A recent graduate from a renowned international high school in Shanghai, Alex (pseudonym, names in this article have been changed to ensure confidentiality) was only 13 when he first cut himself. It was after school, and as he cried alone in his bedroom he took a pair of scissors and made slices on his arm, then his back. Along with the blood came a temporary feeling of relief. At that point, Alex had already been battling depression for many months. In every waking moment, he felt as though he was sinking further and further into a deep, bottomless hole. "I picked up the scissors because I couldn't take it anymore. I wanted everything to stop," he recalls, voice quavering with emotion even now as he reflects on his dark past. Alex is not alone. In fact, many international students in the city grapple with various mental health issues, be it depression, self-harm, anxiety or an eating disorder. The Global Times Metro Shanghai investigates.On paper, Shanghai's small yet elite population of international teens have a picturesque life: wealthy parents, gated communities, private drivers, prestigious educations and often an army of ayi (domestic helpers) who pick up after them.But many of these children often struggle in silence, caught between growing up in an alien culture, the pressure to live up to expectations placed on them by their high-class lifestyles yet stifled by China's general stigma of mental illness.Depression and other mental disorders are in fact a hot topic in China currently, with several reports recently addressing the rapid rise of depression, anxiety and suicides occurring in the country's local schools.However, expat teens and international students face many unique challenges of their own.Dr Timothy A. Kelly, a psychologist who for the past seven years has treated numerous expat teens at private Western hospitals and clinics in Shanghai, estimates that around 33 percent of his practice involves dealing with international students aged 13 to 18, primarily from expat-oriented private schools.When asked what the biggest triggers are for these international students, Dr Kelly immediately responds: "stress, stress, stress."He elaborated that not only are the academic expectations at these private schools extremely high, but so are the social pressures that come with such competitive environments."Even if a teen is doing fairly well (academically), they're often made to feel kind of lacking if they're not right at the top of the class. And even if the teen is good at keeping and making friends, the social structures at these schools can be so powerfully negative if anything goes wrong."Chinese and expat parents' expectations that "their teen should shine and sparkle, both academically and socially" place added pressure on their lives, he said, adding that the constant stress that expat teens face can easily lead to full-blown mental illness, especially if not properly addressed.At some of what Dr Kelly deems Shanghai's more "negative schools," the social environment is extremely harsh and students will develop a hierarchical dog-eat-dog mentality.This, along with the dominance of social media among millennials, has proved destructive to these adolescents' well-being."Let's say the kid get out of sorts (quarrels) with someone who's popular. That popular kid will say and do things that are really vicious and start driving the other kid down," Dr Kelly said.

Many international students in Shanghai grapple with various mental health issues, be it depression, self-harm, anxiety or an eating disorder. Photos: CFP

At an age where social interactions play a huge role in one's happiness, teens often take rumors, gossip and conflicts deeply to heart. Alex himself cited negative social interactions as one of the stressors that triggered his depression."It seemed like a lot of people hated other people (at his school). Classmates were backstabbing each other and I was always stuck in the middle. Just the pain and negativity of it all ... it was scary."International students such as Alex also have to wrestle with the confusion and inner turmoil that comes with being a "third culture kid" (TCK).TCKs are individuals who grow up abroad in a culture different to that of their parents.As TCKs frequently move from country to country according to what their parents' profession designates, they often lack a sense of belonging or rootedness that non-TCKs have.Being forced to constantly leave behind friends, pets and familiar surroundings at an early age is difficult.Such perpetual transition often involves feelings of deep loss, which engenders grief; when unresolved, grief metastasizes into depression.Amanda's family moved from the US while she was a sophomore in high school. She was subsequently enrolled at one of Shanghai's most expensive - and competitive - international schools.With sparkling eyes and a bright smile, Amanda outwardly appears to be a happy-go-lucky girl. However, she too has endured hardship during her time in China.The culture shock that she initially faced along with the struggle to adapt to a new school environment was a big burden for such a young person."My mental state was much more introverted and negative (once she arrived here) than it had been," Amanda told the Global Times, explaining that the vastly different social expectations at her new school made her feel as though she had to "shift her personality depending on where [she] was and who [she] was with."However, the biggest mental and physical battle that Amanda faced was coping with China's unique beauty standards.She quickly became much more self-conscious about fitting in with the other girls, especially in her dance classes, where a female's form is of utmost importance."The pressure to have a dancer's body in a country where the average body size is much smaller than an American's eventually led to a battle with bulimia," Amanda said."I needed to be able to have some sort of control on my life. But in reality, I was out of control."She recalls how emotionally drained she felt when her Chinese ballet instructor would constantly attack her with comments like "you've gotten fat!" Sometimes, her teacher had other students translate her criticisms for Amanda in front of the entire class.The pain and humiliation she endured fueled her negative body image and eating disorder.One might ask, then, what these prestigious schools are doing to address the deteriorating mental health of their respective student bodies. According to Dr Kelly, it varies from school to school."In general, most but not all schools understand the importance of attending to these things (depression, anxiety, self-harm). They've got counselors, support programs, a referral network of professionals and sometimes offer parent-training courses," Dr Kelly said.The schools that are less attentive or effective in addressing various mental illnesses, however, often also have teaching and administrative staff that are not particularly warm or supportive.Katie, a student at one such "inattentive" international school in Shanghai, complained that they only had one counselor, who wasn't very welcoming. "No one really went to her," Katie lamented.The schools themselves are also subject to high degrees of social pressure, as the commercial aggressiveness that takes place between them to woo wealthy parents and maintain elite reputations can also result in favoritism between the staff and the highest-scoring students."With high-achieving popular kids, the school supports them a thousand percent. But with someone who kind of falls behind, they tend to be berating more than anything else. And that just maximizes the pain of what the kid is dealing with," Dr Kelly said.Amanda has similar sentiments about her school, which she said took a "passive" approach to addressing their students' mental health issues."I never went to our counselor for help when I was feeling overwhelmed, the reason being that it seemed like stress and hardship were actually praised as signs of good work."When Alex first started having suicidal thoughts, he did turn to his school counselor for solace. They met a few times.After facing a particularly troubling conflict at school, Alex couldn't hold his pain in anymore. He ended up crying and beating the walls of his counselor's office.The counselor tried to appease him at first, but then called security guards to physically restrain Alex. His parents and the principal were brought in and he was ultimately suspended for a week.Only 13 years old at the time, Alex was quite traumatized by the experience of having security guards pin him down and then being forced to leave school. It was, he said, the ultimate betrayal by his counselor."In that moment, I felt abandoned because I had really developed a bond with my counselor. His office was like a sanctuary and a safe place to talk about my problems."Today, Alex just hopes that Shanghai's international schools will start taking a more professional approach to student counseling, offering confidential safe spaces where students can vent freely and honestly without fear of being punished or suspended.Alex, Amanda, Katie and even Dr Kelly all agree that it is high time that these institutions also begin to recognize just how common depression, anxiety, self-harm and eating disorders are among their student bodies, even if they are not talked about openly."You're not alone. It's not unusual, and it doesn't mean you're broken. But it does mean you need help," Dr Kelly stressed.Beyond the ivy-entwined gates of Shanghai's international school system, counseling is in fact widely accessible at most expat-oriented clinics and even local public facilities such as the Community Center Shanghai, which opened in 2003 and has over 20 counselors from across the globe.Troubled expat teens can also call Lifeline Shanghai, an English-speaking support hot line that offers free and confidential support, at 6279-8990.