Monthly Archives: January 2016

Apps4Counseling: What’s in your digital toolbox?

By Maxine L. Rawlins and Elizabeth A. Hughes January 27, 2016

The increase in mobile device ownership and usage — primarily smartphones and tablets, in that order — has been remarkable for all segments and age groups of the U.S. population. The Branding-Images_toolsindependent market research company eMarketer estimated that just under 2 billion people worldwide would own a smartphone by the end of 2015. Although tablet ownership and usage is generally lower than that for smartphones, the figures are still impressive. Worldwide and U.S. tablet sales for 2015 were estimated to reach 1 billion and 156 million, respectively, which represents a doubling of worldwide sales when compared with 2012 figures.

Among some other U.S. trends in mobile device usage and social networking as reported by various sources:

  • Mobile device ownership and social media usage have increased for all age groups (Pew Research Center, 2015).
  • Smartphones and tablets are used more than any other electronic device by children ages 4-14, prompting the toy division president of market research firm NPD to conclude that “technology devices are as much staples for American families as traditional toys” (NPD, 2014)
  • Increased mobile device usage by children has prompted some schools to adopt hybrid learning BYOD (Bring Your Own Device) policies (Ed Tech, 2015).
  • Almost one-third of adult smartphone owners say they couldn’t imagine living without their smartphone (Pew Research Center, 2014, 2015).
  • Young people, “minorities” and those with lower socioeconomic status (SES) levels are likely to be “smartphone dependent” for Internet access (Pew Research Center, 2015).
  • The highest rates of social networking were reported by young adults, African Americans and those with higher levels of SES and/or education (Pew Research Center, 2014, 2015).
  • Approximately 51.5 percent of millennials in higher education settings report using their smartphones to monitor their personal health (Domo, 2015).

Incorporating mobile devices into counseling

Professional usage of mobile devices by counselors has not sufficiently reflected an awareness of or capitalized on the dramatic shifts in the ways in which large numbers of the U.S. population currently communicate, learn, socialize and obtain, manage and share information. Put differently, counseling, counselor education and wellness promotion strategies have not, for the most part, kept pace with the way that people currently live in and interact with their immediate and larger world. The benefits of actively integrating mobile devices into the teaching and practice of counseling are numerous. These benefits include:

  • Portability
  • Flexibility
  • Effectiveness at embracing multiple learning styles and multiple “intelligences” because of the inherent kinesthetic, auditory and visual components of mobile devices
  • Ability to be customized to match the developmental level, culture, etc., of the target group
  • Range of standard accessibility features
  • Effectiveness with a wide range of cohorts, not only “digital natives”
  • Engaging and interactive nature
  • Potential to enhance brain neuroplasticity and neurogenesis
  • Ability to use a single device with an individual or group of clients/students
  • The ever-increasing plethora of high-quality apps that are free or low cost, many of which can be used across same-system mobile devices

Put another way, an informed use of mobile devices in counseling, counselor education and wellness promotion can significantly increase the size, creativity and effectiveness of our intervention toolboxes. The importance of meeting our clients and students where they are should not be minimized.

Despite the multiple potential benefits of incorporating mobile devices into our work as counselors, there are some primary challenges regarding their use. These include:

  • Reduced counselor experience, confidence and competence, as well as limited research on the use of technology (especially mobile devices) that might enhance our work as counselors
  • The less robust nature of mobile devices compared with computer-based software applications
  • The general “functional fixedness” of counselors
  • Concerns regarding confidentiality
  • Concerns that technology will depersonalize the counseling experience
  • Privacy concerns
  • The “digital divide”

Current project: Goals, genesis and focus

The goal of our current multiyear mobile device and app curation project is to explore ways in which iOS and Android mobile devices and related apps can be used to enhance counseling and therapy, counselor education, training and wellness promotion. Initial emphasis was on the iPad. The hope is that the results of the project will significantly streamline the app search process for counselors, human service and other allied health providers, counselor educators, trainers and counselor education students, and increase the ways and frequency in which mobile devices are purposively integrated into our work. We also hope project results might be useful to and accessed by laypeople to increase their overall well-being.

At the onset of the project in fall 2013, it was estimated that there were more than 1 million apps in Apple’s App Store, with approximately 500,000 of these apps developed specifically for the iPad. Identifying counseling and wellness-related uses of mobile devices and related apps proved to be an arduous and time-consuming process, even when the literature of related fields such as education, special education and communication was considered.

Because the initial project focus was on wellness promotion, an important early step was to identify a wellness model to provide the conceptual foundation for app exploration and selection. After reviewing a variety of models, we adopted the landmark multilayered Indivisible Self Model developed by Jane Myers and Thomas Sweeney (2004).

This Adlerian-compatible, holistic, three-tiered factor structural model includes the unified indivisible self, representing a person’s overall well-being, as its first factor. This is followed by five second-order factors: the creative self, the coping self, the social self, the essential self and the physical self. Finally, these second-order factors are composed of a combined total of 17 third-order factors. For example, the creative self is composed of the following five third-order factors: thinking, emotions, control, work and positive humor.

The current project enthusiastically adopted this model, with minor revisions, because of its evidence-based foundation, its holistic, broad-based definition of wellness and its contextual perspective.

In revisiting the Indivisible Self Model, however, it became clear that some adjustments were needed to reflect current counseling practice and literature. More specifically, this entailed a more inclusive definition of gender identity and the addition of brain health, sleep and sexual orientation as third-order factors. Finally, all third-order factors were further operationalized into a set of “fourth order” categories. Although these factors were not empirically identified, they provided a much-needed structural rubric for the project’s selection of counseling/wellness-enhancing apps and tablet-specific tools. Toward this end, we made every effort for the project to be guided by and to remain as true as possible to the writings and concepts put forth by the architects of the Indivisible Self Model, while simultaneously reflecting current practice and knowledge.

InfographicApp selection process

It became clear at the outset that a structured four-stage discovery and vetting process was required to cull through the plethora of App Store apps and ultimately identify counseling/wellness-enhancing apps for inclusion in the project.

The first stage, Identification, consisted of app searches within counseling and related fields. The procedure entailed arduously culling through the App Store using related keywords, categories and leads obtained from our literature and online searches, monitoring “best new app” listings and exploring other apps offered by the developers of apps we had already identified as promising.

After an app was identified, the Discovery process began, which involved taking several factors into consideration before the potential app progressed to the next stage. Factors included app reviews and user ratings, App Store developer descriptions, price, file size, in-app purchasing, free version restrictions, user suitability ratings (e.g., age), whether the app was accessible on the iPhone, iPad or Apple Watch, the app’s version history and the developer’s attentiveness to required fixes. If these features were deemed to be satisfactory, the app was determined to be ready for further examination in the Analysis stage.

During the Analysis stage, surviving apps were subjected to more robust scrutiny, as we “checked under the hood and kicked the tires.” The apps’ user friendliness and intuitiveness came to be of utmost importance. Relevance and quality of fit with the Indivisible Self Model also came into play, as did the apps’ level of versatility, customizable options and value-added features such as trend analysis, syncing/interfacing with other devices, integrated cloud storage and note-taking/journaling elements. If the app was for children, the degree of available parental control became important, as did the inclusion of follow-up questions, activities, resources or tips for parents.

Exclusionary factors included apps that focused on self-diagnosis, hypnosis or “hookups”; were sexualized; contained an excessive amount of grammatical or spelling errors; appeared to be pushing an agenda or product; cost more than $10; or contained excessive in-app purchasing or excessively intrusive ads. At the end of this stage, we determined whether an app provided sufficient value to warrant downloading or purchasing it to be tested in the project’s fourth and final stage.

In the Selection stage, we test drove downloaded and purchased apps by using actual or hypothetical data to make an informed recommendation about each app’s inclusion or exclusion in the project. For example, we considered ease and reliability of operation, usage restrictions, customizability and information saving/syncing. In this final stage, we raised the bar to reassess each app’s relative value by conducting an informal cost-benefit analysis and determining the extent to which its concept, design, functionality and operation were unique in comparison with similar apps in its category.

The hundreds of hours spent identifying and vetting apps have thus far yielded more than 350 high-quality apps — and counting — that enhance counseling and wellness. It is important to note that the majority of apps that survived the rigorous four-stage evaluation process and ultimately received the project’s stamp of approval were originally developed for purposes unrelated to counseling. It quickly became apparent to us that it was important not to be dissuaded by an app’s stated or intended purpose. To be maximally effective, this necessitated holding any tendencies toward app-specific functional fixedness in check so that each app could be creatively evaluated through an objective and unbiased lens. Put differently, it was critical for the project investigators to deconstruct each potential app, peeling off the layers to highlight its bare-bones core components. This careful mining process was critical in revealing multiple gems.

Case vignette and app-related interventions 

To demonstrate how mobile devices and related apps can be utilized in many ways during the counseling process, consider “John,” a hypothetical case study created to demonstrate app-related counseling and wellness promotion interventions and their potential effectiveness.

John is a talented budding lawyer who is determined to become the youngest partner in his firm. He often heads to work early and leaves late, sacrificing quality sleep and nonwork-related social activities to achieve his goal. John presents to counseling with several areas of concern. Specifically, he states that his lack of “real friends,” absence of nonwork interests and neglect of his overall health and wellness have significantly contributed to his life feeling out of balance.

John says that he:

  • Spends the majority of his time working at the office or at home
  • Eats on the go, typically consuming fast food on a regular basis at his desk, picking up something on his way home from work or skipping meals entirely
  • Has no time to exercise, although he has a gym located in his apartment building
  • Consumes caffeine regularly to keep up with his job demands and increasingly consumes alcohol to help him relax
  • Can’t recall the last time he had fun since moving to this area

John and several of his presenting concerns are good candidates for mobile/app-related interventions, particularly because he offers that he never leaves home without his smartphone and prides himself on being the most tech-savvy employee at his firm. Additionally, he consistently mentions his overall lack of time to address many of his highlighted areas of concern.

John acknowledges that he has neglected his health and put the rest of his life “on hold” in his pursuit of making partner and achieving career success. At several points, he also brings up his overall lack of discretionary time and his perceived inability to attend to his overall wellness. John agrees to give OWAVES (a free app for iPhone, iPad and Apple Watch) a try to evaluate, track and change his current habits.

In response to John’s specific requests for assistance in expanding his social world and interests, he is introduced to the Meetup app (a free app for iPhone, Apple Watch and Android). This app provides users with a community-based way to nurture existing interests, rekindle old passions and explore new locally based activities through its listing of various social and interest groups in the area. John is particularly drawn to this app because he has mentioned an old love of ballroom dancing, a desire to reconnect with this “community” and an increased willingness to meet new people outside of his work environment.

Additionally, John has expressed a wish to reduce his alcohol consumption and explore other ways of relaxing that are compatible with his busy lifestyle. For this, he downloads and agrees to experiment with several mindfulness strategies, especially those that don’t require a large time investment. He is especially drawn to the bite-size mindfulness practices of the Smiling Mind app (free for iPhone, iPad and Android).

John’s insights and positive outcomes

In response to the counselor’s request that John track his daily activities using OWAVES and make efforts to use Smiling Mind and Meetup over the next two weeks, John achieves some insights and realizes some positive outcomes. First, he recognizes that taking time for lunch and eating mindfully actually increases his productivity in the afternoons. He begins to increase his sleep, waking refreshed in the morning. This results in time for exercise before work, decreased stress and less perceived need to use alcohol as a relaxant.

After four weeks, John takes small daily breaks dedicated to relaxation strategies, often using one of the bite-size Smiling Mind meditations. In the process, he increases his alertness during the day, decreases his need for caffeine and frees up some evening hours for social activities. John also uses his newly available time in the evenings (due in part to his increased daytime work productivity) to begin testing the waters with the Meetup app, searching for local groups that pique his interest.

Special considerations 

This hypothetical case was designed to highlight the app selection and implementation processes and the potential impact of app-related counseling interventions. Additionally, our intention is to encourage counselors to take a “blended” approach to incorporating technology into their work.

The incorporation of technology in general, and mobile devices in particular, into our counseling practice does not have to be an all-or-nothing proposition. Such interventions can enhance and supplement — not necessarily replace — traditional counseling.

It is important to note that, first and foremost, John’s goals and fit for technology-incorporated counseling practice were considered. John was an ideal candidate for this type of intervention because of his age, presenting issues, comfort and access to technology, openness to its utilization and perceived lack of time to incorporate other strategies to improve his level of wellness.

App selection 101: Practical applications for counselors

Given the limited body of literature on the use of technology in general and mobile devices in particular in the counseling process, the following recommendations are offered to facilitate informed decision-making by counselors and other allied health providers when assessing the selection and incorporation of mobile devices and apps into their practice.

First and foremost, the provider should take into consideration the needs and goals of the client or student. As with any intervention, intentionality should be the driving force that guides the decision-making process. The app under consideration should be in the best interests of the client or student, taking into account his or her presenting issues and goals. Other factors such as developmental level, age suitability, cultural identification (broadly defined) and client degree of familiarity, experience and confidence in using technology should also be considered.

Although we live in a technological age that is constantly changing, the digital divide has become increasingly important. Client or student access to the considered app, as well as to the technology required to support use of the app, both inside and outside of the counseling session, are important factors that need to be considered. In addition, because confidentiality and privacy of the information generated within most apps cannot be guaranteed, this should be discussed prior to use. Any counselor who intends to utilize apps or other technology-related resources within the counseling process should strongly consider delineating such information in his or her informed consent.

Finally, counselors interested in integrating mobile devices, apps or other technologies into their work are advised to examine clients and students through the lens of their current stage in the counseling relationship and process. The Stages of Change Model (1994) developed by James Prochaska, John Norcross and Carlo DiClemente can also be useful in this regard. These factors may be critical in determining whether the individual will be responsive to and is appropriate for the technology-based intervention being considered.

We invite you to join our growing Twitter and Facebook communities
@Apps4Wellness, @Apps4Counseling and online at apps4counseling.com to access our App of the Month tweets and related online postings, which provide counseling/wellness-related usage ideas, app tips, case studies and sample products using the spotlighted app. We also encourage you to share with us your favorite counseling/therapy, training or wellness-enhancing apps or specific mobile device uses. Please be advised that by submitting your app or mobile device use recommendations, you are giving us permission to post your submitted information on one or all of the Apps4Counseling sites (Twitter/Facebook/website) in the way that it was submitted.

Finally, we invite you to contribute to our international research in this area by taking our brief survey at surveymonkey.com/s/N7339P6. Requests to receive project updates by email can be made at the end of the survey or by going to surveymonkey.com/r/2GFY8BZ. Alternatively, the survey or request for project updates can be accessed by scanning the QR codes on page 58 of the February issue of Counseling Today.

 

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Maxine L. Rawlins is a professor and coordinator of the Counseling Technology Center in the Department of Counselor Education at Bridgewater State University in Massachusetts. Contact her at mrawlins@bridgew.edu.

Elizabeth A. Hughes is a recent graduate from the CACREP-accredited mental health counseling program at Bridgewater State University. She is currently working as a mental health clinician.

Letters to the editor: ct@counseling.org

 

Why can’t we be friends?

By Allison L. Kramer

Over the past three decades, researchers have examined multiple relationships between psychotherapists and their current and former clients, and boundary issues have been explored in the ethics literature. In day-to-day practice, multiple relationships (also known as dual-role relationships) with current clients are commonplace for some practitioners. In some instances, these relationships can be unavoidable and even beneficial. For example, it is not uncommon for a school counselor to also be the coach of a sports team, thus filling both a counselor and a coach role for students.

A_KramerDiscussions of multiple relationships with former clients have been relatively scarce until recent years. In the late 1980s and early 1990s, research began regarding the ethics of counselors entering sexual relationships with former clients, culminating with the ACA Code of Ethics prohibiting sexual relationships with former clients for a period of at least five years post-therapy (see Standard A.5.c.). More recently, studies have examined how therapists view nonsexual relationships with former clients. Interestingly, research suggests that therapists feel less ethically conflicted about entering these relationships with former clients than they have in the past. For example, in 1989, Debra Borys and Kenneth Pope reported that 46 percent of therapists thought that becoming friends with former clients was ethical under some conditions. In a 1996 study, William Salisbury and Richard Kinnier found that 70 percent of counselors held this belief. In 2004, Tracey Nigro and Max Uhlemann found that a whopping 83 percent of counselors thought that becoming friends with former clients was ethical at least some of the time.

Research design

So, what about clients’ perspectives of friending a former counselor? My colleagues Sharon Anderson, Jim Banning, Suzan AlDoubi and I took a mixed-methods approach to study former clients’ experiences of nonsexual post-therapy relationships with their therapists (the research was inclusive of psychologists and counselors).

In the first phase, Sharon collected and analyzed data from a questionnaire. The questionnaire asked former clients to provide demographic data (e.g., their gender, the former therapist’s gender, their ethnicity, the former therapist’s ethnicity, age while in therapy, reason for therapy, estimated time between therapy termination and post-therapy contact, and who initiated contact). In addition, participants were asked to:

1) Describe the post-therapy relationship

2) Indicate whether they thought the post-therapy relationship was positive, neutral or negative for them

3) Explain why they thought the relationship was positive, neutral or negative for them

4) Indicate whether they would be willing to be interviewed about the post-therapy relationship and its impact on them

In the second phase, Sharon conducted interviews with nine former clients who responded to the questionnaire. Participants were interviewed one at a time, and the interviews ranged from one hour to 90 minutes each. Prior to beginning the interview, informed consent was discussed and obtained. A debriefing sheet listing referral for counseling was provided. Participants were informed that the research findings might be published but that their names and identifying information would be altered to protect their confidentiality. All interviews were recorded and transcribed.

Of the nine clients interviewed, eight were female. All participants identified themselves as white or Caucasian. Their ages while in therapy ranged from 16 to 56. Reasons for being in therapy included couples work, grief and loss, self-esteem, anorexia, depression, suicide in the family, suicidal ideation, sexual abuse, family-of-origin issues, transitional issues, dissociative identity disorder and posttraumatic stress disorder. Time in therapy ranged from seven months to five years. The estimated time between therapy termination and post-therapy contact ranged from a few weeks to two years.

Former clients and former therapists were almost equally responsible for initiating post-therapy contact, with five clients initiating contact and four therapists initiating contact. Regarding the former therapist’s gender, there were five males and four females. The ethnicities of the former therapists were reported as African American, German, Jewish, Irish and white.

Results

Our findings examined the following five variables:

1) The type of post-therapy contact between the former client and therapist

2) Which party initiated post-therapy contact

3) The transition between therapy and post-therapy relationship

4) Power issues in the post-therapy relationship

5) The impact of the post-therapy relationship on the former client

Quotes from the former clients (using pseudonyms) are included to highlight these results.

Type of post-therapy contact 

We identified three different types of post-therapy contact that participants described with their former therapists.

1) Incidental 

Simon: “I’ve only seen her in class. I think maybe I’ve stopped by her office once or twice just to say hello, but it’s just been in a classroom where she’s like a TA [teaching assistant] now and I’m a student.”

2) Professional

Jewell: “We are in the same field. She had developed some workshops. Then as I moved into private practice, I began wanting something for my clients that I knew she had to offer. So I began to do some training with her, so there was a process of not therapy anymore, but more training and mentoring.”

3) Personal

Lacey: “Me and my husband have done a couple things with her and her husband, like dinner and things like that. I talk to her on the phone maybe once a month. … I call her, she calls me. It’s not just a one-way thing.”

Alice: “So I went to workshops with her, and I think part of us becoming friends was that I cleaned her house to pay for therapy. And so I kind of got to know her a little bit better that way, and then after, we just hung out. She had been friends with my mom some, but then she got to be closer with me, and we talked on the phone and we were like friends and went out quite a bit, and I went to workshops that she did. I also took a psychology class from her later.”

Jeg: “I wouldn’t really call it a friendship like my other friendships in my life. It’s not the kind of friend that I would call and shoot the breeze with and tell the latest news to. It’s a friendship in the sense of … it’s two-sided. I tell her how I am doing now, and she also shares with me what’s going on in her personal life. Again, I don’t think she shares great intimate details like really close friends might. There’s just a real warm regard and mutual interest.”

Lanette: “I think to me the post-treatment contact … has been kind of leveling, kind of humanizing. [It] kind of keeps things for me in perspective, in terms of ‘you’re a person, I’m a person,’ and even though we have had this very intense and sometimes traumatic contact, basically, we’re just people muddling along the best we can. … I guess what I am saying is, to me, it sort of makes them like friends, although they are not friends in the way most of my friends are my friends. They’re something between a friend and an acquaintance.”

Flo: “I knew he loved me … and his wife loved me as well. I was friends with him, and I was friends with his wife. I’m an artist, and he loved my work and he came to all my openings. … We did some neat things together. It was great.”

Initiator of post-therapy contact

We asked participants to recall who initiated the contact after therapy. Was it the former client, or was it the former therapist who made the first move? Four responses came out of the analysis:

1) Former therapist

Leni: “So, I had initiated the termination in February after we had the discussion about it for about six months, and then I didn’t have any contact with him until June. He wrote me a letter saying that he would be willing [to see me] if I needed anything.”

2) Former client 

Lanette: “We moved from _____, which is just so different. We’ve gone back for each vacation, and last summer we saw him … and this summer I expect we will also. I went back by myself in December and arranged to meet with him.”

Jewell: “As I moved into private practice and I began wanting something for my clients that I knew she had to offer, I started calling her to ask her about ‘What do you do in this workshop?’ and ‘What has been helpful?’ and ‘What’s the theory base?’ [and] ‘Whose work have you drawn on for that?’”

3) Both/mutual

Jeg: “When I go to town, we get together and have lunch. We send Christmas cards. … She sends birthday cards, Christmas cards. A couple of times she sent me a short letter with an article or something like that.”

Alice: “She had been friends with my mom some, but then she got to be closer with me, and we talked on the phone and we were like friends and went out quite a bit, and I went to workshops that she did.”

4) Neither/circumstantial 

Simon: “The person I had been in therapy with is a doctoral student here at ___. I’ve only seen her in class.”

Transition between therapy and post-therapy relationship 

We wondered how the therapist handled this transition. In analyzing this part of the interviews, we found two themes: 1) the termination of the therapy relationship was not clear and 2) the termination was clear, with the termination process being clearly discussed.

1) Unclear termination 

Leni: “He had some formula, being psychoanalytically based, that if you were in therapy this number of years, termination equaled that amount of time. And up to a year of termination was the thought. I was feeling like that would be dragging it on, and we discussed the issue … but he said that would not feel like it was a termination. So I had struggled with that sort of wanting to be successful in treatment but yet not being able to afford it and feeling like it just kept going on and on. He wrote me a letter saying that he would be willing [to see me] if I needed anything … and I saw him one or two times. … It was basically that I still had some wish to sort of bring closure more successfully than it had been done.”

Lacey: “I don’t really remember a termination process. I knew when I was going to see her for the last time [that] it would be the last time … but nothing really was said. Actually, I know there wasn’t any [termination process]. I would have remembered that.”

2) Termination process clearly discussed

Simon: “Our schedules were changing. I had kind of gotten to a place where I didn’t feel like I was making any more progress, so I said, ‘Well, this has been real helpful, but I’ve gotten what I needed to get out of this,’ and so we … did go through what felt like a real formal termination.”

Lanette: “There was a winding down. We’d already gone through a winding down emotionally, and he had preferred to see me once a week until the day that I left. … We talked a lot about termination, which was extremely difficult for me, extremely painful.”

Jewell: “It was gradual in that I probably went fairly regularly to her — maybe every other week. Then it got less frequent, sometimes once a month. … And when my family moved, we talked about it, that phase was ending, and that phone contact would be available if I needed it. I’m not sure what to say about termination except that it was pretty clear, pretty gradual: ‘Call me if and when you need to, but you’re doing well and don’t need it.’ So it was seen as an achievement. It actually was not painful. That was really nice.”

Power issues during post-therapy contact

A power differential exists in the therapy relationship. The therapist is there to offer expertise, and the client is there as a customer who pays for the service rendered. Thus, the counselor is seen as having more power in the therapeutic relationship. But what happens to the power differential in the post-therapy relationship? Two participants saw the power within the post-therapy relationship as being more or less equal. The other seven participants described the power differential as remaining unequal, with the therapist continuing to hold more of the power in the relationship and, at times, transference and dependency continuing.

1) Equal power

Simon: “Toward the end, I felt when I left that she was not like the almighty therapist like when I had originally started therapy a number of years ago. When I first started, I used to think, ‘This person’s like next to God or something.’ [Then I] was able to see her as a real genuine person. I think I still do.”

Flo: “Well, now that I think about it, part of getting healed is getting to feel good about yourself. As the relationship progressed and I got better, that [feeling of being equal] would transpire. … I think it was a combination of his trusting me and my expertise and his openness. He told me … some of the things he was dealing with.”

2) Unequal power

Jeg: “I initially saw her as the person with the answers, a person who was going to tell me what to do so I could make it all better. And a lot of times I was real pissed off at her because she didn’t do that, so in that sense, she was a sort of parent figure for a while. And even now, I think that’s why I would probably say we may not ever be friends in the sense as regular friends are.”

Jewell: “I think power differential in the therapy and supervisory relationship of course are there, though she worked very intentionally on not being the all-knowing, all-powerful person. So I would say there was, in a sense, a power differential, however unintentional, [and] I think it’s been a little tricky … to go into more of a mutual, really truly mutual relationship. I think the fact that I have trouble calling her or taking the initiative has to do with the fact that she is about the age of my mother and some of the difficulty of relating to my mom. I assume that she is not going to be really present, even though she always has been. I sort of think, ‘Well, I don’t want to bother her,’ so I think some of that is still there. Do I mention it to her, set it aside and say, ‘This isn’t my mother’? I think there’s a piece of it that is just there and the relationship is just too big of a trigger for it.”

Lacey: “When I go see my family in the summer, they live in the same town. Should I call her and let her know I’m in town? Should I just wait to see if she calls me before I go? Maybe I should just forget it, but then what does that mean? Can I still call her as a therapist or not? It’s kind of confusing. I don’t sit and ponder those thoughts very often. But you better believe, driving to Texas, I’ll think about that a lot, thinking maybe I should call her. I don’t want her to get mad if I don’t call and she knows I’ve been in town. It’s one of those kind of bitchy friendships a little. It’s just confusing.”

Impact of post-therapy contact 

We were interested to hear participants’ assessment of the impact of the post-therapy relationship. We identified four themes, ranging from harmful to beneficial.

1) Definite harm: To these former clients, post-therapy contact was extremely confusing. Interactions with former therapists were disorienting and harmful, compromising the work accomplished in therapy.

Lacey: “If I was a counselor, I would never do it. I just kind of think … ‘I wonder if she is going to call? Well, should I call her? Well, I’m just kind of confused. This sucks.’”

2) Possible harm: To these former clients, post-therapy contact was conflicting and confusing. Participants were in post-therapy relationships, yet preferred to be completely done with the therapist and on with life. The former therapist continued to encourage connection.

Leni: “When I got the letter, it felt like I was valued and that I was important, and that felt good. At the same time, it felt like I had to read between the lines. … So, I remember carrying the letter around for a long time [because] that gave me some sense of security. But at the same time, [it was] frustrating because it continually sort of challenged me to call him or not call him … call him or not call him … call him or nor call him. Sort of perseverating on that unfinished feeling.”

3) No benefit, no harm: The post-therapy interactions occurred because of external circumstances.

Simon: “I know she works here on campus, and I have stopped in and seen her. It felt real reassuring just to stop in and say hi and touch base. I did that a couple of times and it was like, ‘I can let this go.’”

4) Beneficial, yet confusing: These former clients initiated the post-therapy contact. Participants talked about the good connection with their therapist. At the same time, their statements at times suggested confusion about the relationship.

Lanette: “I always tell them in our Christmas letter when we’re coming out there. … It’s just kind of nice to lay eyes on them again … see that they’re still walking around, kicking, doing the
same stuff.”

Jeg: “The whole experience of working with her I wouldn’t trade for anything. I might put it up there with the most important thing I’ve ever been through. And even now, I think that’s why I would probably say we may not ever be friends in the sense as regular friends are. It is hard for me to completely not have her in that role.”

Jewell: “I don’t want to bother her, and I didn’t know if I would be bothering her or not with that. She said that she wished I would sometimes. That she is an old woman and would welcome it, having that connection. I said, ‘Well, you know you don’t call me.’ She said, ‘I have followed your lead on that part.’ There’s still some of that transition. However, it’s probably been much harder for me than her (laughs). It may sound a little crazy. It is not neat and tidy.”

Discussion

Standard A.6.e., Nonprofessional Interactions or Relationships (Other Than Sexual or Romantic Interactions or Relationships) of the ACA Code of Ethics states: “Counselors avoid entering into nonprofessional relationships with former clients … when the interaction is potentially harmful to the client. This applies to both in-person and electronic interactions or relationships.”

The central theme inherent in all the interviews we conducted was confusion. Is confusion potentially harmful to former clients? We believe it is. Thus, we suggest if there is the potential for a role change to a nonsexual post-therapeutic relationship, then the potential for confusion should be an ongoing discussion in counseling.

Standard A.6.d., Role Changes in the Professional Relationship, states: “When counselors change a role from the original or most recent contracted relationship … clients must be fully informed of any anticipated consequences … of counselor role changes.” Again, we believe the potential for confusion as a result of changing roles should be a part of this conversation.dogLaptop

Finally, we suggest that all nonclinical, post-therapy contact should be initiated by the client. Standard A.4.b., Personal Values, says, “Counselors are aware of — and avoid imposing — their own values, attitudes, beliefs and behaviors … onto clients, especially when the counselor’s values are inconsistent with the client’s goals …”

If clients want to return to counseling, or to transition from a therapeutic relationship to a friendship, the right and responsibility to renew or reinvent the relationship should be theirs alone. Overcoming the power differential inherent in therapy is tricky. Giving clients the power to decide if and when to pursue a post-therapeutic relationship is but one step in acknowledging their autonomy and effort in becoming happier, healthier people.

We believe counselors seeking therapy would expect nothing less from their own therapists.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Allison L. Kramer is associate professor and program lead at Johnson & Wales University in Denver. She is a licensed professional counselor and a level-two certified addiction counselor in Colorado. Contact her at akramer@jwu.edu.

Letters to the editor: ct@counseling.org

Multicultural and Social Justice Counseling Competencies: Practical applications in counseling

By Manivong J. Ratts, Anneliese A. Singh, S. Kent Butler, Sylvia Nassar-McMillan and Julian Rafferty McCullough

During the past three decades, counseling scholars and practitioners have argued that multicultural competence is a central concern to working effectively with diverse clients and to providing culturally responsive counseling environments. Counselors and clients both bring to the therapeutic relationship a constellation of identities, privileged and marginalized statuses, and cultural values, beliefs and biases to which counselors need to attend. Furthermore, clients increasingly bring to counseling issues of inequity that lead to unhealthy risk factors.

The Multicultural and Social Justice Counseling Competencies (MSJCC), developed by a committee consisting of Manivong J. Ratts, Anneliese A. Singh, Sylvia Nassar-McMillan, S. Kent Butler and Julian Rafferty McCullough in 2015, seek to address these issues. Carlos Hipolito-Delgado commissioned the committee during his tenure as president of the Association for Multicultural Counseling and Development (AMCD), a division of the American Counseling Association. Both Branding-Images_justiceAMCD and ACA have endorsed the competencies, which can be found at counseling.org/knowledge-center/competencies. Their endorsement signifies the need to integrate multicultural and social justice competencies into all aspects of the counseling profession.

Built upon the original Multicultural Counseling Competencies (MCC) developed by Derald Wing Sue, Patricia Arredondo and Roderick J. McDavis in 1992, the MSJCC represent emerging multicultural and social justice factors within our global society. The original MCC focused on attitudes, knowledge and skills as the foundation of multicultural competence and were geared toward “majority” counselors working with “minority” clients.

Nearly 25 years later, however, it is clear that the range of diversity, particularly considering the salience of intersectional identities, is truly endless. For example, it is not uncommon for marginalized counselors to work with privileged clients in today’s world. The MSJCC provide a framework for addressing the constellation of identities that clients and counselors bring to the therapeutic relationship. The MSJCC also set the expectation that counselors address issues of power, privilege and oppression that impact clients. Moreover, the MSJCC require counseling professionals to see client issues from a culturally contextual framework and recommend interventions that take place at both individual and systems levels.

In this article, we are highlighting the practical application of the MSJCC in counseling and share how they may be used in conjunction with other ACA-oriented multicultural and social justice competencies. We also emphasize implications for the use of the MSJCC. The January issue of the Journal of Multicultural Counseling and Development (JMCD) provides a more detailed description of the theoretical underpinnings of the MSJCC.

Conceptual framework

The conceptual framework of the MSJCC illustrates the major concepts related to developing multicultural and social justice competence. At the core is the belief that multiculturalism and social justice should be at the center of all counseling. This conceptual framework also introduces new terminology with which it is important for counselors to familiarize themselves: quadrants, domains and competencies.

MulitculturalPraxis_fit

Quadrants: Quadrants reflect the complex identities and the privileged and marginalized statuses that counselors and clients bring to the counseling relationship. Clients and counselors are both members of various racial, ethnic, gender, sexual orientation, economic, disability and religious groups, to list a few. These identities are categorized into privileged and marginalized statuses. A client or counselor may hold either status or both statuses simultaneously. These statuses are prevalent depending on how each individual is experiencing the current interaction.

Being attentive of these statuses highlights how issues of power, privilege and oppression play out between counselors and clients. The interactions are categorized into four quadrants:

  • Quadrant I: Privileged Counselor–Marginalized Client
  • Quadrant II: Privileged Counselor–Privileged Client
  • Quadrant III: Marginalized Counselor–Privileged Client
  • Quadrant IV: Marginalized Counselor–Marginalized Client

Conceptually, client and counselor interactions may fit into the quadrants in numerous ways. They reflect the fluidity of identities and how the dynamics of power, privilege and oppression impact the counseling relationship.

For example, a gay male counselor of color and a heterosexual female client of color may experience their interaction through various lenses. They both may perceive their interaction to stem from Quadrant IV because of shared racial identities — a common experience with respect to issues of racism. Alternatively, the client may consider their interaction from a Quadrant I perspective because of gender differences. The client may feel displaced and at a disadvantage because of the counselor’s male privilege. Another possibility is that the counselor might identify with Quadrant III because of their differences in sexual orientation. In such a scenario, the counselor may be placed at a disadvantage because of the client’s heterosexual privileges.

Domains: Domains are intended to be developmental in nature, and they focus on progressive levels of multicultural and social justice competence. The domains are:

1) Counselor self-awareness

2) Client worldview

3) Counseling relationship

4) Counseling and advocacy interventions

Counselor self-awareness is important for identifying one’s cultural values, beliefs and biases. This insight assists in identifying one’s worldview and hot-button issues that may interfere with helping clients. Second, being cognizant of a client’s cultural values, beliefs and biases may help counselors understand clients’ worldviews and identity development. Next, being aware of the extent to which shared and unshared identities; privileged and marginalized statuses; values, beliefs and biases; and culture influence the counseling relationship may be important in determining appropriate evidence-based treatment interventions. When counselors possess self-awareness, are attuned to clients’ worldviews and are cognizant of how this shapes the counseling relationship, they are better equipped to respond to client needs.

To respond effectively, the MSJCC set the expectation that counselors understand the sociocultural systems that are affecting their clients’ sense of well-being and address the corresponding issues appropriately. To this end, the socioecological model is embedded within the counseling and advocacy interventions domain to provide a framework for interventions and strategies at the interpersonal, intrapersonal, institutional, community, public policy and international/global levels. Moreover, the levels allow counselors to see client issues more contextually and aid in determining whether targets for health promotions need to occur individually or systemwide.

At the intrapersonal level, counselors who are multicultural and social justice competent discuss their own cultures and identities, inquire about their clients and provide open conversations related to how, collectively, privileged and marginalized identities might work to enhance or barricade the counseling relationship. It is essential that counselors are willing to authentically bring this discussion into the room. Such discussions can help counselors gain rich insight into their clients’ cultural backgrounds. Clients and counselors who engage positively in this dynamic may increase mutual trust and enrich the therapeutic alliance.

An important factor at the intrapersonal level is the exploration of client experiences with microaggressions and discrimination. Counselors can help clients develop critical consciousness around experiences with racism, sexism, ableism, classism, religious oppression, homophobia or transphobia and so on. This, in turn, helps clients externalize their oppression. Using culturally appropriate, empowerment-based frameworks and techniques to help clients express powerful feelings of anger or despair resulting from frequent experiences with discrimination and oppression is crucial to improving one’s mental wellness.

At the interpersonal level, counselors who are multicultural and social justice competent take initiative to explore client relationships with family, friends, co-workers and their communities. This work may occur inside or outside of “the office.” For example, counselors may step out of the comfort of their office settings to talk directly with individuals in their clients’ lives (with client permission). This approach may help to identify individuals who support or obstruct client progress.

Relatedly, it is critical to help clients develop networks with caring individuals who share a similar privileged or marginalized identity and with whom they identify. Examples include helping an African American client to connect with an African American student group such as a sorority or fraternity. White clients might find it beneficial to be in an organization in which other White individuals are doing anti-racism work. This exploration process may be enhanced when counselors take the time to attend these meetings with clients. Stepping outside the office setting and working alongside clients will likely create discomfort for counselors who are traditionally trained.

At the institutional level, multicultural and social justice counselors focus their efforts on institutional rather than individual change. Counselors may initially inquire about the climate within a client’s workplace, community organizations or school. For example, a counselor can ask a client, “What is it like being the only Latina woman in a predominately White workplace?” or “How is it to navigate your workplace as a person with a disability?” Counselors could take it a step further by conducting needs assessments of their clients’ workplaces or schools to determine the extent to which these organizations are supportive of the clients. This strategy involves collaborating with clients and their workplaces or schools to conduct a climate survey.

Counselors may also advocate for clients by connecting them to supportive people within institutions who may be instrumental in helping to reduce inequities that clients experience. As change agents, counselors can work to improve climates within agencies, schools or organizations that inhibit client growth and feelings of well-being. For example, a professional school counselor might advocate with, and on behalf of, students who miss valuable instruction time because they use wheelchairs and cannot get to class on time due to overcrowded hallways and a lack of automatic doors. Similarly, a clinical mental health counselor might attend a meeting as an ally at the client’s place of employment to discuss equity issues affecting the client’s work environment.

At the community level, multicultural and social justice counselors focus their attention on the norms and values in society and the influence of these factors on clients’ well-being. It is important for counselors to discuss how clients believe that others perceive them and if they think that society holds negative stereotypes or attitudes about their membership in a privileged or marginalized group.

For instance, a counselor might explore, through societal lenses, the difficulties that a nontraditional female student faces when she doesn’t feel that her mostly male cohort takes her seriously as a medical student. The counselor could explore with the client the societal perceptions of women in science and math fields and the added pressure of having to prove herself repeatedly to male classmates. Creating informative websites may be another positive way to bring the issue to public awareness. Counselors may also use broader social advocacy strategies to vocalize support for women in general or back their participation in male-dominated careers, thus transforming public perception of their strengths and capabilities. Lastly, counselors can conduct research that identifies societal perceptions of particular women groups, explore the impact of these discernments and investigate how to mediate negative attitudes toward them.

At the public policy level, multicultural and social justice counselors focus on the rules, laws and policies that impact clients and other members of their group. This work may involve altering oppressive laws and policies or helping to create more-inclusive policies. An example could include focusing on issues faced by a female transgender client who is forced by city or state laws to either use the public restroom of the gender recorded on their birth certificate or face legal consequences. The counselor might advocate with, or on behalf of, the client by using the counselor’s cisgender (person who is not transgender) privilege to work with city officials to alter policies and practices that are oppressive toward transgender people. Furthermore, counselors, along with their local counseling organizations and legislators, may help to create policies and laws that do not discriminate against the transgender population and other sexual and gender minorities who constantly feel the brunt of stigmatization.

At the international/global level, multicultural and social justice counselors stay current and understand the impact that international activities may have on clients. For instance, the November terrorist incident in Paris involving the Islamic State may create toxic conditions in which Middle Eastern clients in the United States experience a significant increase in discrimination. In addition to discussing the impacts on clients, it would be essential for counselors to increase their knowledge and seek professional development that furthers their understanding of the political and historical contexts surrounding such occurrences. This knowledge may in turn equip counselors with the ability to work with other community leaders to create programs that ward off potential hate crimes.

Competencies: Counselors who are multicultural and social justice competent are in a constant state of developing attitudes and beliefs, knowledge, skills and action (AKSA) that allow them to effectively work with clients from a multicultural and social justice framework. The AKSA competencies are embedded within the counselor self-awareness, client worldview and counseling relationship domains described above.

Attitudes and beliefs refer to possessing awareness of the values, beliefs and biases that counselors possess about themselves and their clients. Knowledge denotes counselors being well-informed on the complexities surrounding counselor and client identity development, worldviews, the nuances of culture and the positive and negative effects of privileged and marginalized statuses. Skills refer to counselors’ abilities to tailor interventions that align with the cultural worldview of clients. Action refers to counselors taking steps to operationalize attitudes and beliefs, knowledge and skills with clients. The action component, also endorsed by Allen Ivey, Mary Ivey and Carlos Zalaquett, is based on the belief that possessing attitudes and beliefs, knowledge and skills is not enough if these competencies are not operationalized.

Using the MSJCC in tandem with other competencies 

Counselors can use the MSJCC alongside other ACA competencies to provide culturally responsive counseling and contextually appropriate interventions. The ACA Advocacy Competencies, which emerged out of Counselors for Social Justice, another division of ACA, were developed to describe how counselors might advocate with clients or on behalf of clients. These competencies further delineate the micro (e.g., student, client), meso (e.g., school, community) and macro (e.g., public arena, public policy) levels of advocacy that counselors may use.

As discussed earlier, the MSJCC embed action within counseling competence, with the expectation that counselor awareness, knowledge and skills are linked to counselor action in addressing issues of privilege and oppression when working with a wide variety of social identities espoused by clients. Therefore, in essence, the MSJCC extend the advocacy competencies to a more comprehensive approach that works with clients and continues outside of the duration of counseling. However, the advocacy competencies still have value, and counselors can consult these competencies together with the MSJCC to identify the most effective levels of action intervention. Interventions should be in collaboration with clients (e.g., developing self-advocacy skills) or on behalf of clients (e.g., advocating for gender-inclusive bathrooms for transgender people).

The Association for Specialists in Group Work (ASGW), another ACA division, developed the Multicultural and Social Justice Principles of Group Work to revise an earlier document titled “Principles for Diversity-Competent Group Workers.” Similar to the need to revise the AMCD multicultural competencies, ASGW was supportive of efforts to integrate multicultural and social justice principles into one document guiding the development of competence in leading group work. Counselors may use the MSJCC to guide both individual and group work with clients, using the MSJCC model to identify social identities of similarity and difference with clients, while also using the three domains of the ASGW Multicultural and Social Justice Principles of Group Work to explore the specific development of multicultural and social justice competence when facilitating group modalities. The three domains of these principles include the awareness of self and group members, strategies and skills (with two sub-domains: group worker planning and group worker processing), and social justice advocacy.

The MSJCC focus specifically on awareness, knowledge, skills and action that counselors should develop in multicultural and social justice competence. Meanwhile, the ACA Competencies for Counseling With Transgender Clients and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling Competencies for Counseling LGBQQIA Individuals explore this competence within CACREP training domains (e.g., social and cultural foundations, assessment) when working with transgender and lesbian, gay, bisexual, queer, questioning, intersex and ally (LGBQQIA) clients. Counselors may therefore use the MSJCC model to identify the privilege and oppression identities of counselor and client, while using the transgender and LGBQQIA competencies to examine these identities specifically within sexual orientation and gender identity.

Other ACA division competencies also exist (see counseling.org/knowledge-center/competencies). The extent to which these competencies specifically address or embed multicultural and social justice competencies varies. When using these competencies, the MSJCC will help counselors specifically give attention to the multiple issues of privilege and oppression that influence counselor awareness, knowledge and action competence.

Summary

The MSJCC provide:

  • A comprehensive framework for viewing one’s attitudes about newly emergent populations
  • A fresh start for looking at the worldviews of populations with whom one may come in contact and provide counseling services for daily
  • An opportunity to examine the impacts of these internalized attitudes and, taken together with client worldview, delve into the influences those dual dynamics have on the counseling relationship, both in traditional and broader senses

Thus, the aspirational quality of the MSJCC is critical in every single counseling encounter. In mental health and school settings, we may continue to serve clients from marginalized groups, and they may continue to overrepresent traditionally beleaguered populations. However, the way oppression is manifest in today’s world is ever-changing. For example, recent immigrants, whether documented or undocumented, face daily persecution. Others might belong to refugee groups that have been oppressed in their countries of origin and come to the United States only to face new subjugations.

Moreover, the expansion of the counseling role, beyond the actual traditional relationship and into a role of advocacy and social action as an expectation of the profession, creates room for stretching and growth on the part of counselors and their delivery models and systems. For example, should a counselor note an inherent bias within the agency structure, a learning curve might exist in terms of figuring out whom to talk to or what actions to take to create change. Consequently, some personal risk to one’s job security may be present in taking such action.

Regarding community action, this role involves a new set of activities on the part of counselors to identify and network with community leaders and become involved with community action networks. Finally, the policy level is often intimidating and overwhelming for counselors in terms of understanding policymaking players and processes. However, consider what could happen if counselors were to become activists in changing managed care, for example, through lobbying and other large-scale education efforts. Not only would clients be better served if that were to happen, but counselors could also avoid becoming caught up in their own webs of helplessness or hopelessness that often lead to professional burnout. Additionally, training gaps often exist between newly trained and veteran counselors who have served in the field for longer periods of time. With the benefit of renewed multicultural competence training, successes and changes may inadvertently serve to engage experienced counselors at new levels, inspiring them to continue striving for multicultural and social justice competence.

 

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Manivong J. Ratts, Anneliese A. Singh, S. Kent Butler, Sylvia Nassar-McMillan and Julian Rafferty McCullough served on the committee that developed the Multicultural and Social Justice Counseling Competencies.

Letters to the editorct@counseling.org

Becoming your own boss

By Lynne Shallcross

A year after Cyndi Briggs graduated with her master’s degree in counseling, she was working as an addictions counselor. The work and the clients were important to her, but it was also a difficult job, and the hours were long. She eventually found herself dealing with symptoms of depression.

Briggs went to talk with a career counselor, and the meeting led to an “aha!” moment for Briggs. “He said, ‘Why do you take low-paying, high-stress jobs?’” says Briggs, a member of the American Counseling Association. “And I [had] literally never considered that there was another option.”

Fifteen years later, Briggs is living her ideal life as a counselor. She works full time as a core faculty member in the clinical mental health counseling program at Walden University, but she also maintains a number of what she calls “side gigs,” including corporate training work and speaking Branding-Images_Officeengagements. Briggs has run a private practice in the past, earned her coaching certification and, for a handful of years, wrote a blog aimed at helping counselors think outside the box. While writing the blog, one of her central messages to counselors was that they could apply their many skills and talents in a variety of professional settings where they could also earn a good living.

Deb Legge shares a similar message with her clients in the coaching and consulting practice that she runs, in which she helps mental health professionals build and grow private practices. Like Briggs, Legge knows from personal experience what it’s like to have a desire to become, and then succeed in becoming, your own boss.

Counseling was a second career for Legge. At the time she was earning her master’s degree in counseling, she was a single mother, which meant that taking her new degree into an entry-level, low-paying job wasn’t an option. From day one in graduate school, Legge says, she was laying the foundation to establish her own private practice, which she now runs in Buffalo, New York (her private counseling practice is separate from her coaching/consulting practice).

Counselors and other mental health professionals who approach Legge for help with the how-tos of starting their own private practices have a variety of reasons for wanting to become their own bosses. But oftentimes, Legge says, it boils down to seeking freedom and better financial opportunities. “My experience has been that most people decide to do it because they are either really burned out from working for someone else, overworked [and] underpaid for too long, or their life circumstances change and they really do need more autonomy and money,” explains Legge, a member of ACA.

When Briggs presents on this topic, there are often weary counselors in the audience who raise their hands and want to know more about how to transition into private practice or become their own bosses in another way. Many times, Briggs says, these counselors have been working in nonprofit settings for many years and are feeling burned out because of overwhelming caseloads and too little pay. “For a lot of people,” she observes, “it’s just rediscovering the joy of why they wanted to be counselors in the first place.”

Risks and rewards

Running a private practice comes with a variety of upsides for counselors, Legge says, from control over their schedules to control over which clients they work with and what work they do with those clients. For example, some of Legge’s clients who are starting out in private practice will ask if they can conduct a daylong seminar, a weekend retreat for couples or an hourlong session with a particular client. “As long as you’re being ethical, and as long as you’re being legal, and as long as you’re abiding by the rules of an insurance company if you’re participating with them, there are no rules,” Legge tells her clients.

But before launching a private practice, counselors need to become licensed. And once they’re licensed, Legge says, they also need to honestly evaluate whether they possess enough clinical experience to set out on their own and whether they have set up the necessary supports and guidance, including supervision, to lean on as they get established.

Going into private practice isn’t the right fit or even the desired end goal for every counselor. For one thing, it requires embracing a certain amount of tolerance for risk and responsibility, Legge cautions. “I don’t want to give people the impression that it’s for everyone or that it’s a bad thing not to be in private practice,” Legge says, adding that she is grateful for all the counselors who choose to work in agencies, schools, hospitals and other settings.

Starting a private practice also isn’t the only way that counselors can become their own bosses. In fact, putting your counseling skills to use in a variety of “gigs” — from consulting to running a private practice to adjunct teaching — can be financially beneficial, says Briggs, who has served as a consultant in various settings. “There’s lots of security from that,” she says. “You’re not relying on one entity to pay your income every month.”

Whatever the environment, working for yourself is creatively empowering, Briggs says, in part because of the flexibility it allows. “You get to decide what you do every day and change it if you need to change it,” she says.

But that freedom also comes with risk and responsibility, Legge points out. “You have to be OK with the fact that when things go wrong, the only person you can look at to turn things around is yourself,” she says.

Likewise, when you become your own boss, some of the security that comes from working for someone else goes away, such as a steady paycheck and covered benefits. Legge refers to those kinds of benefits as “golden handcuffs” because, while valuable, people tend to cling to them at the expense of their larger dreams. They’re “the things that can and do keep them from getting what they say they really want,” Legge observes. “Each one of those things is just a dollar figure that can be figured into a budget so you know how much you need to make to pay for those things yourself.”

Before launching a private practice, Legge recommends that counselors imagine the kind of life they want to live and then design their private practice to fit that life. For instance, if counselors imagine living a life in which they spend more time with their families, then they might want to choose target markets based on clients who won’t routinely need appointments on weeknights and Saturdays, Legge says.

The question counselors need to ask themselves before jumping into anything, Legge says, is “What are you willing to do to get what you say you want?” For many counselors, in the end, the benefits of going into private practice or becoming their own boss in another way far outweigh the risks, she says.

Even so, when counselors strike out on their own, one of their biggest initial fears is that they will fail, Briggs says. “I think we all carry that [fear], like ‘I’m going to fall on my face, and the world’s going to laugh at me, and I’m going to be broke and living in a box under a railroad trestle.’”

Along those same lines, Legge says, counselors who are transitioning to private practice commonly worry whether they are skilled enough and qualified enough to warrant clients coming to their practice. They might start questioning why anyone would choose to see them when there are already so many other counselors in town. “Unfortunately, there are more than enough people who are in need to go around,” says Legge. She encourages the clients from her consulting practice to view those other counselors in their communities as colleagues and potential collaborators.

Some counselors even worry that they’re somehow selling out by moving into private practice, Briggs adds, recalling that when she left her job as an addictions counselor, she initially felt guilty. Because working with clients who struggled with addictions felt so meaningful and honorable, Briggs even wondered whether she was shallow for leaving that position to find a job she enjoyed more.

“A lot of us struggle with that: ‘People are going to think I’m a bad person if instead of working with the homeless population, I’m going to choose to work with college students,’” Briggs says. But her thinking has evolved since those early days. “Everybody’s got their place, and you just have to find the right place for you,” she asserts.

Let’s talk money

Counselors striking out on their own commonly worry about their bottom line, wondering if they will be able to make enough money to survive and keep their doors open. Complicating those worries, Legge and Briggs agree, is that the topic of money is already uncomfortable for many counselors. “I don’t know how it happens, but we’re socialized in [the] helping professions to think that helping others and making lots of money are contradictory,” Legge says.

Briggs concurs. Many times, she says, when counselors enter the profession, they hold tight to the attitude that they are choosing this career path to help people, not to make money. “It’s almost like those things are mutually exclusive, and I have a really big problem with that,” she says. “We’re never taught to be empowered around our skill set. We’re never taught how to ask for a livable wage around what we do. We sort of think, ‘If I’m not helping people directly, if I’m not with the most needy population, then I’m being greedy and squandering my skills.’”

That viewpoint is “absolutely inaccurate,” Briggs stresses. “Helping people and earning a good living are not mutually exclusive.”

Legge has received her fair share of criticism through the years for talking about how mental health professionals can make more money. She says much of the criticism has come from her fellow mental health professionals, including some who label her views as “mercenary.”

“What I come back with is, if you want to be in private practice in three years for [the sake of] your clients, then you have a responsibility to be a good businessperson and to make a living [so] that you can continue to be in private practice,”
Legge says.

Counselors planning to go into private practice need to address any hang-ups they have around money early on, Legge says. “If you want to draw money into your business, you’ve got to deal with your issues regarding money,” she says. “You just have to do it. If you’re afraid to ask for a copay, your client is going to pick that up in a heartbeat. If you’re uncomfortable telling a client over the phone what your fees are, they’re going to pick that up in a heartbeat.”

Legge has found that the more comfortable counselors are talking about money, the more comfortable their clients are with the topic, and the less likely it is to become an issue between them. In addition, counselors need to keep sight of their worth when talking about their fees or collecting payments from clients, she says.

“What is it worth to save a marriage? To save a kid? To live a better life? To save that job? What is it worth to my client?” Legge asks. “You’ve got to think about your worth in terms of what the value is to your client.”

When Briggs was doing a job for one of her first corporate clients a few years ago, she cited her fee for a one-hour presentation. The client replied by suggesting that she research the company and come back with a different price. Briggs returned with a quote five times that of what she had originally asked for, and the client accepted it. “That was really good for me to hear,” she says.

Although Briggs acknowledges that fees are still a topic she wrestles with from time to time, she says it is important for counselors to reach clarity on what they truly need as a livable wage and then to feel confident in stating that to others. To that end, Briggs says, when counselors are determining the fees they will charge, whether in private practice or in another setting, they should calculate what their livable wage is. That number should take into account expenses that are typically covered when working for someone else, such as health insurance and some amount of paid vacation, she says.

Putting yourself out there

Although business owners are responsible for growing their businesses and attracting clients, many counselors bristle at the concept of marketing and sales. When Legge works with helping professionals who want to start or grow a private practice, she reassures them that sales and marketing don’t have to feel “slimy.” A “brand” needs to be nothing more than how you want to be seen in the world — whom you serve, what you do and why you do it, Legge says.

Marketing starts with a paradigm shift that encompasses “going from the fear of being sales-y” to the perspective of getting to know your community and your target market in particular, Legge says, “so they can rely on you, build a relationship with you and so that when they need you, they’ll know where to find you.”

Briggs echoes the point about counselors changing their perspective on what it means to market or sell themselves. Many people equate business with greed, marketing with sleazy sales tactics and networking with schmoozing, but that isn’t necessarily true, she says.

“Networking is walking into a room full of really cool people and getting to know them. Counselors are great at that,” Briggs says. “And marketing is about building relationships — counselors are great at that. And business is about finding a way to apply your skills so that you can benefit the world and earn a decent income. There’s nothing sleazy about any of it when you reframe it in a way that’s authentic for you. The goal really becomes to redefine it in a way that’s authentic for you and [to] own that. And then it stops being creepy and weird and starts feeling more natural.”

David P. Diana is a marketing consultant and licensed professional counselor who runs a marketing firm specializing in serving health care organizations and practices. He is also the author of the book Marketing for the Mental Health Professional: An Innovative Guide for Practitioners. He points out that marketing isn’t a quick-fix process for mental health professionals but rather something that happens over time based on a clinician’s work and actions.

“Too often, people look at marketing in crisis mode,” Diana says. “Perhaps they lose several clients, and then they say to themselves, ‘I need to get the word out about my work to fill these holes.’ The problem with this reactionary mode of marketing is that it rarely works. People often make the decision to advertise their practice, hand out fliers, etc., in the hopes that the phone will ring again. However, marketing involves much more work than that to create change and interest.”

That said, Diana offers a few key points for mental health professionals to consider when they think about marketing. First, he says, put the emphasis on why you do what you do as a counselor, offering potential clients a mission and a story with which they might connect.

Second, Diana says, don’t devote time, energy and resources trying to be the right clinician for everyone. “If you focus on your why, then you have a chance to share a story with an audience that wants to hear that story,” he says. “When your values [and] purpose match up with a group of people with similar values [and] purpose, then you have found your audience.”

Diana concludes by reminding counselors that advertising is not marketing. “Marketing is about conversations and connecting your story to an audience that wants and needs to hear that story,” he explains. “Marketing to a mass audience via advertising yields very little results because there are so many fragmented markets and because we, as consumers, have access to so much information.”

Marketing comes from a “heart of service,” Legge adds, and from a desire to help the community. “If you believe you’re meant to serve others,” she says, “then you have a responsibility to let the community know you exist as a viable resource for them.”

Putting that brand of marketing into action begins by building relationships, Legge says. Especially initially, it means that counselors concentrate not on where they’ll get their next referral, she says, but on finding out more about their target market — what those potential clients in their community need, what their biggest problems are and how that counselor can help.

In getting to know people in their communities, Legge says, counselors will learn about what those people need and where to find them. In turn, those people will learn about the counselor, see that the counselor has credibility and come to rely on and trust the counselor, she says.

Briggs calls word-of-mouth a huge force in driving new clients to counselors. Having a web presence can also help counselors get their message out, “even if it’s just a professional Facebook page where you’re advertising who you are, what you do and what you’re about,” she says. At the same time, Briggs says, social media requires that counselors engage in a “delicate dance” in which they take advantage of the inherent marketing opportunities while simultaneously ensuring that they don’t violate any ethical boundaries.

Briggs also recommends that entrepreneurial counselors offer something for free — but get feedback in return. For instance, if you have a presentation for which you would eventually like to be paid, start out by offering it somewhere for free, but ask for comments and critiques. Another idea Briggs suggests is starting a blog or website focused on what you are interested in offering as a counselor. If you want to work with children, for example, establish a blog for moms and offer parenting tips. “Once people see the information and knowledge you have, they’re much more likely to pay you for it,” Briggs says.

The business of balance

Seeing clients while simultaneously running the logistics of a business can be challenging. Juggling both means a heavy dose of decision-making and delegating, Legge says. For example, it may not make sense to do business with every insurance company, she says. Consider the workload each insurance company would require of you and whether the company pays fairly before choosing to work with it.

Similar decisions must be made about other business tasks such as bookkeeping, billing and taxes, Legge says. “Depending on your talents and your interests, you may choose to do some of those things. But it may be much more reasonable to farm out some of this stuff, even though you’re going to pay to do it,” she says. Private practitioners have to consider the return on investment, she adds. “Does it make sense not to pay the $80 a month for the billing platform when you’re spending three hours a week on billing by hand?”

In terms of juggling client work with business tasks, Legge says each counselor has to figure out what process works best. She likes to finish her to-do list at the end of every workday, but she knows other mental health professionals who are more productive when they pile up their business tasks and do them all at once on a deadline.

Making it all work is a balancing act, says Briggs, who has side gigs that take up 20-30 hours a week on top of her full-time teaching job. One key for her has been learning to say no. She clarifies what her priorities are and dedicates time for them, even if it means saying no to another interesting opportunity.

Both Legge and Briggs recommend that counselors who are running their own businesses reassess their situations and business models regularly, but ideally every 90 days. They suggest reviewing what you’ve been doing, how it has been going, what you might like to change and whether you’re still enjoying the work.

Look before you leap

Although graduate counseling programs are already packed with requirements, Briggs says it seems “criminal” that electives in marketing and entrepreneurship aren’t offered more widely considering how many counselors are interested in private practice.

Many counselors feel very much on their own when they are learning to run a business, Legge says. That’s why many turn to books and blogs for helpful tips and information. In addition, she points out, some communities of mental health professionals have come together to support one another, and business coaches can also help.

One piece of wisdom Legge sometimes passes along to clients starting out in private practice is that they won’t be able to serve everyone all the time. That’s not always welcome news. Legge says some of her clients have expressed frustration that she can’t show them how to make a comfortable living working exclusively with individuals and families with low incomes, for examples. In that instance, she might tell counselors that although some of their practice can be dedicated to working with that client population, they also have a responsibility to supplement that with higher-paying work so they can stay in business for all of their clients. “Dollars are dollars, and it’s got to balance out at the end of the month,” Legge says.

It’s imperative for counselors to have a sense of what they’re stepping into, plus an understanding that it might require them to take baby steps in that direction rather than one big jump, Briggs says. “I’m not an advocate of quitting your job without a plan,” she asserts. Instead, counselors might consider giving themselves a two-year timeline during which they work full time and take a couple of side jobs to “test the waters,” Briggs says.

“Don’t think the bravest thing you can do is quit your day job,” Briggs counsels. Instead, go at the pace that’s right for you as you explore your entrepreneurial options, she says. “Take whatever time you need to take the leap, and don’t push yourself beyond where you’re comfortable.”

Legge further suggests finding support through a national association, continuing education classes or a group of peer clinicians who can provide guidance, encouragement and even group supervision.

Reflecting back to her advice about marketing, Legge says it is also important for counselors to build a foundation before launching their practice. Sometimes, she says, counselors work hard to start their business, hand out business cards and create a website, but then the phone doesn’t ring. The preemptive solution, she says, is to build relationships before starting a practice so that people in the community will know who you are, what you do and why you want to serve your fellow community members.

And perhaps most important, Briggs says, is for counselors to know their true value. “Get really clear on what you’re worth,” she says. “Know that what we do has immense value to others. People are going to be willing to pay for what you’re worth, and you can ask for it.”

 

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To contact the individuals interviewed for this article, email:

 

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Lynne Shallcross, a former associate editor and senior writer at Counseling Today, works for Kaiser Health News as a web producer. Contact her at lshallcross@gmail.com.

Letters to the editorct@counseling.org

 

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Related reading

I want what I’m worth,” one counselor’s journey to diversify her work and take the road less traveled

Look before you leap,” an in-depth piece on what it takes to go into private practice

 

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Immigration’s growing impact on counseling

By Laurie Meyers

They come by air, land and sea. In airplanes, on overcrowded boats, aboard shipping vessels, by train or even on foot. They are immigrants and refugees looking for the same things as previous generations of people who willingly came to the United States: hope, sanctuary and the possibility of a better life.

Everyone in the United States who is not an American Indian or Alaska Native is of course an immigrant or a descendant of immigrants, whether by choice or because of slavery. For much of our nation’s history, most immigrants were of European descent. However, the Immigration and Nationality Act of 1965 eliminated the immigration quotas that favored Northern Europeans. Current immigration policy gives preference to applicants with family ties to U.S. citizens or legal residents and to skilled workers.

Branding-Images_libertyBecause immigration policy no longer gives preference to European immigrants, today’s immigrants come from all over the world but particularly from Latin America and Asia. As a result, the United States is a much more ethnically diverse place than it was 50 years ago.

According to the Migration Policy Institute (MPI), a nonprofit think tank that analyzes worldwide migration, an estimated 41.3 million immigrants lived in the United States as of 2013 (the most recent year for which statistics are available), constituting 13 percent of the population. MPI says that approximately 19.3 million of these immigrants are naturalized U.S. citizens, while the remaining number are lawful permanent residents, unauthorized immigrants or legal residents on temporary visas, such as students and temporary workers. According to the Department of Homeland Security (DHS), approximately 1 million people were granted lawful permanent resident status in 2013, meaning they can legally work and live in the United States but are not yet eligible for citizenship; slightly less than half of these immigrants were new arrivals. DHS records also indicate that 69,909 refugees were admitted to the United States in 2013, while 25,199 immigrants already in the U.S. or at a U.S. port of entry were granted asylum. The DHS estimates that there were 11.4 million unauthorized or undocumented immigrants living in the U.S. as of 2013.

Not everyone is comfortable with this reality. From Republican Party presidential candidate Donald Trump’s stated plans to build a wall on the U.S.-Mexico border and bar entry to Muslim immigrants to the numerous state governors who have announced they will not accept refugees from Syria, current headlines vividly demonstrate the obstacles confronting many immigrants and refugees, ranging from bureaucratic and legal battles to suspicion, prejudice and outright hostility.

Many immigrants and refugees are also unaware that there are professionals such as counselors who can help them navigate this strange new landscape. Those who work with these populations say that as part of the cultural diversity that the counseling profession has embraced, counselors have a responsibility to help immigrants and refugees with everyday challenges associated with community, school, work, health care and other systems.

Strange new world

Although every immigrant’s story is different, they all share one overarching truth — that every aspect of life will be affected by the immigrant experience, says Shabnam Etemadi, a doctoral counseling student at Tennessee State University in Nashville. Etemadi studies and works with immigrants. She is also an immigrant herself.

Most immigrants come from a collectivist culture to settle in the United States, which features an individualist culture, Etemadi says. This means they must grapple with a society whose very nature is fundamentally different from their own, she points out.

Etemadi and her family emigrated from Iran when she was 6, settling in Nashville. Even though the city is home to a large Iranian American population, the family often felt very isolated. Language was probably the biggest barrier to her family’s adjustment, she says. Knowing very little English, the family was afraid to go outside and interact with the world at large. “The main way we learned English was by watching TV,” Etemadi says. “[We would watch] simple kids shows and soap operas.” Her family members also practiced reading, but Etemadi says the television was particularly important because it helped them learn cultural nuances.

Another language barrier had to do with learning that certain phrases and words had meanings beyond their literal definitions, Etemadi says. For example, she vividly remembers her classmates taunting her one day for “cutting.”

“They kept saying, ‘You’re cutting! You’re cutting!” she remembers. Bewildered because she was not physically cutting her classmates, Etemadi eventually realized that cutting meant “cutting in line.”

That one instance offers a small but insightful example of how coming to America fundamentally changed who Etemadi was. “I was an extrovert back home, and when I came here, I became an introvert,” she says. “I was shy, withdrawn and fearful because I didn’t speak the language. I was bullied in elementary [school], and I never made any meaningful relationships with the teachers.”

Etemadi says all the teachers spoke to her in a way that she perceived as “weird” as a child. In reality, she says, they were doing something that many Americans do when trying to communicate with someone who doesn’t speak much English — talking very loudly.

Etemadi says she also felt “marked” because she was in the English as a second language (ESL) program. “I would be a part of [my homeroom] class and, suddenly, I would be taken out by an ESL teacher to talk about my schoolwork,” she recalls. “I was learning English, which was great, but I felt isolated, and my peers would wonder why I was taken out of class every other day.”

School also proved bewildering for her parents, Etemadi says. For example, the grading system was based on a different set of numbers than they were used to, so their understanding of their children’s reports cards was limited. The idea of participating in extracurricular activities — which in the United States plays an important role in getting into a good college, among other things — was virtually inexplicable to her parents, Etemadi says. In Iran, she says, students go to school strictly to study, so her parents had trouble understanding why she might need or want to stay at school after classes were over for the day.

Talking to other Iranian American families in the community eventually proved helpful in understanding the importance of extracurricular activities, Etemadi says. But as a whole, Iranians are protective of their personal lives, she explains, so the family tried to cope with many struggles on their own.

The most profound event for which the family needed support happened a few years after moving to the United States, when Etemadi’s brother died under traumatic circumstances. Unfortunately, the family was still relatively isolated in their new home country and didn’t have anyone to turn to to help them process what had happened. Even the teachers at her school barely acknowledged her brother’s death, let alone her grief surrounding it, Etemadi says.

It is those types of events that might push many Americans to seek counseling. But the idea of counseling is completely alien to Iranians because it just doesn’t exist in their country, Etemadi explains. And that is a point that counselors in the United States need to understand — they should not expect that members of most immigrant communities will simply show up at a counselor’s office if and when they need help.

That is why Etemadi says counselors can and should be advocates for immigrants. She believes that from the beginning of the immigration process, immigrants need someone who can speak their language to provide them with mental health support. They also need to be told that counselors can continue to provide assistance if they run into barriers that they have trouble surmounting.

Because of her personal experiences, Etemadi developed an interest in studying the immigrant experience. As she learned that the types of difficulties faced by immigrants of all cultures are similar, she decided she wanted to help. She ultimately chose to become a counselor because she felt that counseling’s emphasis not just on mental health but also wellness and personal development would be most palatable — and useful — to immigrant populations.

As part of her dissertation, Etemadi is currently studying whether it is possible to develop best practices specifically for counseling with immigrant and refugee populations. Because the notion of counseling is typically foreign to immigrant populations, she believes it might be particularly difficult for these clients to grasp that emotions are connected to actions. Etemadi has found narrative therapy to be particularly useful because it helps clients who have immigrated to the U.S. to look at their stories from an outside perspective, while allowing her to identify cultural differences between the client’s culture and American culture. She can then partner with clients to explore how these differences may be causing difficulties.

The primary thing Etemadi wants counselors to know about the immigrant and refugee populations, however, is that they need help acculturating but don’t generally know where to find this help. She says counselors have a responsibility to reach out to immigrant communities. Because there is often stigma surrounding counseling, especially in these communities, she suggests that counselors use a soft approach to raise awareness. For example, she says, counselors could post their business cards in international restaurants or even settings such as the tire store. She also advises that counselors work with local physicians to make connections. In some cultures, she explains, the suggestion to seek help from a counselor will be much better received if it originates with a doctor.

Communicate to advocate

Saari Amri, a licensed professional counselor in Falls Church, Virginia, agrees that very few immigrants are going to walk into a practitioner’s office. “It’s rare that we have immigrants in general proactively seek out mental health counseling,” she says. “When they come in, they come in after crisis or have gotten to a tipping point. … With torture survivors, domestic violence, they come in through referrals, usually law enforcement or social services.”

Amri practices at Northern Virginia Family Services Multicultural Center, a clinic that receives many of its referrals because the counselors who work there are multilingual and culturally responsive, she says. Many of the clinic’s clients are seeking a counselor who is an Arabic speaker or a Muslim. Amri, a member of the American Counseling Association, is both.

Although similarities exist between different Arabic cultures (including those whose members may be largely Christian) and Muslim societies, Amri cautions against making assumptions. “Cultural competency is a dynamic process even for someone like myself who has a lot of experience with the population and shares their culture and religion,” she says. “I’m always learning something new. [Counselors] always need to explore and understand.”

To get a full sense of the sociopolitical context of a client’s story, Amri says it is important to know not only where that client is from but also to ask about his or her particular experience. For instance, Amri recently had a client who was a former refugee from Somalia. She assumed the woman would be presenting with posttraumatic stress disorder, but it turned out her presenting issue was unrelated to her refugee experience.

Many of the issues with which Amri’s clients present — including depression, trouble sleeping and difficulties parenting their children — are common experiences for those who are struggling to acculturate, she says. She notes that she tries to keep the primary focus of her counseling on addressing clients’ immediate needs and safety. Within her clients’ cultures, people are generally seeking help for a specific issue and aren’t interested in anything touching on the psychoanalytic, she explains. Amri doesn’t believe there is any one method or practice that is most effective with clients who are immigrants or refugees. “You can’t go wrong with keeping it client-centered and meeting the client where they are,” she says.

However, it is important to understand that the immigration journey intertwines with everything the client is experiencing, Amri says. “It’s important to normalize what they are going through, whether it’s struggling with acculturation or coping with the effects of war or torture.”

It isn’t common for the clinic to see immigrants soon after they’ve arrived in the United States, Amri says. Instead, they usually come in years later as problems develop or grow worse. In many instances, this includes providing support to asylum seekers, who are generally coping with mental health issues related to whatever it is they have fled, including torture, war, political oppression or other circumstances.

Many of Amri’s clients are Arabic-speaking women who are subjected to domestic violence. In some cases, the women are immigrants from the Middle East who entered into arranged marriages in which an American man came to the woman’s home country, “picked” her out and brought her to the United States. Once in the United States, the husband becomes abusive. It’s very difficult for these women to find help, Amri says, because they don’t speak the language and may not be allowed to leave the home. The abuse often goes on until neighbors call the police or the woman flees, Amri says. These women often end up in her office through referrals from social services or law enforcement.

Amri also works with couples who are experiencing major cultural clashes as part of an interethnic or interracial marriage. They struggle in particular once they have children and realize that their child-rearing styles and basic values may be very different, she says.

Amri and the other counselors at her clinic also help clients navigate social service providers, school systems, the juvenile justice system and health care providers. The clients find it useful to be accompanied by people who speak the same language they do but, more importantly, Amri says, the counselors are there to make sure these clients actually get their needs met. Because the concept of negotiating with school systems, public service providers and health providers is often completely alien to these clients (let alone trying to do it in a foreign language or new country), Amri and her colleagues are there to help them navigate the cultural nuances and secure the services they need.

With situations such as this, Amri and other counselors have to go beyond traditional counseling techniques. They provide a source of support but also help the clients find outside services they need, such as occupational therapy.

Amri acknowledges that it may be difficult for a counselor who doesn’t come from an immigrant’s culture to provide effective services. At the same time, she says, it is inevitable that counselors will end up working with clients who are immigrants unless the counselors limit themselves to engaging with a specific client group or clinical issue. For that reason, Amri would like to see counseling education programs and professional groups provide more opportunities for multicultural training.

Connecting with the community

If clients won’t come to the counselor, sometimes the counselor needs to go to the clients, says Johanna Nilsson, director of the Empowerment Program, which is part of the Division of Counseling and Educational Psychology at the University of Missouri–Kansas City. The program provides free case management and mental health services to immigrant and refugee women and their families.

The Empowerment Program has a small staff supplemented by women from the immigrant and refugee community. These women not only provide a link to the various immigrant communities but also function as advocates for the clients. Nilsson, a professor currently on sabbatical, also has her students work in the program, coordinating psychoeducational workshops for the immigrant community or counseling women who seek mental health services in the division’s training clinic, Community Counseling and Assessment Services (CCAS). She says this enhances students’ knowledge of cultural diversity and is a good way to introduce the next generation of counselors and psychologists to immigrant communities.

Most of the program’s clients are women who are struggling with family, employment and cultural adjustment issues, says Nilsson, an ACA member. Kansas City’s immigrant population is diverse, but the Empowerment Program’s largest client groups come from Somalia, South America, Central America and Vietnam.

One common concern is parenting, Nilsson says. Many of the women are experiencing a loss of parental authority and struggling with how to parent in an unfamiliar culture in which they are confronted with new expectations for how to raise children. In addition, they tend to lag behind in understanding the language and culture in which their children are so quickly immersed, Nilsson says. The counselors provide a substantial amount of individual psychoeducation, both in CCAS sessions and workshops and when working in conjunction with advocates on visits to clients’ homes. The counselors also present workshops at religious institutions and service organizations on topics such as parenting, physical and mental health, trauma and domestic violence.

In the parenting workshops, the counselors teach parenting skills, conduct role-plays and even bring in local teachers and principals so the parents can get a better idea of how school systems (and public systems in general) work in the United States and how to interact to get what they need from people in positions of authority. One of the larger lessons these workshops help to promote is that immigrants and refugees “have the right to ask questions and seek help,” Nilsson says.

The program also occasionally holds family nights with immigrants and refugees from different cultures. Although language is often a barrier, Nilsson witnesses the women in particular bonding over their shared concerns about family, which helps them recognize that their struggles are common across cultures. In other words, they’re not alone. “It feels very energetic,” Nilsson says.

Nilsson believes it is also important to meet with clients in their homes. The counselors and students are accompanied by the community advocates on these visits. This approach tends to lessen the inherent language and cultural barriers while also helping to put the families more at ease. The home visits provide a way for the counselors and students to get to know members of the immigrant community, see how they are doing and learn what they might need. The visits also allow for opportunities to educate immigrants and refugees about available services, Nilsson says. A nurse will sometimes accompany the team to give health checks and provide additional information.

The program focuses on women not only because responsibility for home and child care often rests on their shoulders but also because refugee communities in particular have high numbers of families that have been separated, Nilsson explains. In many instances, the men have been unable to leave their home countries, so the women and children enter the U.S. on their own, she says.

Unfortunately, program workers also see cases of domestic violence. In addition to the danger and fear experienced by all people who endure domestic violence, women who are immigrants or refugees also tend to face language and cultural barriers that make them feel even more isolated and vulnerable, Nilsson points out. In many cases, these women might not even know what a shelter is or report that the shelter’s staff members don’t seem to understand them, she says. The idea of sharing space with other women and children at a shelter can also be particularly frightening to women who are immigrants or refugees, Nilsson explains.

To compound matters, domestic violence may be widely overlooked or even accepted in the woman’s culture. In fact, choosing to leave an abusive home situation might traditionally result in the woman being shunned, Nilsson says.

The Empowerment Program does partner with a shelter, so there is a place that staff members can take women and children in an emergency, but many immigrant and refugee clients are simply not ready to leave, Nilsson says. In such cases, staff members provide information on what the women’s rights are, what resources are available and how to access those resources. This information is also provided in the program’s workshops and sometimes in the women’s homes if it is safe to do so, Nilsson says.

Nilsson reminds her students that when they encounter instances of domestic violence, it is essential to start with the basics: Does the client have food, clothing and a safe place to live? Like Amri, she also believes that counselors are responsible for supporting immigrants and refugees with whatever they need, even when those needs fall outside the traditional realm of counseling. The Empowerment Program provides assistance with immigration paperwork and also serves as a bridge to other organizations that offer services the program is not equipped to handle.

Nilsson believes stepping outside of the office and into the community to provide what clients need is the future of counseling. She also thinks this kind of training is essential for students. “If students only attend a diversity class, the population is still foreign to you,” she emphasizes. “You have to bring the student out into the community.” It’s not solely the responsibility of immigrants and refugees to seek out counseling, she asserts. Instead, counselors must be intentional about reaching out to and connecting with these individuals and communities.

Undocumented and disadvantaged

As difficult as the immigration experience can be for those who are legal permanent residents, entering the United States without documentation presents an extra layer of barriers.

“This is a population that is frequently and repeatedly marginalized and scapegoated,” says Selma Yznaga, who helped establish the Community Counseling and Training Clinic at the University of Texas-Rio Grande Valley (formerly the Community Counseling and Training Clinic at the University of Texas-Brownsville). “They struggle with prejudice and discrimination, lack of access to basic services, housing and fair wages.”

Brownsville is on the U.S.–Mexico border, so many of the clinic’s clients are from Mexico. The clinic staff does not ask about immigration status, says Yznaga, who is also the interim chair of the university’s department of counseling and guidance. “Their residency status wouldn’t change anything about the way that we serve them and could raise suspicions about our intent for asking,” she explains. Regardless, some of the clients’ circumstances surface in the biopsychosocial histories that counselors gather during assessment, and these factors are considered holistically, she says.

“Clients come in for many of the same reasons people seek counseling in other parts of the country — relational problems, school referrals, issues related to poverty,” says Yznaga, a past president of Counselors for Social Justice, a division of ACA. “The majority of our referrals come from the local department of health and human services and the school districts.”

However, as with any other immigrant or refugee population, these clients’ presenting issues are always intertwined with their cultural struggles, she says. “For many of the undocumented population, basic resources for survival are a priority,” she says.

Obtaining these resources is a constant struggle because although there is a thriving black market in the Rio Grande Valley in which almost anything can be obtained for a price — driver’s licenses, green cards, Social Security cards and jobs — the market is ruthless, Yznaga says. Undocumented workers aren’t protected by labor laws, so they get paid below minimum wage or sometimes don’t get paid at all and are threatened with deportation if they complain, she says.

Not surprisingly, counseling is not typically a priority for this population. In fact, Yznaga says, people from Mexico are unfamiliar with counseling as a concept. In Mexico, mental health services are provided by psychiatrists and psychologists, she explains.

However, Yznaga and other clinic staff work to promote wellness within the immigrant community by going to places such as housing developments, where they can help organize health fairs that include diabetes screenings and depression assessments.

Clinic staff members also educate clients at the health fairs and in the clinic itself about systemic discrimination and marginalization and help clients learn to advocate for themselves. “We help them differentiate between mental health and mental illness and [work] to destigmatize help-seeking,” she says.

Because the undocumented immigrant population is such a stigmatized group, counselors should be careful to avoid the “missionary posture,” Yznaga says. “Undocumented individuals are sensitive and perceptive to people treating them as ‘less than,’ and sometimes well-intentioned assistance can be mistaken for pity,” she cautions. “Mexicans are proud of their tolerance and ability to survive under harsh conditions and can be shamed by the counselor’s perception that they are weak.”

Yznaga also notes the importance of counselors understanding the diversity inherent within the Mexican population. “We should all be very aware of in-group differences and avoid stereotyping any immigrant group,” she says. “For example, there are 31 states in Mexico, as diverse and unique as the 50 United States.”

“When possible, we should do our own background research and tentatively explore what resonates with the client as it relates to the presenting problem,” Yznaga continues. “In other words, as much as we want to know about a new culture, we shouldn’t make it the client’s responsibility to teach us in their counseling sessions.”

Working toward the future

Historically, many immigrants have come to the United States in pursuit of the fabled American Dream — not just for themselves, but especially for their children. That hasn’t really changed in the 240 years since the United States came into being. The path to that dream has undergone some significant detours, however.

In some ways, today’s children who are first- or second-generation immigrants may have greater opportunities for education than did prior generations. After all, these children do not need documentation to enroll in school — only a local address. However, once in school, they may not be given all the resources they need to learn everything the school has to offer, which can hamper their hopes of graduating, getting a job or going to college.

The biggest barrier, of course, is language. Many counselors have heard the occasional news story about schools in areas with large Latino/Latina populations that refuse to offer bilingual education. But most people aren’t aware that in a growing number of areas in the U.S., it is not uncommon for schools to have a student body that speaks five, 10 or even more different languages. How can any school system accommodate that?

This is where school counselors come in, says Diana Wildermuth, a former school counselor who worked predominately with the English-language learner (ELL) population for 14 years. There is much that school counselors can’t control, Wildermuth acknowledges, but she still urges school counselors to be aware of the ELL laws in their states so they can help to ensure that students receive the language services to which they are entitled. These services can vary widely, depending on the state. Students in California, for instance, may have access to bilingual education, but in certain areas of other states, there might not be any teachers who speak Spanish or other needed languages.

Some schools at least maintain a translator service so teachers can meet with parents who don’t speak English or who have limited English proficiency. If the school doesn’t have a translation service or can’t provide translation for a particular language, Wildermuth, now a professor of psychology and education at Caldwell University in New Jersey, recommends contacting local community organizations. At her former school, there was a need for someone who could speak Ukrainian, so she contacted a local community organization that could provide people to assist in translating.

Although this may help the parents, these translation services aren’t typically available to students, she points out. In some places, ELL services may consist of students following along as best they can or being paired with a native English speaker who can help explain through demonstration, she says.

Language isn’t the only barrier with which ELL students contend. The cultural and functional differences in the school experience can contribute to these students feeling like strangers in a strange land, says Wildermuth, a member of ACA. “For instance, in U.S. high schools, students move from classroom to classroom throughout the day,” she explains. “But in other countries such as South Korea, the teacher moves from class to class.”

This may not seem like much more than a stylistic difference, but imagine, Wildermuth says, being a new Korean student who is pointed toward homeroom and then expected to know how to navigate the school schedule for the rest of the day. School counselors need to be aware of these and other barriers that students who have immigrated to the U.S. might face, she says.

“If a brand-new student is coming to school, you have the opportunity to meet and greet them, make them [feel] comfortable and welcome,” she says. Simply letting the student know that you, as the school counselor, are a safe person to come to with any problems or concerns is important, Wildermuth emphasizes.

School counselors can also use some creative approaches to further ease these students’ sense of awkwardness and even help them build their English-language skills, she says. Wildermuth suggests organizing a scavenger hunt for ELL students at the beginning of the school year to assist them in learning the locations of classrooms and other facilities. If the clues are accompanied by short notes, the scavenger hunt can help reinforce the names of the locations in English, she adds.

Wildermuth also suggests engaging in role-play by asking questions with students so they can learn what is considered to be appropriate teacher–student interaction. It’s also important for counselors to make teachers aware of how difficult it can be for ELL students to know what to do or how to behave in the classroom, she says. Teachers are often uncomfortable with ELL students and tend to leave them out of class interactions and discussions, Wildermuth points out, but by educating teachers beforehand, counselors can ease some of their anxieties and pave the way for a smoother transition for the student.

Finally, Wildermuth says that much of what school counselors need to do with ELL students mirrors what they need to do with American-born students — namely, educating them on the role of the school counselor and how the counselor can help the student.

 

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The professionals interviewed for this article realize that it is unrealistic to expect the average counselor to possess all of the skills needed to work with every client who is an immigrant or refugee. At the same time, they emphasize that all counselors need to educate themselves and seek training in those skills. As a growing number of people from diverse cultures continue to enter the United States, these counselors emphasize that our society and, accordingly, the role of the counselor must continue to evolve.

 

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Additional resources

For those who would like to learn more about the topics addressed in this article, the American Counseling Association offers the following resources:

Books (counseling.org/bookstore)

  • International Counseling Case Studies Handbook edited by Roy Moodley, Marguerite Lengyell, Rosa Wu & Uwe P. Gielen
  • Culturally Responsive Counseling With Latinas/os by Patricia Arredondo, Maritza Gallardo-Cooper, Edward A. Delgado-Romero & Angela L. Zapata
  • Counseling for Multiculturalism and Social Justice: Integration, Theory and Application, Fourth Edition, by Manivong J. Ratts and Paul B. Pedersen
  • Counseling Around the World: An International Handbook edited by Thomas H. Hohenshil, Norman E. Amundson & Spencer G. Niles
  • Multicultural Issues in Counseling: New Approaches to Diversity, Fourth Edition, edited by Courtland C. Lee

Webinars (counseling.org/continuing-education/webinars)

From ACA’s trauma webinar series:

Podcasts (counseling.org/knowledge-center/podcasts)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org