Monthly Archives: January 2006

Medicare and counselors: Frequently asked questions

Scott Barstow, Christopher Campbell and Brian Altman January 7, 2006

At presstime, Congress was still considering budget reconciliation legislation that included language establishing Medicare coverage of state-licensed professional counselors. American Counseling Association members are strongly encouraged to check www.counseling.org/publicpolicy for updates on the status of this legislation and the possible need for grass-roots support for this provision. This website and the related website at http://capwiz.com/

counseling will include information regarding members of Congress to contact and suggested messages for discussing the issue.

To help familiarize counselors with both Medicare and the legislative process involved in working to gain recognition of counselors under this program, ACA’s Office of Public Policy and Legislation offers a list of “frequently asked questions” (and answers!).

 

Q: What is Medicare? Who are Medicare’s beneficiaries?

A: Medicare is the federally run and financed health insurance program covering an estimated 40 million older Americans (age 65 and older) and Americans with disabilities. Medicare is the single largest health insurance program in the country. It should not be confused with Medicaid, the health insurance program for low-income uninsured children and families funded jointly by states and the federal government. States control their Medicaid programs, including eligibility and benefits criteria, within certain basic federal guidelines. Congress controls Medicare, although the program is administered in each state by one or more intermediaries.

Q: How do I get a Medicare provider number?

A: Right now, you can’t. Currently, psychologists and clinical social workers are the only nonphysician mental health professionals covered under the program. Congress writes Medicare’s benefit package. At presstime, Congress had yet to pass (and the president had yet to sign) legislation establishing Medicare coverage of licensed professional counselors.

The Senate has passed legislation establishing Medicare coverage of state-licensed professional counselors and state-licensed marriage and family therapists, but this is only the first step in the legislative process. Before any legislation can be enacted, it must be approved in exactly the same text and format by three separate entities: the House of Representatives, the Senate and the president. (The House and Senate can enact legislation by overriding the president’s veto, but this is a rare occurrence.)

Q: Since Medicare coverage of counselors has passed the Senate, does this mean it’s going to become law in a certain amount of time?

A: No. The Senate has passed legislative language establishing Medicare coverage of counselors before, but without subsequent House approval of the same language. Each chamber (the Senate and the House of Representatives) routinely passes legislation that the other chamber chooses not to approve. Simply because the Senate has passed something doesn’t automatically mean it’s going to become law.

In this case, the Senate included a counselor coverage provision in its broad budget reconciliation bill, S. 1932. The House budget reconciliation bill does not include this provision. At presstime, a group of House and Senate members was working together to reconcile differences between the two bills. As mentioned previously, before a bill becomes law, the same exact language must be passed by both the House and the Senate and then be signed by the president. The House and Senate conferees on the budget reconciliation legislation are working through a long list of contentious issues.

ACA is working alongside the American Mental Health Counselors Association and the American Association for Marriage and Family Therapy to see that the counselor/MFT coverage provision is retained in the conference report (the name for the compromise version of the legislation written by the House-Senate conferees) developed on the budget reconciliation legislation.

Q: If the Medicare language passed by the Senate on counselor coverage is enacted, which counselors would be covered?

A: The provision passed by the Senate would establish Medicare coverage of state-licensed professional counselors who have obtained the highest level of licensure. Thus, the provision would not apply to any mental health counselors in states without licensure (California and Nevada). School counselors would receive reimbursement for services provided to Medicare beneficiaries only if they were licensed in their state as independently practicing mental health counselors.

Q: What groups are opposing this provision?

A: The only groups we know of opposing Medicare coverage of licensed professional counselors and marriage and family therapists are the American Psychiatric Association and the National Association of Social Workers. The opposition of these two groups is disappointing, if not surprising.

The American Psychiatric Association has a long history of opposing efforts to expand direct access to nonphysician providers (including psychologists, clinical social workers and licensed professional counselors) under Medicare and other public health programs.

The National Association of Social Workers appears to share the American Psychiatric Association’s desire to protect its members’ “turf” at the expense of patient access to services. This is despite the strong similarities in counselor and social work training standards and the fact that clinical social workers are routinely licensed with significantly less actual graduate coursework than licensed professional counselors. Many — if not most — graduate programs in social work give students as much as a full year of credit for bachelor’s level coursework.

Q: If counselor coverage is enacted, when would it go into effect?

A: Most likely sometime in 2007. Under the legislation passed by the Senate, coverage of state-licensed professional counselors would begin Jan. 1, 2007. However, House and Senate conferees on the measure could change this date. In addition, the U.S. Department of Health and Human Services and its Centers for Medicare and Medicaid Services will need time to develop regulations implementing this and any other changes in Medicare law. The regulatory process is sometimes painfully slow.

Q: Would getting Medicare coverage affect reimbursement under Medicaid?

A: Only indirectly. As noted above, states control their Medicaid programs and have free reign to cover (or not cover) many services and populations. Under federal law, state Medicaid programs must cover physicians’ services, but they are not required to cover psychologists’ services or those of other nonphysician mental health professionals. Recent budget shortfalls have forced nearly all states to cut back on their Medicaid programs.

However, Medicare coverage will help demonstrate to state officials that counseling is a legitimate mental health profession. This, combined with counselors’ cost-effectiveness, may cause more states to establish or expand coverage of counselors for their Medicaid beneficiaries.

Q: How would this affect private health plans?

A: Again, only indirectly. Changing the benefit package of one of the primary public health insurance programs doesn’t mean that private sector plans have to change anything. However, they will likely be more inclined to recognize and reimburse licensed professional counselors if they know we’re covered under Medicare. Medicare law prohibits “Medicare+ Choice” managed care plans from discriminating against providers on the basis of their type of license.

Q: How much does Medicare pay?

A: Medicare is not known for its generous reimbursement rates, and one of the major policy discussions taking place is the extent to which Medicare’s small payments to providers are leading them to stop seeing Medicare clients. Medicare pays for services through a complex fee schedule that takes into account the difficulty of the service provided, the resources necessary to provide the service and geographic cost factors.

Medicare generally pays 80 percent of the cost of outpatient treatment, with the beneficiary responsible for the remaining 20 percent. However, for outpatient mental health treatment, Medicare only pays 50 percent of the cost, with the beneficiary responsible for the other half. This inequitable copayment requirement remains unchanged in both the House- and Senate-passed bills.

The Senate’s bill would pay state-licensed professional counselors and marriage and family therapists at the same rates as clinical social workers. If and when this provision is enacted into law, counselors can find out what Medicare payment rates are for outpatient mental health services in their area by contacting their state’s Medicare carrier.

Q: Can I do anything to help Medicare coverage of counselors become law?

A: We think so! As stated previously, either check the ACA website at www.counseling.org/publicpolicy or contact Brian Altman with ACA’s Office of Public Policy and Legislation at 800.347.6647 ext. 242 or via e-mail at baltman@counseling.org to get an update on the status of this legislation.

If Congress hasn’t already decided on this issue by the time you receive this issue of Counseling Today, we may need you to contact your Representative to ask him or her to contact the respective chairs of the House Ways and Means Committee (Rep. Bill Thomas) and Energy and Commerce Committee (Rep. Joe Barton) to express support for Medicare coverage of licensed professional counselors.

You can find your Representative through the ACA Internet Legislative Action Center at http://capwiz.com/counseling. Since the Senate has already approved our provision, we need to focus on getting House members to support this as well.

ACA Ethics Case Study Competition open to graduate counseling students

The purpose of the American Counseling Association Graduate Student Ethics Case Study Competition is to support the ACA Ethics Committee’s charge to help educate members of the association regarding ethical issues. The competition engages graduate counseling students (master’s and doctoral level) in critically analyzing a potential ethical case and creating an appropriate ethical decision-making plan to respond to the ethical situation.

The ACA Ethics Committee will begin accepting registrations for its second annual virtual case study competition for master’s and doctoral level students in counselor education programs beginning Feb. 1. The registration deadline is noon Eastern time on Feb. 15.

Team structure and rules

Members of the Ethics Committee will create two mock ethical scenarios, one for master’s students and one for doctoral students, with each addressing a current ethical issue facing the counseling profession. Teams may be composed of three to four master’s students or three to four doctoral students enrolled in the same counselor education program. Master’s and doctoral student teams will be judged in two separate categories. Each team must also have a faculty member to serve as an administrative contact person for the institution. Other pertinent information regarding team structure and rules:

  1. Each counselor education program will be allowed to enter only one team of master’s level students (i.e., programs may not have two teams of students from different specialty areas) and one team of doctoral level students in the competition.
  2. Each team member must currently be enrolled (in good standing) in a master’s or doctoral level program in counselor education and also be enrolled for the spring 2006 term for a minimum of three credits.
  3. Each team member must be a member of ACA (team members may submit membership applications online when they submit their competition registration forms).
  4. Teams should utilize the 2005 ACA Code of Ethics and information from relevant counseling literature for their case study responses.
  5. Utilization of outside sources, websites, articles, etc., is encouraged for the case study, but graduate student team members may not consult with anyone outside of their case study team, including their faculty contact or other members of their faculty.
  6. By submitting a case study response, teams agree to allow their names to appear online and  in Counseling Today and for their responses to be posted online.

Registration and submissions

Teams must complete an online application by noon Eastern time on Feb. 15. Further information and registration forms will be available after Jan. 27 on ACA’s website at www.counseling.org. Each team will designate a contact person. After teams have registered, the primary contact person listed for each team will receive further instructions on accessing the appropriate case study and submitting responses to the case study. Team members will be able to access the case scenario on Feb. 24. Completed responses to the case study must be submitted by midnight Eastern time on March 22.

Student teams are to present their responses to the case study in a brief paper (maximum of 15 pages) addressing the details of the case. Teams should clearly identify what they believe the dilemma to be, the proposed action they would take in this case (i.e., what they believe are the most ethical actions) and the justification for their proposed action(s), and provide a description of the model used to arrive at that decision. The decision-making model should be one that has been discussed in the professional literature, and team members are to offer a rationale regarding why they chose to apply that model to the case study.

Teams should cite appropriate literature and must give proper credit to the authors of any decision-making models used to analyze the case. Team members are to cite any sections of the 2005 ACA Code of Ethics (and may include other ethical guidelines) that they considered.

The role played by the ACA Ethics Committee

In addition to creating one case study for master’s level teams and one case study for doctoral level teams, ACA Ethics Committee members will serve as judges for the competition. Ethics Committee members may not serve as the faculty contact for teams from their institutions. Furthermore, should an Ethics Committee member be associated with an institution that registers a student team for the competition, that Ethics Committee member will recuse herself or himself from judging that particular project.

Prize awards

Prizes will be awarded to recognize the top two master’s teams and top two doctoral teams. In addition, one master’s team and one doctoral team will receive an honorable mention. The names and institutions of the winning master’s and doctoral teams will be published in Counseling Today and posted online. In addition, the winning responses will be posted online.

First place prize: Each team member will receive a $75 gift certificate to the ACA Bookstore and a framed certificate.

Second place prize: Each team member will receive a $25 gift certificate to the ACA Bookstore and a framed certificate.

Honorable mention: Each team member will receive a certificate.

Timeline

  • The deadline for team registration if Feb. 15 (there is no fee to register).
  • The cases will be available to teams on Feb. 24.
  • The case submission deadline is March 22.
  • The judges’ decisions will be made April 24.

If you have questions about the competition, contact ACA Ethics Committee Co-Chairs Harriet L. Glosoff (hglosoff@virginia.edu) or Samuel Sanabria  ( ssanabria@argosy.edu). If you have questions regarding technical aspects of the competition (e.g., problems with registering online), contact ACA Ethics Committee staff liaison Larry Freeman at lfreeman@counseling.org.

ACA Foundation Message

Jane Goodman

First, let me thank the many members of the counseling community for your generosity. Your contributions of both time and money have been exemplary. The American Counseling Association Foundation has asked for donations and you have responded as we continue to raise funds this year for the Counselors Care Fund and our other projects, including the Growing Happy and Confident Kids program.

You have been reading about the Counselors Care Fund in a number of issues of Counseling Today in part because so many of us are deeply committed to helping “our own” directly, as well as helping our colleagues provide assistance to the many people suffering from the recent hurricane disasters. I am pleased to note that at its most recent board meeting, the ACA Foundation trustees approved a motion that established the Counselors Care Fund as a permanent part of our activities. While there will unfortunately be other disasters, the ACA Foundation wants to be in a position to help.

We are delighted to provide funds to the worthy activities I have described, as well as a number of other endeavors that benefit many aspects of our profession. But, of course, we need your continued support to do so. I have been touched by the gifts I have had the privilege of receiving this year on behalf of the ACA Foundation. However, we need lots more. Please check the ACA Foundation website at www.counseling.org/foundation  and donate — right now while you are thinking about it. Or send a check made out to ACAF in care of Theresa Holmes at ACA headquarters, 5999 Stevenson Ave., Alexandria, VA 22304.

Let me brief you on some of the ACA Foundation’s other projects. The ACA Foundation supports students in the counseling profession in a number of ways, including scholarships to the annual conference and the first timer’s lunch, a special lounge reserved for students in the exhibit area, and the graduate student essay contest. We support other ACA activities by sponsoring events for the ACA Governing Council, the Council of Presidents and Region Chairs, and at the four regional leadership development meetings. We also support the ACA awards program.

These are ongoing activities of which we are proud. But last year, under the leadership of Clemmie Solomon and the rest of the board, we began a signature project, Growing Happy and Confident Kids. This emotional literacy project is about to be implemented in more than 25 sites, and we are confident we can raise more money to support more sites if we have applications. So check the ACA Foundation website and, if you meet the guidelines, please apply.

As I write this, I am gazing out at a beautiful winter landscape. I have heat, lights, hot water, food to eat and work to do. I have a loving, supportive family and good friends. I am grateful to be so fortunate. And even though I don’t say no very well, I am healthy emotionally and have been able to find good counselors in times of personal need. There are so many who have lost or who never had what I often take for granted. Please help counselors to help these people.

Jane Goodman is chair of the ACA Foundation. She also serves as ACA treasurer and is a past president of the association.

Embracing the deep structure of multicultural counseling

Michael D’Andrea and Judy Daniels

The multicultural counseling movement has taken center stage in the counseling profession. In doing so, it is transforming the way many persons think about their roles as professional helpers and the types of competencies they need to acquire to foster the healthy development of larger numbers of people from diverse groups and backgrounds.

While the movement continues to revolutionize the mental health professions in general and the counseling profession in particular, it is disconcerting to note how many people who view themselves as multicultural advocates have lost sight of or perhaps never really understood the deep structure of the multicultural counseling movement. In this month’s column, we discuss that deep structure and include a description of both the goals and purposes of many of the pioneers of the multicultural counseling movement.

We proceed by examining how the trend toward human diversity, diversity counseling and human relations training has led many counselors to a more comfortable and superficial understanding of the deep structure of the multicultural counseling movement.

Last, we outline specific recommendations that will help counselors reconnect with the spirit and principles underlying the deep structure of this revolutionary movement.

Building a more sane and just society 

The genesis of the multicultural counseling movement can be traced to the cultural revolution of the late 1960s and early 1970s. This was a time of great change in the United States, as many traditional social institutions, policies and practices were challenged by people in oppressed groups, especially African-Americans, who took part in the civil rights movement, and feminists, who supported the women’s rights movement.

It was during this time that Black counselors and psychologists, as well as feminist advocates and persons from other oppressed groups, described the many ways in which gender, cultural and racial biases were embedded in all the theories of human development, counseling and psychotherapy. The early multicultural and feminist counseling pioneers provided a strong and consistent voice that protested overuse of these theories by helping professionals. These theories were noted to result in ineffective and even harmful psychological outcomes in many instances when utilized among women and persons of color.

The early multicultural-feminist counseling pioneers underscored two major factors to substantiate their arguments. First, many of these pioneers pointed out that the cultural/racial/gender-biased theories were harmful to persons in oppressed groups. The professional practices reflected a set of values, biases, preferences and worldviews that were in conflict with those held by persons from oppressed groups. Persons from oppressed groups were already psychologically vulnerable because of the stresses they experienced in their everyday lives. By imposing their conflicting cultural/

racial/gender biases, it was believed that counselors further undermined the individual and collective strengths that women and culturally/racially different persons brought to the counseling setting. This observation led some of the early multicultural counseling pioneers to refer to counselors who insisted on using culturally and racially biased theories in their professional practices as “tools of oppression” and “handmaidens of the status quo.”

That action underscores a second important observation made by pioneers of the multicultural counseling movement. Many counselors, they noted, seemed most interested in helping clients make personal changes that would enable them to more effectively adjust to the status quo. In so doing, it was thought that individuals would experience more satisfying and productive lives within the context of the existing social order.

From a multicultural perspective, there is a problem with this biased approach to helping. Namely, many aspects of the status quo are not just; these aspects continue to perpetuate various forms of racism, sexism and cultural oppression that are antithetical to the mental health and psychological well-being of culturally and racially different persons. The consistent assertion that it is unethical to use culturally and racially biased helping theories to assist people in adapting to a status quo that is fundamentally in opposition to their well-being is a key element of the multicultural counseling movement’s deep structure.

Biases built into society

The deep structure of the multicultural counseling movement is grounded in a clear understanding of the various ways in which racism, sexism and other forms of cultural oppression are built into all the social, educational, professional, economic, religious and political institutions that constitute our contemporary society. These forms of cultural oppression are reflected in:

  • Increasing levels of racial segregation in housing and public education
  • Disproportionate annual incomes of persons from different racial/ethnic groups
  • The continued violence that is imposed on women
  • Inaccurate and negative ethnic/racial images in the media
  • The disproportionate number of persons of color in our nation’s prison system and on death row
  • Significant health disparities among persons in different racial groups

This list contains only a few examples; there are many others.

From the inception of the movement to the present time, some multicultural counseling advocates have understood how the previously mentioned issues represent deep structural problems that adversely affect the development of millions of people in our society. These individuals also recognize that an extensive and coordinated effort by large numbers of persons in the counseling profession is required to effectively address these complex problems. This understanding has led some persons in the multicultural counseling movement to acknowledge that these structural problems are maintained by what noted Black psychology scholar Asa Hilliard calls “pillars of dominance.” Hilliard points out that these pillars of dominance continue to negatively impact every institution in our society, including the fields of counseling and psychology.

Pillars of dominance

Contrary to what many people would like to believe, the mental health professions have not made the sort of substantial progress that early multicultural counseling pioneers had hoped would occur during the past 35 years. There is no doubt that progress has been made, both in the mental health professions in general and in the counseling profession in particular. This progress has left many counselors pleased with the accomplishments of what is now commonly referred to as the “diversity counseling movement” (a term many counselors seem more comfortable using than “multicultural counseling movement”).

Much of the success of the diversity counseling movement is tied to an increasing awareness of, sensitivity to and respect for human diversity. This includes but is not limited to:

  • Helping people gain a better understanding of why it is offensive to use culturally and racially offensive terms in public
  • Promoting a better understanding of the types of competencies that counselors need to acquire to work more effectively with persons in diverse groups
  • Establishing various activities in schools and communities that affirm the cultural integrity of culturally different persons in our society. This is notably reflected in the celebration of Black History Month in our schools and an increasing number of Gay Pride parades in our communities

While these and other similar efforts are useful in promoting human dignity through diversity, we agree with Hilliard’s assertion that such achievements represent relatively superficial accomplishments that fall far short of the deep structure of the multicultural counseling movement. Specifically, such achievements fail to substantially affect the pillars of dominance that continue to encapsulate our nation in general and the counseling profession in particular.

If multicultural counseling advocates are to more substantially impact the mental health and psychological well-being of larger numbers of persons who continue to be adversely affected by the pillars of dominance, they must acquire a clearer understanding of the movement. Gaining this understanding of the deep structure of the multicultural movement and the pillars of dominance necessitates expanding our vocabulary and conceptual understanding of other related issues. To assist counselors, we briefly discuss two terms that are beginning to gain greater attention among some multicultural and social justice counseling advocates.

Exploring hegemony, hegemonic structures and multicultural counseling

The term hegemony is defined as the “dominant influence of one state or group over all others.” Cultural critics such as bell hooks, Cornel West and Noam Chomsky have documented the many ways in which White, European, heterosexual, physically abled, middle class and Christian cultural/racial values, beliefs, preferences and worldviews underlie the hegemonic thinking that characterizes our contemporary society. This sort of thinking leads to the development and maintenance of “hegemonic structures.”

Hegemonic structures refer to how hegemonic thinking leads to the creation and maintenance of institutions that make up the infrastructure of a given society to maintain the pillars of dominance that are fueled by a particular set of cultural values, biases, preferences and worldviews. Although some progress has been made in understanding how the counseling profession continues to perpetuate hegemonic structures within our professional ranks, this understanding is limited to a relatively small number of persons who are cognizant of the multicultural counseling movement’s deep structure.

A few of the many ways that hegemonic structures and thinking still exist in our profession:

  • Continued use of culturally biased counseling interventions in clinical practice
  • Ongoing publication of counseling textbooks that provide a superficial analysis of the cultural implications of counseling and human development theories
  • Professional training programs that continue to use culturally biased entrance examinations in their selection processes
  • Professional accreditation and licensing bodies that continue to direct insufficient attention to cultural/racial issues
  • The tendency of counseling professionals to overgeneralize research findings that are not representative of persons from culturally and racially diverse groups

Further embracing the deep structure of the multicultural movement

Recently, the American Counseling Association has made significant progress in acknowledging the pillars of dominance that adversely affect the mental health of millions of culturally different and oppressed persons in our nation. This progress involved the advocacy efforts of leaders in Counselors for Social Justice who successfully secured the formal endorsement of the ACA Governing Council for eight multicultural-social justice resolutions. These resolutions acknowledge the adverse impact that ableism, ageism, racism, classism, sexism, heterosexism, religious bigotry, and war and violence have on healthy human development.

The resolutions also state the important role counselors can play in ameliorating these unhealthy pillars of domination. To accomplish this, counselors will have to address the hegemonic structures that sustain these pillars of dominance and, more fundamentally, the hegemonic thinking that underlies the creation and maintenance of these structures.

In doing so, counselors will more fully realize the deep structure of the multicultural counseling movement and more effectively foster the dignity and development of larger numbers of persons from diverse groups than ever before.

When East meets West

Jim Paterson

The startlingly tall, thin young Vietnamese man was standing naked in the middle of a busy city street talking to himself as motorcycles and bicycles whizzed by him. Perhaps even more peculiar was the reaction from others — there was none.

Libby Zinman-Schwartz was watching the man out the window of the old French villa in Vietnam’s Ho Chi Minh City where she was staying during one of her several visits to better understand the country’s traditional healing techniques. The experienced American therapist and counselor was surprised by the reaction from the other people on the busy street. And when she called the authorities, she got a similar response.

“The police and the local hospital just told me, ‘He is not harming anyone. Leave him alone.’ No one felt they should be involved. That incident became part of my mission to bring psychotherapy to this country.”

What Zinman-Schwartz found in that event was the culture’s avoidance of certain serious mental illnesses. It spurred an effort by her that was contrary to — and conveniently connected with — her first mission, which had been to learn and put to use Vietnamese methods of helping people with emotional pain. Now she was beginning to realize that this culture, which had for so long treated emotional distress with its mixture of Confucianism and Buddhism, was being turned upside down by the influence of Western culture. Ironically, perhaps, the treatments she revered and came to study were not enough.

“Traditional methods for the health of the mind and the body that stress things like rest and diet and herbal remedies — and even just principled ways of behaving with kindness and compassion to others — are what I wanted to learn,” she said. “They are secrets that have been passed along through generations, and they work so beautifully. However, for emotional disorders and for treatment of things like schizophrenia or depression, there is no Vietnamese frame of reference. There is no treatment in this country that really addresses these problems.”

So Zinman-Schwartz moved permanently to this Southeast Asian nation that shares a strained and sad history with the United States and began the process of introducing certain Western therapeutic techniques that she thought would help. She spoke to the health community and opened a free clinic where the first therapy of this type could be practiced in Vietnam. Gradually, her voice began to penetrate deeper into the culture.

Where it began

In contrast to the subdued people of Vietnam whom she so warmly describes, Zinman-Schwartz is intense and excitable. She is passionate about the things she holds dear — most notably her work and the people of this “amazing” culture. She rattles out sentences vigorously in rapid fire, skipping from topic to topic and hardly catching her breath. There is little doubt that her advocacy would benefit her chosen cause.

Zinman-Schwartz received her undergraduate degree and master’s in literature in the early 1960s. She earned her doctorate in education and her master’s in psychology in 1982. She was also interested in traditional forms of healing and how they might be used to deal with emotional distress. She visited other nations to learn more about their use, spending time in several Central American countries and in Mexico. In 1996 she went to Vietnam and immediately was drawn to the people.

“I fell in love with them,” she said. “This is the most supportive, warm and caring culture I’ve seen in all my travels. They are artistically gifted and have a high level of emotional intelligence. There is so much that is so interesting and attractive about these people.”

While on that first visit she found that there was much to learn, and as she spent more time in Vietnam, she began to sense the nation’s need for other therapeutic techniques. She also discovered that the Vietnamese culture was perhaps not ready for her message or for the guidance she wanted to offer.

In one situation, she asked a group she thought was well-versed in modern therapy techniques who Freud was — but she got no response. In other cases, segments of the mental health industry were combative. “No one was really ready to hear what I had to say. But there was beginning to be an interest,” she said. “Some people saw the value in new ways of doing things.”

That interest in her ideas grew as she continued to visit Vietnam. In 2001, when she finally moved to Vietnam, she was gaining attention both there and in the West. American Counseling Association member Patricia Stevens, then chair of the Counseling Department at Eastern Kentucky University, was one of several experts who heard Zinman-Schwartz’s message, saw her clinic in travels to Vietnam,or learned about her through press coverage and the books and articles she was writing. “When we visited Vietnam for an International Counseling Conference in Ho Chi Minh City,” Stevens said, “she asked us to come see her clinic. I was incredibly impressed with what she was trying to do. We then asked her to come to the conference to talk about counseling in Vietnam.”

Stevens knew that other cultures faced similar pressures, but Vietnam — rocked by the war and the ensuing U.S. economic embargo — was now rapidly being thrust into a new age. “They are so quickly faced with all the issues we have dealt with for 50 to 60 years,” Stevens said. “We’ve sort of come full circle in how we handle things — looking toward traditional techniques. They understand those techniques but probably need more. Libby is trying to take what works in an Eastern culture and combine it with what might work from the West.”

Stevens said it is both fascinating and challenging work, noting that Zinman-Schwartz faces the same opposition to new therapy techniques or approaches in this culture as counselors in Western cultures have faced for ages. Along with that, she faces a culture steeped in a very different tradition.

But Zinman-Schwartz has made inroads, and her ideas have taken root and gained ground. She has been the only board-certified Western counselor operating privately in Vietnam and has served as a consultant for Western clinics and hospitals. For the first time in the country’s history, she offered training in Western psychotherapy at a local university. She has also gathered research on the relationship between Vietnamese culture and psychological disorders.

In addition, Zinman-Schwartz has become a popular speaker at universities and hospitals and was recently asked to head the Department of Psychotherapy in a new building at the Ho Chi Minh University of Medicine and Pharmacology, one of the nation’s most prestigious schools. Her free clinic, which she operates from her home, has also expanded, with facilities at a military hospital and a pediatric clinic. And more than 200 people attended a two-part conference she sponsored last June.

The approach

Zinman-Schwartz came to understand that the Vietnamese culture might benefit from a new, unique way of counseling. “There was not a psychological approach here,” she said. “They had never seen psychotherapy practices. Some were fascinated by the field, but no one had seen it. There was no infrastructure for it.”

But she also understood that the culture had traditions that were strong and potent. “The family is at the center of Vietnamese life, and they all live together,” she said. “In that environment, children are nurtured in this incredible way. There is nothing better for a child than that sort of nurturing.” She found some aspects of the culture that she didn’t like — a tradition of physical violence against women and children, for instance — but Zinman-Schwartz said the culture’s mix of Buddhism and Confucianism generally creates happy, emotionally healthy people.

However, she also discovered that more difficult issues needed additional attention — for instance, serious mental illnesses such as schizophrenia and depression, as well as issues resulting from the influence of Western culture, including divorce and, among adolescents, drug abuse and suicide. Those problems got Zinman-Schwartz’s attention, but she was determined to treat them with respect for Vietnamese society’s traditions.

“My Vietnamese student counselors and I have learned how to promote Western ideas with a deep and mindful respect for Eastern values,” she said, noting that she often uses and trains her staff in a few simple techniques. Thus far she has trained five student counselors, and three more are in the process of being trained. “There are hundreds waiting,” Zinman-Schwartz said, “but I still do not have the large room I need to train with a one-way mirror and an audio hookup.”

She said clients are often receptive to new approaches to their problems and constructive suggestions because their culture treats authority and education so respectfully. “Vietnamese culture has a level of politeness and generosity I’ve never seen anywhere else,” she said. “When they learn about our approach, without exception, every client agrees.”

That counseling approach is something Zinman-Schwartz stumbled upon, but she now believes it works particularly well in Vietnamese society. She sits in on sessions held by her new counselors, along with other students and interpreters. She often offers comments or seeks information during the sessions so that the new counselors can receive direction and observing students can learn about the counseling process. They can also interject.

“While the translators were excellent and I felt that I was well aware of the client-therapist communication process taking place in front of me, eventually I became more impatient and wanted to check what the client had said before the counselor responded,” Zinman-Schwartz said. She began intervening with questions and encouraged other students to do likewise, especially when clients proved comfortable with the practice.

“The (counseling) model fused with the Vietnamese family and cultural life,” she said. “The extended family and trust it engenders is a foundation of Vietnamese life and social security. We simply fit ourselves into that existing cultural construct of tolerance for inclusion of others. The shifting from one counselor to another and the different personality of each prompts clients to react and reveal to us behavior we might not have otherwise noted. What evolved is a process related to ‘team theory’ and other techniques that have been successful in group therapy. It was well suited in Vietnam because of the critical link by individuals to their families.”

Because of those strong ties to family, counselors often must introduce concepts such as countertransference, internalizing and interjecting parental figures and attitudes, Zinman-Schwartz said. Additionally, parents in Vietnamese culture frequently are excessively dependent on their children and overly involved in their development, which can cause distress to both parties.

In addition, Zinman-Schwartz said, the counselors must try to combat one significant cultural problem — an unwillingness to express themselves. The counselors often simply attempt to get clients to be more open with their feelings.

“It is a process of seeing what works from both cultures and putting it to use,” she said. “And our clients are very comfortable with that approach. It works.”