue to battle with the idea of struggling, let alone being depressed and seeking help for it from an unknown professional.17

Of course, within the same culture, an individual will express his or her emotions differently, going through a struggle process at a different pace from another, or perhaps getting stuck in one particular ‘phase’, while others move on quickly and seemingly without as much pain.18 Still others may not go through experiences of culture shock at all and find the process of arriving in a different culture very exciting.19 So while generalisations are helpful it is important to hold that in tension with the reality that each human being is made up of an incredibly complex network of relationships, life situations and genetic characteristics, not simply the culture they come from.

In the story of any international student coming to study in the UK, there will be a variety of main characters: the international student herself/himself, the institution that the student is studying in, and people that the student comes into contact with. However, there also exists a far more important layer, one which is almost entirely invisible to people whom they meet: that of their home culture and background. This is made up of language, family, friends, food, weather, temperament, unspoken ‘norms’ and subconscious reactions to social cues. Couple this with the new social norms, pedagogy, academic standards and expectations of the academic institution that they have arrived to study in and a more complicated picture emerges. This process of cultural acclimatisation fits into the ‘adaptive’ model Christodolou wrote about,20 but can also move into a dysfunctional response.

Supporting learners and learning to support

I am mindful that I also come with my own background: representing the organisation that I work for, my own culture that I grew up in, my own family situation and the experiences that I go through each day. Part of the training that I go through is to be more aware of my own responses and the responses of those around me, having time to understand the students and thinking through their needs, as well as recognising my own. David Augsberger, an Anabaptist minister, who specialises in pastoral care across cultures and with people in conflict, describes this process of observation as having a ‘bidirectional strength’ – being able to see ourselves and to see others as we and they are.21 He states that it requires intentional thought and study because it is akin to learning about the atmosphere around us – invisible until compared to another atmosphere.22 A Malay proverb describes the process in a different way: ‘Seperti katak dibawah tempurung’ – ‘Like a frog under a coconut shell’. This proverb describes the frog thinking that the shell is the whole world until the shell is lifted and the frog meets another environment. When working across cultures it is easy to fall into a trap of thinking of international students as being those for whom the shell is being lifted, but it is important to recognise that we are all ‘frogs’: our own environments become apparent when our shells are lifted and we see someone else's background.

The intentionality of learning and observation is perhaps all the harder to undertake in the twenty-first century, where developed countries have access to speedy travel and ever-increasing sophistication in technology. It has particular relevance for the – increasingly – affluent international students studying in the UK, because a few hours of air travel leaves little time to reflect on the upcoming arrival in a new place. Technology enables cultural ‘norms’ of a host culture to be analysed from afar, along with ready communication with loved ones back home. However, the same technology can also provide escapism back to a previous life and it may switch people off to engaging with one another by ‘timing out’ into gadgets. These challenges illustrate further that those who listen to stories and engage in ‘shell lifting’ cannot operate in a vacuum.23 There is a need to engage with diversity more than ever before, to observe fully and be aware of another and of oneself throughout.

This ‘bidirectional’ process is well illustrated in Tolkein's The Hobbit. In the second chapter, the reader finds Bilbo Baggins – a home-loving hobbit – about to sit down for a meal, before being ‘gatecrashed’ by a group of dwarves and a wizard. His reaction is one of surprise, followed by anger and retreat. And yet, when he wakes the next morning to find them gone, ‘in a way he could not help feeling just a trifle disappointed. The feeling surprised him.’24 Tolkien paints the scene well – of Bilbo's ‘coconut shell’ being lifted as others came into his space, followed by the desire somehow to journey along with them rather than to return to his shell alone.

Supporting students through their and my own journey means sitting both under and outside the shell: someone who is of my own culture, and yet one who also stands with a foot in someone else's. This enables a greater opportunity to listen and share life together. In my own experience, it is more comfortable to do this when things are positive. When struggle hits, it is natural for an individual to retreat under their familiar shell; not only that, but with an expectation for others to follow. When someone retreats for comfort because they’re struggling, it may be necessary to understand where it is they have found safety and perhaps try to go there with them. This love and ‘being with’ comes out of a Christian basis of the nature of God as love,25 and is shown most particularly in the nature of Jesus (John 1:14; Philippians 2:5–8), demonstrating God's love through incarnational ministry with and among people. These foundations help to understand Christian hospitality and welcome, and they underpin international student ministry, working with students from all over an increasingly globalised world.

Amid the opportunities for many to travel and explore, some have criticised the growing trend of focusing on the similarities between cultures. Robert Hughes writes as Time magazine's art critic and, in his book The Culture of Complaint, he suggests that there is a need to step into engaging also with the differences in order to bring together a fragmented modern-day America. He suggests that it is necessary to acknowledge ‘that the differences between races, nations, cultures . . . are at least as profound and durable as their similarities; that these differences are not divagations from a European norm, but structures eminently worth knowing about for their own sake’.26 Interestingly, writing from a different context, Pat Grant has researched cultural differences within staff teams of counsellors, and he echoes the same point: to engage with the many differences in order to appreciate the individual more.27 When encountering students from all over the world, there exists the exciting challenge of having wide-ranging world-views walking alongside each other – postmodern cultures sitting alongside cultures with ‘pre-modern cultural assumptions’;28 people from one religion studying with someone from another and giving equal rights between men and women – whether or not this would take place in both cultures.29

Becoming aware of the symptoms of difference

Given inherent cultural differences from around the world and the sheer volume of material, my aim is to focus on a few cultures in the hope that through researching what others have written on the subject of communication, I can discover whether different ways of communication in cultures are echoed with different expressions of struggle and responses to it – for example, is a naturally talkative culture therefore more likely to talk about struggle? In order to do this, I have found a practical model created by Richard Lewis for helping businesses engage with cultural differences particularly helpful. This model has been used as a guide in Lewis's training to show ‘how our own culture and language affect the ways in which we organise our world, think, feel and respond,’30 and when someone showed me a picture of the model it led to wondering whether helpful connections could be drawn within my own field of work.

Richard Lewis's model divides cultures into three types:32 ‘Linear-active’, ‘Multi-active’ and ‘Reactive’. I have decided to look at six countries from these categories: the USA and the UK on the ‘Linear-active’ spectrum; China and Japan on the ‘Reactive’ spectrum; and Italy and Spain on the ‘Multi-active’ spectrum. The diagram in Figure 1 shows this division, with countries on a scale between the different nodes.

Figure 1
Figure 1

Richard Lewis's culture model31

Citation: Holiness 2, 3; 10.2478/holiness-2016-0007

Under these three different headings, Lewis describes attributes that he sees as common to these cultures. Those who fall into the Linear-active model – for example, the UK and the USA – Lewis suggests, have a tendency to be polite but direct, result-oriented, use restrained body language, and confront difficulties with logic. Multi-actives – for example, Spain and Italy – tend to multi-task, are emotional and relationship-oriented, use unrestrained body language and deal with situations by confronting with emotion. Finally, those from Reactive backgrounds – for example, Japan and China – have a tendency to listen more of the time, react to the actions of others, are polite and indirect, are harmony-oriented, using subtle body language, and tend not to use confrontation.

Notice that these headings do not suggest that Multi-actives are ‘more emotional’, nor that Linear-actives are incapable of multi-tasking. Just because those in the Reactive group tend to listen more and are perhaps more restrained in expression does not mean that they are not people-focused. It is important to note that these categories from Lewis's model are generalisations, highlighting particular traits, but do not mean that everyone from a particular culture will fit exactly within that cultural description.33

Linear-active cultures

In communication terms, the UK and the USA are included on the Linear-active scale, and research into emotional expression showed that people from these cultures tended to express emotion using individualistic words34 and wanted to express struggle to others more directly,35 rather than hold back from disclosure.

Interestingly, it has also been noticeable how facial expressions seem to be much stronger for Linear-active cultures than for Reactive cultures. A study by Rachael Jack in 2011 found that Chinese participants relied more on the subtleties in the eyes, whereas British participants’ expressions were more noticeable around the mouth and eyebrows.36Figure 2 illustrates the difference between Western Caucasians (WC) and East Asians (EA) and how they perceive six basic facial expressions of emotion.

Figure 2
Figure 2

An illustration from research on perception of facial expressions37

Citation: Holiness 2, 3; 10.2478/holiness-2016-0007

It is interesting to note the outward expressiveness of the WC faces. The subtler expressions from the EA participants links in with the careful need to establish and maintain harmony with one another, whereas a Westerner may seek to solve an issue using a logical and problem-solving attitude.

Just as, culturally, Linear-actives tended to apply logic and task-oriented methods to a problem, so also their approach to dealing with struggle was to focus on a solution, found often through one-to-one therapy, with a GP in seeking medication, and being up-front about what they felt.38 Where this didn’t happen – for example, through embarrassment – it bucked a more common trend from that culture.39 It was significant to discover that European-heritage participants were more likely to seek help when struggling with anxiety than their Chinese-heritage participants, even if both sets of participants were living in the USA, known for its more individualistic culture.40

A further question arose when looking at the categories of mental disorders, namely that Western wording and references used specifically Western psychotherapeutic models.41 An example of this is found even in the use of the word ‘depression’. Some cultures ‘do not have the English equivalent term for depression’.42 This does not mean that the experience of ‘something like depression’ doesn’t exist, but ‘rather that the experience may be embedded in a different cultural context which thus alters its meaning and subjective appraisal’.43 Junko Tanaka-Matsumi and Anthony Marsella went on to ask Japanese nationals, Japanese Americans and Caucasian Americans for words used to describe ‘depression’. Significantly, the words used by Caucasian Americans and Japanese Americans were ‘references to internal mood states’.44 A Reactive culture, such as the Japanese, may seek to live more in harmony with others and nature, but a Western model tended to name the emotion and to ‘objectify the . . . experience’.45

Linear-active cultures on the Lewis model are said to communicate in a logical way and are result-oriented in purpose. Perhaps some would think that admitting to depression would not be an acceptable part of that cultural background. However, the overwhelming amount of research shows that people within Western cultures have an open expression of struggle within an individualised model and that they benefit from a boundaried, psychotherapeutic and/or medical model of care. It is interesting to note from Jeanne Tsai and Yulia Chentsova-Dutton46 that one of the signs of depression is based on a ‘depressed mood, loss of interest in pleasurable activities and decreases in self-esteem’. This demonstrates how Linear-active cultures assume ‘having positive emotions and feeling good about oneself is a normal and healthy way of being’.47 Reactive cultures may consider these ‘disturbances’ as being about interpersonal relationships, with the locus of importance being on social harmony rather than the struggle within an individual. Perhaps Linear-active cultures run the risk of trying to ‘treat’ struggle as quickly as possible48 rather than seeing it as a natural – ‘adaptive’ – response.49

Based on the large volume of research from Linear-active cultures, there is much more I could say. However, the very availability of this research by comparison to the more limited amount available for Multi-active and Reactive cultures demands noting here, as it demonstrates the dominance of the Western psychotherapeutic model in this topic and the accessibility of help for depression within these cultures.

Reactive cultures

Reactive cultures include Japan, China and other East Asian cultures. The natural style of communication, represented on the Lewis model, is one of being good listeners, eager to compromise, accommodating and polite. The key to understanding communication in Reactive cultures is to recognise that social harmony is of paramount importance. Reading Michael Bond's book, Beyond the Chinese Face, was a fascinating journey for me in considering this topic of communication. To begin with, even the object of learning to communicate in written form has been described as ‘a Herculean chore’ – while English children need to master 26 letters in their alphabet, Chinese pupils need to learn 214 ‘radicals’.50 Education begins at a much younger age and follows a stricter pattern of rote learning and quiet respect for those in authority. This method of education and learning leads to Chinese students learning in silence and repeating what the teacher says.51 Whereas Linear-active cultures view the individual purpose to be of central importance, Reactive cultures see goals and achievement ‘as being for the benefit of a group’.52 This structured model of finding a place within society, with a strict hierarchy of superiority claims,53 can lead to individuals not expressing emotion in case it brings shame to someone in authority. Western cultures may place high value on clear and direct consultation and communication, but Chinese culture views this as ‘adversarial logic . . . as they believe it will leave lingering animosity’,54 because ‘yesterday's opponent may become tomorrow's superior’55 and ‘a word once uttered cannot be drawn back, even by a team of four horses’.56 The basic rule in this Reactive culture is to ‘honour the hierarchy first, your vision of truth second’.57

This focus on social harmony isn’t unique to Chinese culture. I have already recorded that research conducted by Tanaka-Matsumi and Marsella revealed that the descriptions of depressive feelings were different across the Western/Eastern divide more generally. It is perhaps not surprising to hear that Japanese nationals used ‘external’ words such as ‘rain, dark, worries, grey, cloudy, suicide, solitude, exams,’58 rather than internalised words. The writers concluded from their findings that whereas the list of the words from Caucasian Americans are references to individualistic ‘mood states’,59 the Japanese nationals are so influenced by their non-individualistic culture that the ‘larger social context which surrounds the individual’ dominates.60 Even the Japanese word for person – ningen – is made up from two words: ‘man’ – nin – and ‘the space between’ – gen – ‘which emphasizes the space between persons as central to an encounter’.61 If struggle is expressed, it is more likely to treat ‘emotional’ problems physically, hence trips to herbalists, masseurs and acupuncturists, as more acceptable types of treatment.62 Within Chinese culture, it is far more likely for people to talk intimately within family or close friendship circles without brief blocks of time spent with a stranger.63

Quite apart from who to talk to, however, is the issue of whether to talk at all. One therapist wrote about her observations of being a therapist in Japan:

Back in the 1980s I remember hearing young mothers encouraging their toddlers to have gaman: they were not to whine or complain but to ‘endure’ . . . However, its shadow side is that if a Japanese person talks about personal problems it can be perceived (by other Japanese people) as weak and self-indulgent.64

This raises a question about different models of care through a time of suffering. The idea of gaman, of not mentioning struggle, might feel unhelpful to our Western psychotherapeutic model, but may be the most helpful process for someone from Japan because it fits more widely into their cultural system – to which the student will return at the end of their course of study. One final passing comment is also worth noting, this time based on Chinese culture. Chairman Mao's opinion about psychology has almost certainly made a huge difference to the use of counselling and psychotherapy in China. Mao believed ‘the study of psychology was 90 per cent useless with the remaining ten per cent distorted and bourgeois phoney science’.65 It is important to note, therefore, the emotional, social and psychological hurdles a Chinese student might need to cross in order to visit first a GP, but also then a counsellor.

Multi-active cultures

On Lewis's model of communication, Multi-actives – for example, Hispanic and Mediterranean cultures – are said to be naturally outgoing and emotional, expressive about feelings and very warmly focused on relationships. Interestingly, though, finding research from Multi-active cultures about depression was much harder and there were fewer results about counselling for depression, in comparison to Linear-active (and even Reactive) cultures. Some have suggested this may be to do with economic conditions in Spanish-speaking countries, perhaps leading to fewer resources to input into research about the prevention and treatment of depression.66 Quite apart from financial constraints, though, the more immediate expression of emotion – more naturally assumed of someone from a Multi-active culture – seemed to be somehow suppressed when it came to depression.67 One student from Bulgaria – on the Multi-active spectrum – suggested that there was a ‘psy-stigma’ attached to seeing a counsellor.68 Although Multi-active and Reactive cultures look very different from each other in methods of communication and expression, one seeming more ‘open’ than another, there is a strong sense in Reactive cultures to express the problem within the family,69 whereas research in Multi-active cultures suggested that 75 per cent of participants believed that depression should be ‘experienced in solitude’.70

Where Reactive cultures have a more collectivist mentality, perhaps reflecting a less individually expressive system, Multi-active cultures tend towards being more individualistic in expression; therefore, they ‘reinforce verbal expression of negative emotion . . .’ because ‘sharing emotions represents a good form of coping’.71 It is interesting, considering both the strong sense of individualism in Western countries, but also the communicative nature of emotions in Multi-active cultures, to find research showing a stigmatisation of depression in these same cultures. Figure 3 is a table showing the results from research undertaken in Europe, which reveals the suspicion felt by these participants about people suffering with depression. A higher percentage of participants from Spain even showed unwillingness to offer a job to someone with depression, whereas participants in Germany – a Linear-active culture – had a lower level of concern. Notice, however, the percentage levels in Spain that showed that this same stigma was not carried over into family support.

Figure 3
Figure 3

Percentage of respondents endorsing stigmatising attitudes towards depression72

Citation: Holiness 2, 3; 10.2478/holiness-2016-0007

Having seen the descriptions from Richard Lewis's model, I wonder whether Linear-active cultures see Multi-active cultures as just ‘more expressive and exuberant’ versions of themselves; and perhaps Multi-active cultures see Linear-actives as being more repressed! And yet, at the point of need, these cultures seem to shift in expression – Multi-actives becoming cautious about expressing depression, but Linear-actives now becoming more overt in naming how they feel. Reactive cultures, while being less forthright in expression most of the time, may come across as more positive when struggling, especially when with people in seniority – in contrast to Linear-active participants, who tended to be consistent in behaviour whatever the context.73 A tutor may be forgiven for being perplexed about why an East Asian student is indicating that they are struggling, when on the surface she smiles and is eager to please.74 Michael Bond gives a more detailed observation about the role of ‘respectful silence’ in learning in Chinese schools.75 This has huge impact for British pedagogy when Chinese students come to study in the UK.

Symptoms, expressions and words for depression

Another interesting issue to note at this point is about symptoms of struggle and depression: that of ‘guilt feelings’ in Western cultures, and notably that of presenting depressive symptoms in feelings of guilt. Some have connected this with the Judeo-Christian tradition and individualism that grew from out of Western cultures.76 Further, Phillip Kendall and Constance Hammen found that non-Western cultures – particularly East Asian and African cultures – presented depression in bodily symptoms of pain and weakness rather than in feelings of self-reproach.77 Thus, quite apart from different cultural expressions of communication and different ways of expressing depression, there are also different ways of experiencing depression.

A Western model of treating mental illness ‘with medication and some cognitive restructuring’ has been challenged by some who see it as an inadequate model in comparison to community providing the first and main line of support.78 While I agree that this challenges a malaise in Western society that has tended towards an isolated experience of living, this challenge doesn’t go to the heart of the cultural differences: it is not just that Western societies could become stronger in community care towards others. It is rather that someone from East Asia, for example, may not see themselves as an individual in need of community, but rather that their very identity is made up more profoundly of those with whom they relate. If seeking societal harmony is of greater importance than how an individual feels,79 then being in a country that doesn’t operate in that way is far more fundamentally difficult.

Take an example of a student from China, whose fear of failure and the shame that would bring to his family drives him to work longer and longer hours. His moods become lower and his health deteriorates. He doesn’t understand his lecturer, but to express this would bring shame to the lecturer – someone older than him and in a position of authority – so he works all the harder. This problem is not just about struggling to understand, but is about honouring relationships with his family back home – who are counting on him to succeed – as well as his seniors in his host culture. A tutor may observe the work output and see it as a huge achievement – which it is – but the tutor may not realise that the student may well be crying out for help.

Conclusion – a complementary paradigm?

I started this article with a concern for international students and how to spot struggles they may experience, particularly given that different cultures may express struggle and depression differently. The Lewis model gave me tools to understand how different cultures communicate, and how that presents in voicing – or not voicing – struggle and depression. Cultures where people use more logical methods of communication on Lewis's model do not necessarily shy away from discussing the complexities of struggle and depression; and yet people from more expressive cultures seem to hold a greater stigma with regards to depression and tend not to reveal so much of their struggle. More private and hierarchical cultures sometimes hold the group in higher regard than the individual, but struggle is communicated within intimate family groups and handled together more openly. The combination of the variety of ways in which cultures communicate and, separately, the different ways that people express struggle, make it that much harder to work through it when in a cross-cultural environment. Learning to be aware of my own ‘shell’ and the very different ‘shells’ of those from other cultures increases awareness of the problems of cross-cultural communication. Being able to lift those shells, even a little, helps to take that first significant step of comprehending the complexities of another's culture and experiences, which are so hard to understand without exposure and interaction.80 I have gained a deeper appreciation of the task of living alongside – and living with one foot under – others’ ‘shells,’ while also participating within and under a larger ‘shell’ or story.81 This feeds into my own theological reflection and ministry to and with individuals from around our diverse globe.

Ten days after losing her knitting, Linda was cycling home, a route she had searched repeatedly in the weeks previously, only to find her knitted baby jumper in good condition lying next to the path. Elated, she returned to her host family, who rejoiced with her. It was a deeply profound faith experience for her, and a sense of hope grew for her future return home.

I began with a story about Linda's knitting and I think it is right to finish here too as I reflect on what it means for me and other Christians engaging with international students to accompany them. These small moments of deep significance for international students are so easily missed. Seeing the background behind the story being told is very hard to spot, particularly when communicated across cultures. In The Integrity of Pastoral Care, David Lyall reflects on the progression of practical theology over the decades and concludes that ‘theological reflection is only possible when we listen to the stories of individuals and communities as well as to the stories which have shaped the Church and its message’.82 Listening to stories occurs when we walk alongside people – whether over long periods of time or more briefly – and we take time to understand across the cultures. The knitting group grew out of a desire to enjoy creativity together. Something beautiful grew out of this small group. It wasn’t on a term card, or part of a strategic plan, or providing professional care for those in need. And yet it did provide care. Linda later told me of a Japanese friend who was incredibly lonely, so much so that she ended up at the university GP who prescribed antidepressants and counselling. She felt so ashamed about this that she didn’t tell her parents, who would have disagreed with this form of medical treatment. Linda told me quietly, ‘I think the knitting group might have helped her too,’ but by that point the student was considering quitting her course. She later returned home.

Journeying with international students as they struggle in no way detracts from the importance and necessity of professional care, but it has been helpful to reflect on a complementary paradigm of care. This pattern of care began in a different culture, and evolved over thousands of years before the Western psychotherapeutic model grew. It continues to take place in everyday stories that people live and tell around the world today. Drawing alongside international students is a multifaceted ministry, most particularly because, while it comes out of a desire to reflect God's love incarnate (Philippians 2:5–8), it also requires careful consideration of doing so among people of different faiths and backgrounds, who live on the edge of the culture they now inhabit, and often particularly on the edge of the church community in which I dwell and from which I operate.

It can be hard to spot our own cultural idiosyncrasies until we step outside them, hard to recognise that what is normal for one seems strange to another. Meeting one another not only provides the genuine possibility of discovering another person's story – and for the other to do the same about us – but also for us to better understand ourselves. I think a crucial part of my own journey in ministry has been learning both the joys of journeying with others from around the world and also the often inherent awkwardness of it. There are times when it is uncomfortable to communicate and easier to retreat. It has brought a new light and perhaps a deeper meaning for me to the text, ‘And the Word became flesh and lived among us’ (John 1:14).83

Bibliography

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  • Atanassov, N. 2013. ‘Out from the Underground’, Therapy Today 24(7) (September): 23–26. Available from British Association for Counselling and Psychotherapy, BACP House, 15 St John's Business Park, Lutterworth LE17 4HB.

  • Augsberger, D. 1986. Pastoral Counseling across Cultures. Philadelphia, PA: Westminster Press.

  • Bennett, Z. 2013. Using the Bible in Practical Theology: Historical and Contemporary Perspectives. Farnham: Ashgate.

  • Bennet Moore, Z. 2002. Introducing Feminist Perspectives on Pastoral Theology, Sheffield: Continuum.

  • Blazer, D. 2005. The Age of Melancholy. New York: Routledge.

  • Bond, M. 1991. Beyond the Chinese Face. Oxford: Oxford University Press.

  • Butcher, A. 2002. ‘A Grief Observed: Grief Experiences of East Asian International Students Returning to their Countries of Origin’, Journal of Studies in International Education 6(4): 354–368. Available from: http://jsi.sagepub.com/content/6/4/354 (accessed July 2015).

    • Crossref
    • Export Citation
  • Butcher, A., McGrath, T. and Stock, P. 2007. ‘Friends and Allies: The Impacts of Returning Asian Students on New Zealand–Asia Relationships’, Outlook Edition 05 (August): 1–22.

  • Callow, R. 2014. ‘Lifting the Lid on Cross-Cultural Pastoral Care’, Insight Journal: A Journal for International Student Ministry in the UK 13 (Winter 2014/2015): 11–14.

  • Christodoulou, G. 2012. ‘Depression as a Consequence of the Economic Crisis’, in Depression: A Global Crisis, pp. 14–18. Available from: http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf (accessed June 2015).

  • Comas, A. and Alvarez, E. 2004. ‘Knowledge and Perception about Depression in the Spanish Population’, in PubMed.gov US National Library of Medicine, National Institutes of Health 32(6) (November–December): 371–376. Abstract only. Available (in Spanish) from: http://www.ncbi.nlm.nih.gov/pubmed/15529227 (accessed October 2015).

  • Dimitra. 2013. ‘Out from the Underground’, Therapy Today 24(7) (September): 9.

  • Fernández, I., Carrera, P., Páez, D. and Sánchez, F. 2008. ‘Interdependent Self-Construal, Competitive Attitudes, Culture and Emotional Reactions on Sadness’, Psychologia 51: 214–234. Available from: https://www.researchgate.net/profile/Flor_Sanchez/publication/228482981_Interdependent_selfconstrual_competitive_attitudes_culture_and_emotional_reactions_on_sadness/links/09e4150a64c7ec7226000000.pdf (accessed October 2015).

    • Crossref
    • Export Citation
  • Gerkin, C. 1984. The Living Human Document: Re-Visioning Pastoral Counseling in a Hermeneutic Mode, Nashville, TN: Abingdon Press.

  • Graham, E. 1996. Transforming Practice, London: Mowbray.

  • Grant, P. 1999. ‘Issues of Cultural Difference in Staff Teams and Client Work’, in Lees, J. (ed.), Clinical Counselling in Context: An Introduction. New York: Routledge.

  • Hitchens, S. 2013. ‘Stoicism in Tokyo’, Therapy Today 24(7) (September): 9.

  • Hofman, S., Asnaani, A. and Hinton, D. 2010. ‘Cultural Aspects in Social Anxiety and Social Anxiety Disorder’, Depression and Anxiety 27(12): 1117–1127. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075954/ (accessed November 2015).

    • Crossref
    • Export Citation
  • Holder, S. 1992. ‘Culture Shock: Personal and Organizational Responses to an Expatriate Life-style’, in Noonan, E. and Spurling, L. (eds), The Making of a Counsellor. New York: Routledge.

  • Horn, A., Cañizares, C. and Gómez, Y. 2014. ‘Prevention of Adolescent Depression in the Spanish-Speaking World’, Int J Environ Res Public Health 11(6) (June). Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4078541/ (accessed July 2015).

  • Hughes, R. 1993. The Culture of Complaint: The Fraying of America. New York: Grand Central Publishing.

  • Jack, R. 2011. ‘Perception of Facial Expressions Differs across Cultures’, American Psychological Association (1 September). Abstract. Available from: http://www.apa.org/news/press/releases/2011/09/facial-expressions.aspx. Reprinted with permission.

  • Kendall, P. and Hammen, C. 1995. Abnormal Psychology, Boston, MA: Houghton Mifflin.

  • Lartey, E. 2003. In Living Colour. London: Jessica Kingsley.

  • Leach, J. and Paterson, M. 2010. Pastoral Supervision: A Handbook. London: SCM Press.

  • Lewis, R. D. 2016. When Cultures Collide. Available from: http://www.crossculture.com/product/when-cultures-collide (accessed January 2014).

  • Lister-Ford, C. 2007. A Short Introduction to Psychotherapy. London: Sage Publications.

  • Lyall, D. 2001. Integrity of Pastoral Care. London: SPCK.

  • Marcus, M., Taghi Yasamy, M., van Ommeren, M., Chisholm, D. and Saxena, S. 2012. Depression: A Global Public Health Concern. Available from: http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf (Accessed: June 2015)

  • Munizza C., Argentero, P., Coppo, A., Tibaldi, G., Di Giannantonio M., Picci, R. L. and Rucci, P. 2013. ‘Public Beliefs and Attitudes towards Depression in Italy: A National Survey’, in PLOS ONE 8(5): e63806. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0063806 (accessed October 2015).

    • Crossref
    • Export Citation
  • Nauert, R. 2015. ‘Are Emotions Universal?’, Psych Central. Available from: http://psychcentral.com/news/2010/01/27/are-emotions-universal/10999.html (accessed August 2015).

  • Pescosolido, B., Olafsdottir, S., Martin, J. and Long, J. S. 2008. ‘Cross-Cultural Aspects of the Stigma of Mental Illness’, in Arboleda-Flórez, J. and Sartorius, N. (eds), Understanding the Stigma of Mental Illness: Theory and Interventions. Chichester: John Wiley & Sons Ltd.

  • Robinson, S. 2004. Ministry among Students. Norwich: Canterbury Press.

  • Royal College of Psychiatrists. 2011. The Mental health of Students in Higher Education, College report CR166. London: Royal College of Psychiatrists.

  • Sartorious, N. 1983. ‘Depressive Disorders in Different Cultures’, in World Health Organization Collaborative Study 458. Available from: http://apps.who.int/iris/bitstream/10665/37139/1/9241560754_eng.pdf?ua=1 (accessed August 2015).

  • SparkNotes Editors. 2005. Emotion, in SparkNotes LLC. Available from: http://www.sparknotes.com/psychology/psych101/emotion/section1.rhtml (accessed July 2015).

  • Tanaka-Matsumi, J. 2001. ‘Abnormal Psychology and Culture’, in Matsumoto, D. (ed.), The Handbook of Culture and Psychology. New York: Oxford University Press.

  • Tanaka-Matsumi, J. and Chang, R. 2002. ‘What Questions Arise when Studying Cultural Universals in Depression?’, Online Readings in Psychology and Culture 10(2). Available from: http://scholarworks.gvsu.edu/orpc/vol10/iss2/2/ (accessed May 2015).

  • Tanaka-Matsumi, J. and Marsella, A. 1976. ‘Cross-Cultural Variations in the Phenomenological Experience of Depression: I. Word Association Studies’, Journal of Cross-Cultural Psychology 7(4) (December): 379–396. Available from: http://jcc.sagepub.com/content/7/4/379.short (accessed May 2015).

    • Crossref
    • Export Citation
  • Tolkien, J. R. 1937. The Hobbit, London: George Allen & Unwin.

  • Tsai, J. and Chentsova-Dutton, Y. 2010. ‘Understanding Depression across Cultures’, in Gotlib, I. and Hammen, C. (eds), Handbook of Depression. London: The Guildford Press. Available from: http://psych.stanford.edu/~tsailab/PDF/Understanding%20depression%20across%20Cultures.pdf (accessed: May 2015).

  • Veling, T. 2005. Practical Theology. Maryland, NY: Orbis Books.

  • Welch, E. 2011. ‘Does Depression Look the Same around the World?’, CCEF (May). Available from: http://www.ccef.org/resources/blog/does-depression-look-same-around-world (accessed: July 2013).

  • World Mental Health Day. 2012. Depression: A Global Crisis: http://wfmh.com/wp-content/uploads/2013/11/2012_wmhday_english.pdf (accessed October 2015), now available from http://www.squarepharma.com.bd/neurotale/Neurotale_2_2012.pdf (accessed August 2016).

Footnotes

1

Veling 2005, p. 159.

4

Indeed, Blazer challenges the notion that depression is simply to be viewed as an individualised, medicalised disease and points to a wider, sociological dimension to research about depression. Blazer 2005, pp. 6–8.

9

Returning home and experiencing reverse culture shock can sometimes affect international students even more than the initial culture shock on arrival in the UK. Butcher 2002, p. 361.

11

Although, see Sartorious 1983, pp. 57 and 125–126, and Bond 1991 p. 92.

13

Grant 1999, p. 115.

14

Bond 1991, p. 105.

15

Bond 1991, p. 91.

16

Bond 1991, p. 106.

23

Lartey 2003, pp. 40–41.

26

Hughes 1993, p. 100.

27

Grant 1999, p. 107.

28

Lartey 2003, pp. 40–41.

29

See, for example, Edinburgh University's ‘Equality and Diversity’ mandate: www.ed.ac.uk/equality-diversity/about/equality-diversity.

50

Bond 1991, p. 27.

51

Bond 1991, p. 32.

52

Bond 1991, p. 17.

53

Bond 1991, p. 36.

54

Bond 1991, p. 66.

55

Bond 1991, p. 55.

56

Chinese adage, quoted in Bond 1991, p. 53.

57

Bond 1991, p. 83.

62

Bond 1991, p. 103.

63

Bond 1991, p. 91.

65

Bond 1991, p. 93.

69

Bond 1991, p. 91.

75

Bond 1991, p. 29.

78

Lister-Ford 2007, p. 81, and Welch 2011, p. 2.

80

Veling 2005, p. 159.

81

Lyall 2001, p. 181.

82

Lyall 2001, p. 31.

83

NRSV.

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • Altarriba, J., Basnight, D. and Canary, T. 2003. ‘Emotion Representation and Perception across Cultures’ in Online Readings in Psychology and Culture 4(1). Available from: http://www.wwu.edu/culture/altarriba2.htm (accessed October 2015).

  • Atanassov, N. 2013. ‘Out from the Underground’, Therapy Today 24(7) (September): 23–26. Available from British Association for Counselling and Psychotherapy, BACP House, 15 St John's Business Park, Lutterworth LE17 4HB.

  • Augsberger, D. 1986. Pastoral Counseling across Cultures. Philadelphia, PA: Westminster Press.

  • Bennett, Z. 2013. Using the Bible in Practical Theology: Historical and Contemporary Perspectives. Farnham: Ashgate.

  • Bennet Moore, Z. 2002. Introducing Feminist Perspectives on Pastoral Theology, Sheffield: Continuum.

  • Blazer, D. 2005. The Age of Melancholy. New York: Routledge.

  • Bond, M. 1991. Beyond the Chinese Face. Oxford: Oxford University Press.

  • Butcher, A. 2002. ‘A Grief Observed: Grief Experiences of East Asian International Students Returning to their Countries of Origin’, Journal of Studies in International Education 6(4): 354–368. Available from: http://jsi.sagepub.com/content/6/4/354 (accessed July 2015).

    • Crossref
    • Export Citation
  • Butcher, A., McGrath, T. and Stock, P. 2007. ‘Friends and Allies: The Impacts of Returning Asian Students on New Zealand–Asia Relationships’, Outlook Edition 05 (August): 1–22.

  • Callow, R. 2014. ‘Lifting the Lid on Cross-Cultural Pastoral Care’, Insight Journal: A Journal for International Student Ministry in the UK 13 (Winter 2014/2015): 11–14.

  • Christodoulou, G. 2012. ‘Depression as a Consequence of the Economic Crisis’, in Depression: A Global Crisis, pp. 14–18. Available from: http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf (accessed June 2015).

  • Comas, A. and Alvarez, E. 2004. ‘Knowledge and Perception about Depression in the Spanish Population’, in PubMed.gov US National Library of Medicine, National Institutes of Health 32(6) (November–December): 371–376. Abstract only. Available (in Spanish) from: http://www.ncbi.nlm.nih.gov/pubmed/15529227 (accessed October 2015).

  • Dimitra. 2013. ‘Out from the Underground’, Therapy Today 24(7) (September): 9.

  • Fernández, I., Carrera, P., Páez, D. and Sánchez, F. 2008. ‘Interdependent Self-Construal, Competitive Attitudes, Culture and Emotional Reactions on Sadness’, Psychologia 51: 214–234. Available from: https://www.researchgate.net/profile/Flor_Sanchez/publication/228482981_Interdependent_selfconstrual_competitive_attitudes_culture_and_emotional_reactions_on_sadness/links/09e4150a64c7ec7226000000.pdf (accessed October 2015).

    • Crossref
    • Export Citation
  • Gerkin, C. 1984. The Living Human Document: Re-Visioning Pastoral Counseling in a Hermeneutic Mode, Nashville, TN: Abingdon Press.

  • Graham, E. 1996. Transforming Practice, London: Mowbray.

  • Grant, P. 1999. ‘Issues of Cultural Difference in Staff Teams and Client Work’, in Lees, J. (ed.), Clinical Counselling in Context: An Introduction. New York: Routledge.

  • Hitchens, S. 2013. ‘Stoicism in Tokyo’, Therapy Today 24(7) (September): 9.

  • Hofman, S., Asnaani, A. and Hinton, D. 2010. ‘Cultural Aspects in Social Anxiety and Social Anxiety Disorder’, Depression and Anxiety 27(12): 1117–1127. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075954/ (accessed November 2015).

    • Crossref
    • Export Citation
  • Holder, S. 1992. ‘Culture Shock: Personal and Organizational Responses to an Expatriate Life-style’, in Noonan, E. and Spurling, L. (eds), The Making of a Counsellor. New York: Routledge.

  • Horn, A., Cañizares, C. and Gómez, Y. 2014. ‘Prevention of Adolescent Depression in the Spanish-Speaking World’, Int J Environ Res Public Health 11(6) (June). Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4078541/ (accessed July 2015).

  • Hughes, R. 1993. The Culture of Complaint: The Fraying of America. New York: Grand Central Publishing.

  • Jack, R. 2011. ‘Perception of Facial Expressions Differs across Cultures’, American Psychological Association (1 September). Abstract. Available from: http://www.apa.org/news/press/releases/2011/09/facial-expressions.aspx. Reprinted with permission.

  • Kendall, P. and Hammen, C. 1995. Abnormal Psychology, Boston, MA: Houghton Mifflin.

  • Lartey, E. 2003. In Living Colour. London: Jessica Kingsley.

  • Leach, J. and Paterson, M. 2010. Pastoral Supervision: A Handbook. London: SCM Press.

  • Lewis, R. D. 2016. When Cultures Collide. Available from: http://www.crossculture.com/product/when-cultures-collide (accessed January 2014).

  • Lister-Ford, C. 2007. A Short Introduction to Psychotherapy. London: Sage Publications.

  • Lyall, D. 2001. Integrity of Pastoral Care. London: SPCK.

  • Marcus, M., Taghi Yasamy, M., van Ommeren, M., Chisholm, D. and Saxena, S. 2012. Depression: A Global Public Health Concern. Available from: http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf (Accessed: June 2015)

  • Munizza C., Argentero, P., Coppo, A., Tibaldi, G., Di Giannantonio M., Picci, R. L. and Rucci, P. 2013. ‘Public Beliefs and Attitudes towards Depression in Italy: A National Survey’, in PLOS ONE 8(5): e63806. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0063806 (accessed October 2015).

    • Crossref
    • Export Citation
  • Nauert, R. 2015. ‘Are Emotions Universal?’, Psych Central. Available from: http://psychcentral.com/news/2010/01/27/are-emotions-universal/10999.html (accessed August 2015).

  • Pescosolido, B., Olafsdottir, S., Martin, J. and Long, J. S. 2008. ‘Cross-Cultural Aspects of the Stigma of Mental Illness’, in Arboleda-Flórez, J. and Sartorius, N. (eds), Understanding the Stigma of Mental Illness: Theory and Interventions. Chichester: John Wiley & Sons Ltd.

  • Robinson, S. 2004. Ministry among Students. Norwich: Canterbury Press.

  • Royal College of Psychiatrists. 2011. The Mental health of Students in Higher Education, College report CR166. London: Royal College of Psychiatrists.

  • Sartorious, N. 1983. ‘Depressive Disorders in Different Cultures’, in World Health Organization Collaborative Study 458. Available from: http://apps.who.int/iris/bitstream/10665/37139/1/9241560754_eng.pdf?ua=1 (accessed August 2015).

  • SparkNotes Editors. 2005. Emotion, in SparkNotes LLC. Available from: http://www.sparknotes.com/psychology/psych101/emotion/section1.rhtml (accessed July 2015).

  • Tanaka-Matsumi, J. 2001. ‘Abnormal Psychology and Culture’, in Matsumoto, D. (ed.), The Handbook of Culture and Psychology. New York: Oxford University Press.

  • Tanaka-Matsumi, J. and Chang, R. 2002. ‘What Questions Arise when Studying Cultural Universals in Depression?’, Online Readings in Psychology and Culture 10(2). Available from: http://scholarworks.gvsu.edu/orpc/vol10/iss2/2/ (accessed May 2015).

  • Tanaka-Matsumi, J. and Marsella, A. 1976. ‘Cross-Cultural Variations in the Phenomenological Experience of Depression: I. Word Association Studies’, Journal of Cross-Cultural Psychology 7(4) (December): 379–396. Available from: http://jcc.sagepub.com/content/7/4/379.short (accessed May 2015).

    • Crossref
    • Export Citation
  • Tolkien, J. R. 1937. The Hobbit, London: George Allen & Unwin.

  • Tsai, J. and Chentsova-Dutton, Y. 2010. ‘Understanding Depression across Cultures’, in Gotlib, I. and Hammen, C. (eds), Handbook of Depression. London: The Guildford Press. Available from: http://psych.stanford.edu/~tsailab/PDF/Understanding%20depression%20across%20Cultures.pdf (accessed: May 2015).

  • Veling, T. 2005. Practical Theology. Maryland, NY: Orbis Books.

  • Welch, E. 2011. ‘Does Depression Look the Same around the World?’, CCEF (May). Available from: http://www.ccef.org/resources/blog/does-depression-look-same-around-world (accessed: July 2013).

  • World Mental Health Day. 2012. Depression: A Global Crisis: http://wfmh.com/wp-content/uploads/2013/11/2012_wmhday_english.pdf (accessed October 2015), now available from http://www.squarepharma.com.bd/neurotale/Neurotale_2_2012.pdf (accessed August 2016).

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