Tag Archives: advocate

Accepting failure as part of professional advocacy

By Whitney N. White May 25, 2016

In recent months and years, I’ve seen counseling and mental health move up the list of “hot topics.” Influential actors, leaders and even government officials have spoken up and drawn these areas into the light in a new and brilliant way. As a culture, we are talking about mental health now and reaching out for help more than ever. I find this inspiring and believe that all of this bold new conversation and outreach is changing lives for the better.

First lady Michelle Obama has spoken publicly about the importance of mental health and the need to end associated stigma. Kate Middleton, the Duchess of Cambridge, recorded a video message this year in support of Children’s Mental Health Week. Actor Jared Padalecki, of Supernatural fame, talked publicly about his own mental health struggles and launched the Always Keep Fighting charity T-shirt campaign (I regularly see clients sporting the clothing that is sold to support the cause). MTV has run news segments on celebrities working to shut down stigma related to mental health. Leonardo DiCaprio talked about his struggle with obsessive-social justicecompulsive symptoms after filming The Aviator. While filming the movie, he stopped trying to control his tendencies toward obsessive-compulsive disorder and ended up developing stronger symptoms that lasted long after filming had ended.

For these reasons, I thought at least a tiny bit of the battle was over. What battle? The battle for counseling to be taken seriously as a profession, the battle to get people to understand that mental health is as important as all other aspects of health and the battle to get help to those who need it. I believed these changes and new discussions meant that the control tower had cleared the runway and all we needed to do as a profession was fly in and land.


A bubble burst

I didn’t want to be like many of the mental health professionals — counselors, caseworkers and others — I met during my school-related practicum. I’d hear them speaking about red tape, see the cynicism in their expressions and sometimes even sense their disdain for my fresh-out-of-the-box, new counselor, can-do attitude. But they knew what I’m beginning to understand.

The battle isn’t over. It won’t ever be over. We can’t rest from this as a profession. We have to keep going, keep working and keep educating. When a chiropractor points out that his church shut down its free counseling program because “counseling is just talking and doesn’t really work,” we have to smile and use that as an opportunity to educate. When a woman in line at Starbucks sees the American Counseling Association gym bag we’re holding and assumes that we just help kids get into college, we can speak up about what we really do.

My bubble was burst a few months into my first real counseling position at a nonprofit agency serving children in Texas. Texas is a large and, for the most part, very rural state. Many of its small cities don’t have any licensed mental health professionals. In addition, there are many people without the money or insurance to pay for services despite the Affordable Care Act, and many others lacking the resources to travel half an hour or more to access counseling services. Most families have parents and caregivers who work. Taking a block of time out of their workday for counseling has a price attached, both in terms of money and stress.

In an effort to provide services to populations in these circumstances, the agency where I work allows counselors to set up satellite offices in neighboring communities. This helps when families can’t make the trip to the main office or can’t afford to take off work to make that trip. To take this a step further, we often gain permission from schools in these outlying areas to see children in the schools where they attend (with proper consent and releases). Because of other tasks that require their time and expertise, school counselors don’t typically have the time to provide in-depth mental health counseling to students in need.

I received a few calls from residents of a nearby town who wanted a counselor to come provide services to children in the community. Each of the referral calls came from families with children in the local school district, so I was surprised when I reached out to the school to offer counseling services and got a “no” in response. The school’s lead administrator informed me that I could use space on the campus one day per week, but students would be permitted to miss only music class.

This was bad news on a couple of levels. First, because the school is small, each grade level goes to music class together. In other words, I wouldn’t be able to have two clients in the same grade because my sessions are 45 minutes long and music class is 50 minutes. Second, it would be impossible to protect the privacy of my clients under those circumstances. It wouldn’t be long before every kid in the school knew that if a student left music class, he or she was going to counseling. Never mind the underlying message that music (the arts) is frivolous — just like counseling.

I responded to the stipulated offer by explaining the privacy concerns I had about the situation. I also reiterated that multiple families with students in the school had sought services and that I wouldn’t be able to see everyone during music classes. I mentioned that I always talk with parents and children about what time of day will work best for them based on the child’s performance in each class and when that class occurs. I reminded the school administrator that Texas permits children to miss school to attend counseling appointments, just like they are permitted to miss class to see a medical doctor.

I communicated this all very professionally and from a place of love and advocacy for my would-be clients, my profession and my agency. In response, I got another “no” that included an explanation of how and why academics are the focus of this particular school. This school’s administration either doesn’t understand the way that mental and emotional health (which counseling supports and develops) affect academic performance, or they do and choose to ignore it. I’ll never know. I did my best to provide a basis for conversation and education about counseling. It didn’t work, and I was frustrated. A school — the place where so many issues are first identified — was refusing to help its students.

Months prior to this disappointing outreach, I had volunteered to present at a local high school career day. After the rejection of my services by the other school, I was hesitant to follow through on this career presentation. How would I possibly line up next to police officers, doctors and teachers as a career option? Had anyone even signed up for my presentation on mental health counseling as a career? Would the cynicism building up inside of me because of others’ rejection and resistance to mental health progress dull my eyes, spirit and voice as I talked to potential future counselors?

When the day arrived, more than 120 students had signed up to hear my presentation on mental health counseling. They asked great questions. For instance, a freshman asked, “How does working with others and their problems affect you as a counselor?” A ninth-grader asking about vicarious traumatization! They were listening! And interested! I opened up about what it is like for me to be a counselor.


Getting to ‘yes’

In a nonprofit agency, we often wear many hats. Sometimes we are counselor, case manager, outreach coordinator, guest speaker, educator and secretary. Sometimes we are all those things and more within a single hour of the day. We are advocates for our clients and would-be clients. I advocated for potential clients with the area school in hopes of making services available and easily accessible and to require less time out of class. I failed, but I tried. Sometimes we’re disappointed that others — professionals affected by our work — don’t understand its importance or take it seriously. But on some days, we get through. Some days we get a “yes.” That “yes” means the world to the people we work to serve.

It is vitally important that as a profession, we continue to advocate and communicate with professions that touch ours. Medical professionals, teachers and many others have contact with our clients. Their perspective on counseling can have an effect on how our clients view counseling — on whether or not they seek and receive the services they need. In the face of frustration, it is important to remember to talk openly and to stay educated about the research that supports our field and the interventions we use. The next time you’re brave enough to speak up, you may get a “yes” that changes minds and outcomes for better down the road.

The disconnect I’ve experienced across professions is often a result of my desire to avoid perceived conflict by not speaking up and telling someone how fantastic my research-supported profession is. Talk about our profession. Talk about it anytime you’re given a chance like I was at my chiropractor’s office. When you’re in line at Starbucks, talk about it with the woman who comments on your ACA bag. Talk about it on social media. Speak up about what we do and the research that supports it, and be ready to power through the possible frustrations of a “no” or disagreement.

We don’t just expect children to learn algebra “naturally.” We educate them from their first day of school until their last, which prepares them to do algebra in real-world settings. Yet the attitude of public educators is at best “refer for counseling”; at worst, “kids can do that away from ‘education’ time.”

The “yes” I hope to witness someday is a big one. In my head, every school in my state — in the United States — will welcome vetted agencies to enter schools and provide in-depth services on campus when they’re needed and with appropriate consent from guardians. I envision a time when I’ll call or visit a school campus that welcomes me and my bag of counseling goodies every time (it does happen!). I close my eyes and see schools with life skills courses — entire courses devoted to bettering the whole person in which kids can learn about emotions, coping skills, communication and healthy relationships.

My vision of counseling science as a cornerstone of health and education is a big one. Imagine! Sending kids into a classroom to learn how to communicate effectively with one another. Producing high school graduates with all the tools to truly live life to their fullest, most successful potential. This vision may seem very far away, but there was a time when children weren’t educated about math beyond what they might learn at home. In my moments of frustration, I close my eyes and see these things and remember to speak up for my profession, my colleagues and my clients.

Recently, Prince Harry, who has long been outspoken on mental health issues related to veterans of war, spoke with Good Morning America. He stated, “Psychological illnesses can be fixed if sorted out early. … We’ve got to keep the issue at the forefront of people’s minds. … Just talking about it makes all the difference.” The counseling profession must continue that battle, talking not just about mental health but about what we are able to do to help.





Whitney N. White holds a master’s degree in clinical mental health counseling. She is a national certified counselor and a licensed professional counselor intern in Texas, where she is employed in the nonprofit sector working with youth. Some of her passions are working with youth struggling with self-injury; using yoga to connect body, breath and mind; and spending time with her family. Contact her at whitneywhite82@gmail.com.

Don’t use the ‘t’ word and five other tips for counselor advocacy

By Kevin Doyle March 29, 2016

After 30 years in the counseling profession, I have arrived at the conclusion that we counselors are sometimes our own worst enemies. When a unified voice could be the key to advancing our profession — such as with current efforts to expand reimbursement for counselors’ services under Medicare, initiatives to standardize our licensing standards and outreach to get more counselors Branding-Images_Avocacyhired to positions within the Department of Veterans Affairs — we at times seem to be fighting our own internal battles instead.

How, then, can the individual counselor do his or her part to advance the profession that we all love? In the spirit of helping the counseling profession achieve the status that 40 years of licensure would indicate, I’d like to offer six concrete, yet relatively simple, suggestions.


First, as my students would corroborate, I have a visceral resistance to using what I call the “t” word: therapist. Although probably well-meaning in most instances, when counselors use this word, they miss opportunities to use an even better one: counselor. The same principle exists for use of the word therapy when counseling could be used.

In our culture, most people do not know the differences between counselors, social workers, psychologists and even psychiatrists. Each time that we call ourselves by the correct name (counselor), we are taking advantage of an opportunity to educate the public about our profession — to help with our own branding, if you will. Similarly, each time that we use therapist or therapy, we are missing out on that same opportunity and in a small way contributing to the ongoing diminution of our professional identity. When referring to a multidisciplinary group of helping professionals, using therapy or therapists is, of course, appropriate.

A second concrete action that each of us can take is to refer to other counselors. Obviously, our primary obligation is to our clients, and if the appropriate and best referral is to a helping professional in one of our sister professions, then so be it. But in making referrals, we are afforded another opportunity to help our profession advance, so we should include professional counselors as often as possible when we refer.

In my hometown of Charlottesville, Virginia, several licensed professional counselors got together a few years ago and formed a loosely organized group. We meet monthly for informal support and discussion and engage in quarterly trainings together for required continuing education. But in addition, we have also established an active professional network that has allowed us to learn more about the expertise of local counselors, which has greatly enhanced our ability to make appropriate referrals. Rarely does a week go by without a member of our group posting a message to our distribution list asking for help in identifying a fellow counselor to work with a particular type of client. Referring to other counselors, when appropriate, is one of the best ways that each of us can support our profession.

My third suggestion relates to the electronic age in which we currently operate. We must not underestimate the power of the Internet. Unfortunately, many counselors in our community do not have websites, so the referral process I outlined above is often complicated by the fact that most clients want to read about the person they were referred to before pursuing services with that professional. Because of that, we may be forced to refer to a professional from another discipline who does maintain a website. Lest counselors be discouraged by expense, several low-cost or even free web-design templates are available (for example, see weebly.com, wix.com and web.com). Using these or other templates, the main cost involves purchasing the domain name and hosting the site, which is typically quite affordable (often less than $100 per year). In addition to generating referrals for your practice, having a website helps to solidify the presence of counselors on the Internet and further legitimizes our profession in the eyes of the public.

A fourth step in advocating for our profession induces fear in some counselors and may not be for everyone: talking to the media. Local newspapers, radio stations and television outlets are on a continuous quest for fresh content related to issues of the day. Some counselors routinely turn these requests down (I know, because they refer the media to me), missing another chance to educate the public about themselves and the profession.

Dealing with the media can be tricky, of course, but simply discussing what our profession does can be a valuable public service and an opportunity to teach about what counselors do. Commenting on particular cases or specific clients would be problematic and even potentially unethical, but participating in an interview on a particular issue, such as a counseling approach, what counselors do or a topic of interest to the local community, could be entirely appropriate and valuable. American Counseling Association staff members are available for consultation on talking to the media as well.

Getting to know your state and local legislators is a fifth way for counselors to engage in advocacy for the profession. State legislatures vary greatly, but most are composed of part-time legislators who spend much of their time in their local communities. These legislators are almost always extremely open to meeting with constituents (another word for voters!). Waiting until an issue is in front of the legislature to visit with your elected representative is often too late. By that time, whatever opposition exists may have already made its position known, meaning you may be up against a formidable adversary in a politically charged environment. A better approach is to proactively establish a relationship with local legislators. This can be done by inviting them to visit the program where you work, introducing them to other counselors, considering honoring them for work they may have done that is helpful to your clients or considering making a campaign contribution. Any or all of these steps can make a real difference when counselors in your state legitimately need the help of the legislator on a particular issue.

If you are uncomfortable or overwhelmed with the idea of visiting your local legislator, think about going as a group. Several counselors, perhaps with different specialties, can attend a meeting together, allowing the elected official to learn from multiple perspectives on a single visit and maximizing the effectiveness of your time. Remember, legislators are people just like us.

Finally, a sixth suggestion relates to the all-important governing bodies that oversee the practices of many of us: state licensure boards. Early in my career, my role in state professional associations led me to attend numerous meetings of our state board of counseling. Not only was this necessary and valuable as it related to the issues under consideration, but it also contributed to my interest in serving on the board and eventually resulted in my appointment to this position in my home state of Virginia. Before my appointment, while attending the meetings and advocating for things that weren’t necessarily in line with the board’s thinking at the time, I received a wonderful compliment when one of the board members said to me, “We don’t always agree with what you have to say, but we appreciate the way you conduct yourself.”

Opportunities to advocate for the profession frequently present themselves, and we need to take advantage of them, whether our audience is the general public or our fellow counselors. Attending a meeting of your state counseling board is an easy step; most boards must meet in open session, and their activities are matters of public record. Public comment is usually received at the beginning of each meeting, not just when controversial items are being debated. These are free, easy opportunities for counselors to speak in a public way about issues of importance to the profession. Serving on such a board is also a very valuable way to engage in advocacy on behalf of the profession.

Clearly, there are numerous ways for counselors to engage in advocacy. Each of us should be able to identify a few ways to get involved, either based on the suggestions in this article or by staying alert to other advocacy opportunities. Whether it involves the somewhat tongue-in-cheek avoidance of the “t” word or the more substantial activity of attending a state counseling board meeting, each counselor is presented with daily opportunities to engage in the activity of advocacy.

To this counselor at least, it seems that we earn the right to express our displeasure only when we actively engage in advocacy. Not doing so contributes to some of the obstacles we currently face in attaining the respect and consideration that the counseling profession both needs and deserves.




Kevin Doyle, a licensed professional counselor and licensed substance abuse treatment practitioner, is an assistant professor and co-coordinator of the counselor education program in the College of Education and Human Services at Longwood University in Virginia. Contact him at doyleks@longwood.edu.

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Immigration’s growing impact on counseling

By Laurie Meyers January 27, 2016

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.




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.




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)




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

Letters to the editorct@counseling.org

Medicare bill gains critical co-sponsor

By Bethany Bray November 23, 2015

U.S. Sen. Michael Bennet has agreed to co-sponsor a bill that would allow professional counselors to be reimbursed for care of clients who have Medicare health insurance, an issue the American Counseling Association has long advocated for.

The Colorado Democrat’s endorsement of the bill carries significant weight because he sits on the U.S. Senate Committee on Finance.

Bennet’s decision to co-sponsor the bill came after months of advocacy by American Counseling Association members in the Denver area. He is now one of 11 bipartisan lawmakers who co-sponsor the bill.

[Editor’s note: Soon after this article was posted, the bill gained another co-sponsor: Sen. Sherrod Brown (D-Ohio). As of December 2015, the bill has 12 co-sponsors.]

Senate bill 1830, or the Seniors Mental Health Access Improvement Act of 2015, would establish reimbursement of licensed professional counselors (LPCs) and licensed marriage and family counselors (LMFTs) for the treatment of clients whose primary coverage is Medicare, the federal

ACA member and LPCC Denise Magoto (on left) and LPC and licensed addictions counselor Katherine Bujak-Phillips are pictured at an advocacy to Sen. Michael Bennet's office this spring. Bujak-Phillips leads the LPC peer supervision group at the Medical Health Center of Denver, where Magoto works.

LPCC Denise Magoto (on left) and LPC and licensed addictions counselor (LAC) Katherine Bujak-Phillips are pictured at an advocacy visit to Sen. Michael Bennet’s office this spring. Bujak-Phillips leads the LPC peer supervision group at the Medical Health Center of Denver, where Magoto works.

health insurance program for citizens who are age 65 or older. Medicare has covered psychologists and licensed clinical social workers (LCSWs) since 1989, but does not cover LPCs.

“For years now we’ve ben hearing about the baby boomer generation coming onto Medicare. They’re already predicting shortfalls in healthcare, and mental health is no exception,” says Denise Magoto, an ACA member who has advocated for Bennet’s support of S.1830. “There’s not enough licensed clinical social workers to go around. We’re already seeing that shortfall.”

Magoto, a licensed professional counselor candidate (LPCC) at the Mental Health Center of Denver, is all too familiar with the headaches that counselors face over the Medicare reimbursement issue.

Every time a new client comes to the Mental Health Center of Denver, the intake department works to match the client with a clinician based on what insurance they have and whether or not the center would be reimbursed for their care.

“It really complicates the process,” says Magoto, who handles a caseload of clients with serious or persistent mental illness, often coupled with substance abuse.

The crux of the problem is that it keeps professional counselors from helping an entire slice of the U.S. population — more than 40 million people. Senior citizens are far from immune to depression, suicide and other mental health issues, Magoto notes.

Magoto has worked with the ACA government affairs team through the spring and summer to draw Sen. Bennet’s attention to the need for counselor reimbursement through Medicare. She has met with Priscilla Resendiz, a constituent advocate in Bennet’s office, twice; last month, Magoto gave Resendiz a tour of the center where she works.

Resendiz was “incredibly receptive,” Magoto says. When they met for the first time in May, what Magoto expected to be a 10-minute session stretched to an hour and a half.

Dillon Harp, grassroots organizer in ACA’s Department of Government Affairs, says local advocacy, like Magoto’s efforts, is critical for S.1830 to gain momentum and support.

“(Resendiz’s) visit and the tour were a huge success and it was instrumental in Senator Bennet co-sponsoring this important piece of legislation. Denise was able to highlight the important work that LPCs do and show the staff member why this bill must be passed,” says Harp, who attended Magoto’s meeting with Resendiz in October. “Getting Senator Bennet’s co-sponsorship was a major milestone in ACA’s efforts to get this bill passed. Obtaining Senator Bennet’s support was a crucial because of his seniority in the Senate and because he is a senior member who sits on the all-important Senate Finance Committee, which has jurisdiction over the Medicare program. ACA could not have secured Senator Bennet’s support without all the advocacy work that ACA members in Colorado performed.”

Bill S.1830 was introduced into the Senate on July 22 by Sen. John Barrasso (R-Wyo.) and co-sponsored by Sen. Debbie Stabenow (D-Mich.). After its introduction, the bill was referred to the finance committee; It won’t go for a full Senate vote until more co-sponsors support the bill, says Harp.

One lesson Magoto says she’s learned through this process is to never think that your hands are tied, or that you can’t do advocacy work if you aren’t politically savvy. She admits she’s a novice when it comes to the intricacies of government. Magoto simply knew there was a problem that was affecting her daily work as a counselor and contacted ACA to see what could be done.

“Initially I had some fear … The biggest thing that I’ve learned is that it (advocacy) is a learning process and that’s OK. It doesn’t mean you shouldn’t (advocate or get involved),” she says. “Even though I had no idea what I was doing, I had a resource [ACA] to reach out to and walk me through it.”

(Left to right) Katherine Bujak-Phillips, Priscilla Resendiz (constituent advocate in Sen. Bennet's office) and Denise Magoto.

(Left to right) Katherine Bujak-Phillips, Priscilla Resendiz (constituent advocate in Sen. Bennet’s office) and Denise Magoto.




To get involved in ACA’s advocacy for the Medicare bill, and other issues that affect professional counselors, email Dillon Harp at dharp@counseling.org or visit counseling.org/government-affairs


To receive ACA’s Government Affairs newsletter and action alerts, email dharp@counseling.org





Seniors Mental Health Access Improvement Act of 2015

Follow the bill’s progress at congress.gov: 1.usa.gov/1QysDjy


S.1830 co-sponsors (As of December 2015; listed in the order in which they agreed to co-sponsor)

Sen. Debbie Stabenow, D-Mich. (original co-sponsor)

Sen. Al Franken, D-Minn.

Sen. Kelly Ayotte, R-N.H.

Sen. Jon Tester, D-Mont.

Sen. Thomas Carper, D-Del.

Sen. Kristen Gillibrand, D-N.Y.

Sen. Charles Schumer, D-N.Y.

Sen. Susan Collins, R-Maine

Sen. Angus King, Jr., I-Maine

Sen. Richard Blumenthal, D-Conn.

Sen. Michael Bennet, D-Colo.

Sen. Sherrod Brown, D-Ohio




Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

Extending the reach of counseling

By Laurie Meyers

People in need of help don’t always show up automatically on counselors’ doorsteps and request services. Sometimes counselors have to be intentional about first forming connections with potential clients and inviting them to investigate the therapeutic process. In other instances, counselors may Mountain-Climber-Helpneed to get out of their offices and connect directly with people in their own environments to even make them conscious of counseling and let them know that help is available

The American Counseling Association members we spoke to for this article have engaged in different kinds of outreach and advocacy efforts so they can better assist communities in need. In the process, they have deepened their own understanding of different cultures and client populations.

Traffick stop

Human sex trafficking is not something that is limited to developing nations. The practice also goes on in the United States and is more common than most people would ever imagine, according to Stacey Litam.

A doctoral student in counselor education and supervision at Kent State University in Ohio, Litam also works as a licensed professional counselor (LPC) and clinical resident at Moore Counseling and Mediation Services in the Cleveland/Akron area. The practice, which specializes in mental health and substance abuse treatment and mediation, has developed a partnership with the Cleveland court system to identify and assist women who have been or are currently being trafficked for sex.

The practice’s CEO, Martina Moore, has a doctoral degree in counselor education and advocates for trafficking survivors, but it was the Cleveland Municipal Court that approached Moore with the idea of collaborating to create a human trafficking docket (a list of legal cases to be tried in court), says Litam, who became part of the collaborative team at the time of her hire in October 2014. Litam notes that fellow Ohio city Toledo has the fourth-highest rate of human sex trafficking cases in the United States, and she suspects that the success of that city’s human trafficking task force influenced Cleveland’s decision to find ways to identify and help trafficking survivors. Moore Counseling staff members had previous experience working with the Cleveland Municipal Court on other specialized dockets, such as those being heard in drug court.

The Cleveland Specialized Human Trafficking Court Docket identifies women who have been charged with solicitation of prostitution and assigns them to probation officers who work with Moore Counseling to set up an evaluation. Litam conducts the evaluations, looking for criteria indicating that a sex worker is being trafficked or has been trafficked in the past. Sexual trafficking is defined as the recruitment, harboring and transportation of a person for a sexual act using force, fraud or coercion, Litam explains.

For many Americans, the phrase sexual trafficking conjures up images of kidnapping and forced servitude, of someplace “other” or foreign. Litam acknowledges that she held those same perceptions before she began working with the trafficking docket.

“When I first I got into this [work], I thought it was an issue that other countries dealt with,” says Litam, a board member of the Ohio branch of the Association for Humanistic Counseling, a division of ACA. However, she quickly learned that a substantial percentage of women and girls who engage in sex work are actually trafficked.

“I have probably completed about 45 assessments, and about three-quarters of those women met the criteria for trafficking,” says Litam, who adds that trafficking is “very insidious and pervasive.”

“A single woman might meet a man who helps her pay for food for her child or helps her with the rent,” Litam explains. “And then the guy says, ‘If you loved me, you would do this [have sex for money].’ He’s not using violence, but if the woman doesn’t do it, she may lose her housing or her child will go hungry.”

Another tactic that lures women into sex trafficking is a seduction of sorts, Litam says. A trafficker will pursue a romantic relationship with a woman, lavishing her with praise and gifts, until suddenly the woman “owes” him for the “gifts” of fine jewelry or nice clothing and has to pay off her debt, Litam continues.

In other instances, sex trafficking is all about survival, Litam notes, citing the experience of children living on the streets as an all-too-frequent example. “Children who are trafficked are usually runaways, ‘throwaways’ or [in many cases] LGBT [lesbian, gay, bisexual or transgender],” she explains. “Once they are on the street, they will be approached by a trafficker within 48 hours. Imagine that — you are an adolescent, and you are alone and need help. Traffickers are really good at finding them.”

Indeed, traffickers possess many of the skills associated with predators, such as the ability to sniff out the “wounded” and vulnerable, Litam continues. For many adult women who are trafficked, their journey to the streets began years earlier, because they were either trafficked or sexually abused as a child. In other cases, she says, women get caught up in trafficking to feed an addiction.

If Litam’s evaluation determines that a woman has been trafficked, she is eligible — after serving jail time for any solicitation charges — for the voluntary rehabilitation program that Moore Counseling has designed. The two-year program includes mental health counseling, intensive outpatient or residential treatment, substance abuse treatment and group counseling.

Trafficking survivors and women who are still being trafficked often live in unstable environments — typically with other women under the control of a trafficker, in housing they have a hard time paying for, with people who have substance abuse problems or in a home where they are being abused. In some instances, they may even be homeless. Living under such precarious circumstances makes it more difficult for these women to get off the street, let alone seek assistance for substance abuse or mental health issues, Litam points out.

“The two-year duration [of the rehabilitation program] was established in the hope that within this time period, our services would stabilize the client’s mental health, provide addiction treatment and aftercare, and help the client establish safe and stable housing,” Litam says. “Ultimately, I would like to see clients attend at least eight counseling sessions with me. Or, if the client is in need of substance use treatment, I would love for her to complete intensive outpatient treatment and aftercare while meeting with me once a week and perhaps continue to receive counseling afterward if needed.”

However, multiple factors keep many of the women from committing to the full program. “Women do not want to disclose,” Litam says. “I’ve never had a woman say outright, ‘Help me.’”

Some women aren’t ready to leave their traffickers, and those who stay, even if they are willing to come to counseling, are up against a fundamental problem. To the trafficker, time is money.

The women come to Moore Counseling and the rehabilitation program after spending time in jail, which can be as long as five days. By that time, the trafficker is already angry because he’s losing money, Litam explains. So the women are very vigilant and fearful of any time they spend away. Even an hour away will be noticed and questioned, Litam says.

“The benefit of counseling has to outweigh the cost of being away,” Litam says. Most of the women who are still being trafficked determine that isn’t the case, she concludes sadly. Many of the women who are eligible for the rehabilitation program will attend only a few sessions — or even just a single session. Litam says she treats each session as if it were the last one because, in many instances, it might be.

At a bare minimum, Litam makes sure that the women get a card that includes the phone number for the national human trafficking hotline. She also talks with them about having a safety plan, which involves figuring out where they can go, even if only temporarily, if they feel they are in danger. She encourages them to always have a “go” bag prepacked with any necessary personal items. Litam may also use motivational interviewing to help a client explore her ambivalence about her addiction or toward her relationship with her trafficker.

Women aren’t necessarily ready to engage in intensive counseling even if they are no longer being trafficked, Litam says. On average, trafficking survivors come in for four or five sessions before stopping, she says. But it’s not uncommon for these women to contact the program to begin counseling again a few weeks or months after their initial round, she adds.

“Some women may need to briefly touch on the trauma for a few sessions, take a few weeks off, then come back,” Litam explains. “I always welcome the women back when they do call. Trauma work is not on my time; it is on theirs.”

Litam uses a variety of techniques based on the client’s history and current circumstances. “Of course, every survivor will present with different needs depending on her individual resources and history. It’s whatever the client needs,” she emphasizes. “Sometimes they just want to sit and talk and not be judged. Sometimes it’s [the conversation] just about how worried they are about their child.”

One of Litam’s clients has made a significant amount of progress using creative-based interventions to express and release her trauma experiences. “We have also focused on addressing and reframing the cognitive distortions she developed while being trafficked,” Litam says.

Another of Litam’s clients has taken what she has learned through psychoeducation about how trauma affects the brain and applied it to her emotional regulation. “[She] finds peace in her ability to self-regulate her emotions outside of our sessions, has identified triggers and uses diaphragmatic breathing and progressive muscle relaxation as part of her daily self-care routine,” Litam says.

With other clients, Litam uses narrative exposure therapy to help them integrate complex trauma experiences into the context of their lives. “Establishing a timeline may look like placing a piece of rope on the ground with one end representing ‘birth’ and a balled up end representing ‘life that has yet to be lived.’ Clients place objects along the rope to represent positive and traumatic events along their timeline,” Litam explains. “Processing the trauma narrative in a safe place empowers clients to habituate to the trauma. Also, clients can feel empowered to see that much of [their] life has yet to unfold. It is a beautiful reminder and metaphor that things can get better.”

Litam also started a women’s resilience group at the practice where she works. She established it primarily to serve as an extra source of support for her female clients who have been trafficked, but she didn’t want the participants to feel labeled in that way, so she opened the group up to other female clients as well. She says the group represents a place where any woman can feel comfortable seeking peer support. Litam and several other counselors facilitate the group, which meets weekly.

Litam’s advocacy work doesn’t stop at her office door. She is also raising awareness within the law enforcement community about the prevalence of sex trafficking. Currently, she is working with a probation officer to set up a trafficking panel to better educate police officers.

Litam says police officers often lock up women for solicitation without looking for signs of coercion, even if the woman has visible bruises or other injuries. Her hope is that greater awareness by police officers about how common sex trafficking is might lead to earlier intervention and assistance for those being trafficked.

Litam is also an adjunct professor at Northeast Ohio Medical University, where she teaches students to use empathic communication in their patient interviews and examinations to look for signs that an individual is being trafficked or might be in danger. These indicators include constantly watching the door and being hypervigilant of her surroundings and the passage of time (time for which a trafficker will be wondering why she isn’t out making money).

Litam is also excited about research she is conducting with Jesse Bach, executive director of The Imagine Foundation, a nonprofit organization in Cleveland dedicated to ending human trafficking. Litam and Bach are studying human sex trafficker behavioral patterns, demographics and other characteristics in an attempt to establish a kind of trafficking “typology.” Their hope is that by identifying how different human sex traffickers operate, they can better understand how women (or men) are selected and kept under the trafficker’s control. Litam thinks that understanding these factors will also help identify intervention methods that might be more successful when counseling survivors and those currently being trafficked.

“Take, for example, a survivor who came from an unstable home and lacked a strong support system. Unfortunately, traffickers are predators and are excellent at identifying vulnerable women,” she says. “After months of ‘courting’ behaviors in which the trafficker convinces the woman he loves her and showers her with nice things, she may become conflicted in her ability to resist when he finally asks her to engage in commercial sex acts. This woman may need more intensive counseling on topics such as establishing appropriate boundaries, increasing self-efficacy, building strong support systems and CBT [cognitive behavior therapy] techniques.”

Litam says working with survivors and victims of human sex trafficking has become her passion. She believes that she can help these individuals not only by using her counseling skills with them but also by raising awareness of the prevalence of human sex trafficking.

“I would love for the average counselor to know that this is not a problem specific to Third World countries or inner cities, but that it is everywhere,” Litam says. She emphasizes that no neighborhood is exempt from human trafficking, regardless of whether that neighborhood is located in an upper-class suburb, a small town or even a rural area.

‘Learning’ rather than ‘teaching’

Counseling must always start with an understanding of the client’s cultural values, says Rachael Goodman, an assistant professor in the counseling and development program at George Mason University (GMU) in Fairfax, Virginia. This is one of the underlying tenets of counseling and a thread woven through all that counseling students learn as they work toward their degrees. However, Goodman says, experiencing others’ cultural traditions firsthand can impart an understanding that is more powerful than anything learned in the classroom.

In 2013, Goodman, as part of an effort facilitated by Counselors Without Borders, helped lead a group of GMU graduate students on a trip to the Pine Ridge Reservation in South Dakota. There they spent time with the people of the Oglala Lakota Nation as they prepared for and performed their annual Sun Dance ritual. Counselors Without Borders, founded by ACA member Fred Bemak, a professor of counseling and development and director of the Diversity Research and Action Center at GMU, is an organization committed to providing culturally sensitive humanitarian counseling in post-disaster situations.

Goodman thought it was particularly important for the students, who were taking a cross-cultural counseling class, to be exposed to other traditions. “It’s important for us [counselors] not to simply impose what might be misaligned Western models,” she says. “With any community, understanding what their traditions are is important for social justice so that we are not exacerbating marginalization.”

Goodman, who is also a member of Counselors for Social Justice, a division of ACA, planned the trip to coincide with the Sun Dance ritual so the counseling students could see practices that have both spiritual significance and a healing purpose for the Lakota people. A girl’s coming-of-age ceremony was also taking place at the same time.

Goodman and the students arrived before the ceremonies began to help with the preparations. For Lakota traditional services, the ground must be prepared in a certain way — for instance, the students helped build a circular space and a traditional arbor. (Because the Sun Dance is so sacred to the Lakota, Goodman says she is not comfortable giving details about the ritual). The counseling group also helped the young women with their rituals such as quilting and quillwork, which involves dyeing porcupine quills for use in traditional art.

These ceremonies have many healing and spiritual elements, perhaps the most important of which is a reclaiming of the Lakota culture, Goodman says. “It’s very important because of the history of genocide,” she elaborates. “For a long time, the United States government outlawed a number of native practices. The idea that you [as a Lakota person] wouldn’t be able to practice these ceremonies is in itself a trauma, so being able to perform them again is healing in itself.”

The Lakota are reclaiming not just their traditional ceremonies but also their native language, which was also outlawed for a long time, Goodman says. The group she led spent time with school students who were taking a language immersion class intended to sustain and widen the use of the Lakota language.

“I wasn’t aware of the importance of language in spirituality,” Goodman says. “They [the ceremonies] are conducted in Lakota, and if you don’t know [the language], you would have trouble understanding spiritual traditions.”

Goodman and her group also learned about the Lakota method of equine assistance therapy, which she describes as an interesting mix of Western culture and native practices. She says that for the Lakota, the horse doesn’t serve simply as a “feedback” instrument but rather is part of a person’s healthy connection to nature and all beings.

Goodman says all of the activities the group participated in taught the counseling students not only about Native American cultural practices but also helped them realize that counseling and therapy don’t necessarily have to occur in a formal, 50-minute, one-on-one sit-down. Counselors can provide support to clients and communities simply by listening, understanding and witnessing, she says.

Something else that struck Goodman during the trip was how the historical trauma of the Lakota is still very much a part of their present challenges. The people she spoke with emphasized that while the media and even well-meaning helping professionals often focus on issues such as substance abuse and violence on Native American reservations, they are seeing only the surface issues and not recognizing the historical trauma that underlies it all.

The people of Pine Ridge also had a parting message for Goodman and her group: “Let people know. Go back and tell our stories.”

Creative college counseling

Sometimes the biggest need for outreach is in a counselor’s own backyard — or campus. College students remain one of the counseling profession’s most underserved populations, not because there aren’t counselors available to help students but because these students are unlikely to come to the college counseling center for help, even when they desperately need it.

Research indicates that many college and university students aren’t just stressed, but depressed and anxious as well. In fact, 42.4 percent of the almost 75,000 undergraduate students who completed the 2015 annual American College Health Association National College Health Assessment reported experiencing more than average stress within the past 12 months, and 10.3 percent reported feeling tremendous stress. When asked about depression and anxiety during the previous 12 months, 35.3 percent of survey respondents reported feeling so depressed that it was difficult for them to function; 57.7 percent indicated feeling overwhelming anxiety.

At the same time, only a fraction of students in distress appear to be seeking help. The 275 college and university counseling centers that participated in the 2014 National Survey of College Counseling, an annual report sponsored by the American College Counseling Association (ACCA), a division of ACA, reported that only 10.9 percent of college or university students had sought services at a campus counseling center in the past year.

Clearly, “build it and they will come” is not a fitting slogan for campus counseling centers. Tamara Knapp-Grosz, who was the director of the Savannah College of Art and Design (SCAD) counseling center for 15 years, wondered what might happen if the center was proactive about going to the students instead. She started the process by offering workshops on depression at the counseling center and at various other campus meeting facilities, but most students still chose to stay away.

“I started thinking, ‘What is the goal of outreach?’” says Knapp-Grosz, an ACA member who is leaving SCAD to become director of the counseling center at the University of North Texas. First and foremost, she believes college counseling outreach should build a connection not only between the counseling center and the students but also between the students themselves because they have the potential to serve as secondary sources of support for one another.

But Knapp-Grosz, who had become interested in positive psychology during the beginning of her tenure at SCAD, was also struck by the idea of creating “shifts in the energy and atmosphere” during stressful times such as final exams. As she and the counseling center staff brainstormed ways to bring some positivity and levity to the students, their first creative outreach endeavor was born.

When stress levels got high, the counseling center staff and interns would visit various classrooms and celebrate a famous artist’s birthday. Knapp-Grosz, the immediate past president of ACCA, wanted to truly personalize the events and target the students by their areas of study, so the birthday parties were specific to the students’ specialties. For instance, a class of painting students might celebrate Van Gogh’s birthday with a themed cake and trivia. A birthday party for Peanuts creator Charles M. Schulz, thrown for students in the sequential arts (narratives accompanied by illustration such as those found in comic strips, graphic novels and storyboards), produced laughing and dancing, she notes. Word would spread throughout the building about the birthday parties, attracting additional students to join the celebrations.

The birthday party tradition continues through the present day, and Knapp-Grosz believes the benefits extend beyond providing students a brief break from stress. “Students start to connect with each other,” she points out.

They also start to connect with the counseling center personnel. Fliers detailing the services that the counseling center offers are always available at the parties, but that is secondary to the influence of the interactions between the counseling staff and the students, Knapp-Grosz asserts. By being at these “parties,” counseling staff are introducing themselves in a nonthreatening way and helping students become familiar with mental health professionals, perhaps even demystifying their role in the process, she says.

Other in-classroom interventions include “brain breakers,” a brief interval during which a counseling center staff member arrives with a limbo stick and music and invites students to limbo.

Yet another outreach tool, the Pizza Fairy, has achieved almost cultlike status, Knapp-Grosz says with amusement. The Pizza Fairy is a counseling center staff member who shows up in the student residence halls with free pizzas (accompanied by counseling center fliers) that are donated by a local hospital. There is no set schedule, so it is always a surprise when the Pizza Fairy appears.

“He’s become almost an urban legend,” Knapp-Grosz says. “People will text each other about it — ‘Have you seen him? Is he coming?’” In fact, students have even shown up at the counseling center looking for the Pizza Fairy, she notes with satisfaction.

The creative outreach doesn’t stop there. The counseling center has also featured Doughnut Divas who dressed up in costumes and handed out doughnuts in front of classroom buildings in the morning. The Doughnut Divas were replaced by Granola Goddesses when the students requested healthier food.

Then there is a certain iconic character in a big red suit who makes appearances on campus. “Toward the end of the quarter, we do ‘psycho Santa,’” Knapp-Grosz explains. “[Staff members or interns] put on a typical Santa costume but with goofy socks or something, and we’ll have an article about [topics like the] holiday blues. They [the Santas] usually go to the dining halls and hand out candy canes. We’ll sometimes have elves and reindeer too.”

The creative outreach seems to have paid off. Knapp-Grosz notes that over time, use of the counseling center at SCAD has risen to include approximately 50 percent of the student population.

The unconventional approach to outreach also seems to benefit the counseling center staff, Knapp-Grosz observes. “You have less burnout and compassion fatigue,” she says. “It’s refreshing to be out and about, and we are interacting with a broader student population.”

Knapp-Grosz says that before she starts making similar outreach plans at her new job at the University of North Texas, she will need to meet the center staff and learn more about the needs of the student population. She does, however, have an idea involving therapy dogs, inspired by her own dog, a standard poodle. As a breed, poodles have a penchant for dancing.

“If it fits the culture, I would like to have poodle dancing [in the classroom or other campus locations],” Knapp-Grosz says with a laugh. “I just think that would be really cool.”

Connecting with communities

Advocacy and outreach are two of the values at the core of the counseling profession, says ACA President Thelma Duffey, who has made counselor advocacy and outreach one of her presidential initiatives.

“I think counseling outreach provides a way for us to connect with our communities and to participate in advocacy and services,” she says. “It’s an opportunity for counselors to contribute to their communities by offering their areas of knowledge and expertise — at times to people who feel, and sometimes are, unsupported or disconnected.”




To contact the individuals interviewed for this article, email:



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

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