Monthly Archives: November 2019

Counseling Connoisseur: Autumn lessons in turning inward and letting go

By Cheryl Fisher November 27, 2019

“At first we do not know what deeds or misdeeds, what destiny, what good or evil we contain, and only the autumn can show what the spring has engendered; only in the evening will it be seen what the morning began.” — C.G. Jung

The leaves rustle in the trees as the wind grazes the tops, now bleeding color from the stems. Golden, russet and brown shades color the tips of the horizon as the seasons move from summer to fall. The earth begins to bring its energy toward its center as it prepares for the cooler months.

I begin my rituals of nesting. I cover the herbs and berry plants with straw and fill the feeders—assuring my feathered friends will have seeds and full bellies. Salads and light fair are replaced with soups and stews. The house is filled with the alchemy of savory and sweet spices.

I don shawls and pashminas and shuffle around in fleece-lined footwear. The shift toward autumnal consciousness brings quiet and an inward focus that is forgiving of extra pounds hidden under tunics and capes. I welcome the harvesting and gathering by all creatures as we prepare for the often-dreaded winter months that lie ahead.

Nature’s seasons offer guidance and are witness to the phases of change in our human experience. The first half of our lives—the spring and summer of our youth and young adulthood fade into the beginning of the second half—an autumnal middle adulthood that can offer peace and solace as we learn to turn inward. Just as the last of the leaves gently fall to the ground, we learn to let go of that which we no longer need. We let go of judgment and self-loathing, external validation and the defenses of the ego of youth.

The arrival of autumn

Our early years are characterized by quick growth and the establishment of our own separate identity. We build our sense of self from numerous factors: I am female. I am tall. I am a writer. I am a helper. I am a hard worker.

Once we have established our place in the world—one that centers on our individuality—a shift in perspective occurs. Autumn has arrived and we begin to look for greater meaning.

In “Falling Upward: A Spirituality for Two Halves of Life,” Richard Rohr, a Franciscan priest and founder of the Center for Action and Contemplation, says that the shift [to the second half of life] “… feels like a return to simplicity after having learned from all the complexity.” According to Rohr, life’s second half offers the understanding that peace and tolerance far outweigh an air of judgment and righteousness. Knee jerk reactions are replaced with contemplation and discernment. We begin to welcome the wisdom gained from many years of experience and coaching from others. We have started to cultivate our own sense of internal guidance and others may look to us for mentorship. We may recognize a sense of power — a force acting from within that we know is not our ego, and we begin to trust it.

A time of change

As we enter our middle to later adulthood, we may find judging people more difficult and that accepting people as they are is more in keeping with our heart’s desire. We no longer have to prove that our ethnicity, religion or socioeconomic group is superior to another. We have a greater understanding of our narrative and the mistakes we’ve made and are more able to view the errors of others in the context of humanity. According to Rohr, “Creating drama has become boring!”

During this time, we may begin to see love as something to be offered unconditionally, rather than given only for what we receive in return. Erik Erikson theorized that in middle adulthood — by his definition a span encompassing the ages of 40 to 65 years old — people begin to develop concern for others that extends beyond self and family. He called this need to nurture others—particularly the next generation—generativity. Erikson believed that this desire to give back to the world is so strong that if we are unable to contribute to the greater good, we feel a sense of failure and “stagnation.” Alfred Adler wrote extensively on the value of Gemeinschaftsgefuhl, or social interest — extending beyond oneself to creating a useful lifestyle. As counselors, we can help clients identify their gifts and find ways to make offerings to the world.

A different compass

According to Rohr, the first half of life is constructed through “impulse controls; traditions; group symbols; family loyalties; basic respect for authority; civil and church laws…”

However, in the second half of life, rules as a basis for action give way to authenticity and power directed from an internal moral compass. With age comes the understanding that there can be a difference between what is legal and what is moral. For example, there was a time in the not-so-distant past when it was illegal for black Americans to eat in the same restaurants as white Americans. While this was the law, it certainly challenges my moral compass. Throughout history, many activists—such as Martin Luther King, Jr.; Mother Teresa; Mahatma Gandhi; and Jesus Christ—have broken the laws of their time to move society toward higher moral ground.

The test of time has provided us with the experience of knowing to pick our battles. No longer feeling the need for competition and keeping up with the Joneses, we are able to enjoy just being in the general dance. We feel at peace more often with what is, and we appreciate things the way they are in the moment. We look to simplify our lives—making space for relationships and pleasure. Much needed playtime re-enters our calendars that have suffered years of overcommitment. We turn inward and welcome the peace.

As we work with clients who are transitioning from the summer of their youth to the autumn passage of middle adulthood, we can remind them of their strengths and the gifts they have cultivated throughout their lives. We can promote their generous offering of time and talents in service to their communities. We can help them identify their beliefs and values, and challenge the dissonance between their internal moral compass and the life they live. We can encourage their inner dialogue and the wisdom that they possess. As counselors, we can promote these changes by offering affirmation of their strengths and the beauty of coming into one’s own self in a way that is authentic, liberating and powerful.

Perhaps this is what the poet Jenny Joseph intended to capture in “Warning,” written in 1961 when she 29.

When I am an old woman I shall wear purple
With a red hat which doesn’t go, and doesn’t suit me.
And I shall spend my pension on brandy and summer gloves
And satin sandals, and say we’ve no money for butter.
I shall sit down on the pavement when I’m tired
And gobble up samples in shops and press alarm bells
And run my stick along the public railings
And make up for the sobriety of my youth.
I shall go out in my slippers in the rain
And pick the flowers in other people’s gardens
And learn to spit.

You can wear terrible shirts and grow more fat
And eat three pounds of sausages at a go
Or only bread and pickle for a week
And hoard pens and pencils and beermats and things in boxes.

But now we must have clothes that keep us dry
And pay our rent and not swear in the street
And set a good example for the children.
We must have friends to dinner and read the papers.

But maybe I ought to practice a little now?
So people who know me are not too shocked and surprised
When suddenly I am old, and start to wear purple.

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Pushing through the vape cloud

By Lindsey Phillips November 26, 2019

Four years ago, Hannah Rose, a licensed clinical professional counselor in private practice in Baltimore, started vaping as a way to quit traditional cigarettes, but she ultimately found that it was even more difficult to stop vaping. “I was vaping at work, round-the-clock, in between clients,” Rose recalls.

One day after leaving a yoga class, she instantly reached for her vape. In that moment, she felt conflicted because her nicotine addiction did not line up with her values of being mentally and physically healthy. This values conflict made her want to quit, but the thought of doing so gave her anxiety.

Part of Rose’s anxiety stemmed from the fact that nicotine, which is in most vape juices, can be highly addictive. One pod (about 200 puffs) of the electronic-cigarette brand Juul contains 20 cigarettes’ worth of nicotine. Gail Lalk, a licensed professional counselor (LPC) and licensed clinical alcohol and drug counselor in private practice at Young Adult Therapy in Morristown, New Jersey, says she has seen teenagers who have gotten addicted after vaping one or two pods.

E-cigarettes often introduce nicotine to teenagers who were not previously smoking traditional cigarettes. This has been the case for the majority of Lalk’s younger clients. Lalk asserts that she hasn’t had a single client younger than 18 who started vaping because they were trying to quit cigarettes.

Recent statistics confirm the popularity of vaping among teenagers. According to the Food and Drug Administration, from 2017 to 2018, e-cigarette use grew by 78% among high school students (from 11.7% of students to 20.8% of students) and increased 48% among middle school students (from 3.3% to 4.9% of students). In December 2018, Surgeon General Jerome Adams issued an advisory about the dangers of e-cigarette use among teenagers and declared it an epidemic in the United States.

But why have e-cigarettes gained popularity so quickly? The big draw is the flavor, says Rose, who has experience working with clients battling addiction. Traditional cigarettes aren’t known for their good taste. The first time someone smokes a traditional cigarette, they usually start coughing and are left with a tobacco or menthol aftertaste.

Compare that experience with vaping: It doesn’t feel harsh when the user inhales, yet the user still gets a buzz of nicotine. And this experience comes in almost any taste imaginable — mango, mint, apple pie, cake, bourbon, coffee and so on. The options are so plentiful that some online vape shops organize the flavors by categories such as cream and custard, candy, sour and beverage.

However, after a recent outbreak of lung injuries associated with vaping, e-cigarettes have been coming under increased scrutiny. The Trump administration has proposed a policy to ban flavored vaping liquids, and several states such as Michigan, New York and Massachusetts have already enacted similar bans. In October, Juul announced it was immediately suspending sales of its e-cigarette flavors.

Watch your language

Jennifer See, an LPC and a licensed chemical dependency counselor in private practice in San Antonio, advises counselors to be honest with their clients about the attraction of vaping. “These substances make these kids feel good, even if it’s just temporary. So, saying that they don’t is just not a good approach,” notes See, a member of the American Counseling Association.

Instead, counselors should acknowledge that vaping can be pleasurable and ask clients what they like about it, she says. At the same time, clients can be reassured that they have the ability to quit, even though it will be difficult, and that the counselor will be there with them every step of the way, she adds.

When referring to the issue of vaping during intake or in session, counselors need to be specific about the language they use, See says. Smoking is not “an umbrella [term for vaping] because people don’t really associate [vaping] with tobacco or nicotine,” she explains. “It’s almost its own category.”

On her intake form, See used to ask clients if they were using nonprescribed substances such as alcohol, tobacco or nicotine, or whether they smoked. However, she was finding that clients who vaped often responded no to these questions because they didn’t consider it to be the same as smoking. Now, See clearly asks if clients vape or Juul (the most popular brand of e-cigarettes).

This advice extends to the language counselors use on their websites and in how they advertise their clinical services. Rather than listing only general terms such as substance use or smoking, counselors should specifically list vaping if they are trained and feel comfortable working with the issue, See suggests.

Rose doesn’t believe that vaping should be the focus of counseling sessions, at least not initially. “Vaping is not the problem,” she explains. “It’s just a symptom of the problem. So, counselors [first] need to tap into that core-issue work.”

As Rose points out, even 12-step programs view substances as symptoms of a larger issue. “The 12 steps are not about not drinking [or smoking],” she says. “The only step that even mentions alcohol or nicotine is the first step. The other 11 steps are all about introspective work, practicing integrity, and looking at what patterns of behavior are no longer useful.” The success of this approach lies in looking for the underlying issue, not treating the substance as the problem, she says.

Parents often call See in a panic because they have caught their child vaping and want the child to stop. Parents — typically out of concern and fear — may try to punish or shame their children into quitting. See avoids any hint of shaming her young clients for their choices or even making assumptions about their readiness to quit whatever substances they are using “because I think that is a great way to alienate [the client],” she says.

Rather than launching into a discussion about vaping, See instead starts her sessions by getting to know the client. She will ask about school, home life and friends. She may ask, “What do you do in your free time? What activities are you involved in? Did you recently move? Do you have any pets?”

Often, these conversations reveal the role that vaping plays in clients’ lives, See says. For instance, a client may have started vaping because they just moved and wanted to fit in with a new group of friends, or because they are stressed out about applying to college.

See specializes in substance use and abuse and has expertise working with clients and their family members on issues around vaping. She has found that younger kids want to talk about vaping not only in social settings but also in counseling because they don’t consider it illicit and because they feel it is novel or cool to bring up the latest vape tricks and challenges. One popular challenge is for users to “hit a Juul” as many times as they can for 30 seconds. Another involves the “ghost inhale,” in which users inhale the vapor into their mouths, blow it out in the shape of a ball, and then quickly sip it back into their mouths.

Finding the underlying issue

Using motivational interviewing, See eventually asks clients if they want to quit vaping, if they are worried about their health if they continue vaping, and what their goals are for therapy. Part of the purpose of this questioning is to figure out the underlying reason that clients are vaping in the first place, See says. Is it because they are anxious or depressed? Is it simply because they want to appear cool?

To help clients pinpoint their underlying issue, See asks them to keep a journal to track their thoughts and behaviors connected to vaping. Often, as clients track when and where they vape — for example, when they’re alone in their room, when they’re with friends in their car, or when they’re bored — they also discover the real reasons they do it.

Clients keep track of their vaping habits for a few weeks or in between sessions, and then with See’s help, they look for patterns and clues that point to the underlying reason. This exercise also helps clients gain greater awareness of how much time and energy they devote to vaping, See notes. Often, people spend much more time vaping than they would smoking a cigarette, she adds. “Vaping is almost like chain smoking,” she explains. “That’s just another element that people don’t take into account.” See says some of her clients were vaping for two to three hours per day and didn’t realize it until they started tracking it in their journals.

As Rose notes, “Counseling can be helpful to look under the surface of the behavioral piece and bring a level of mindfulness to what is the thought or feeling that precedes [a client] picking up that vape.” She contends that this is not the time for counselors to use a solution-focused approach to try to quickly get clients to stop vaping.

“Smoking or vaping is a symptom, and the core problem is something internal,” Rose asserts. That’s why she believes counseling has so much to offer to people who want to quit vaping — because counseling goes beyond merely reducing the symptoms and helps to address the underlying issue. “A good competent counselor can really bring a deeper level of awareness to that core issue, [and] if that wound begins to heal, it prevents the problem from continuing,” Rose says.

A few years ago, Lalk, an ACA member who specializes in working with adolescents and young adults, had a teenager come to her because she had attempted suicide, was depressed, had past trauma, and was using lots of substances, including vaping. For the next two and a half years, Lalk worked with the client on her anxiety, depression, and maladaptive behaviors such as lying. After successfully addressing these underlying issues, the client announced on her own that she wanted to quit vaping and be substance free when she started college. In addition to continuing with counseling, the client used a nicotine patch and was able to slowly wean herself off of nicotine. Lalk says this was possible because the client started from a state of good mental health.

A mindfulness ‘patch’

See has had clients who, without thinking, pulled out their vaping devices in session. That showed how much of a habit it had become for them, she says.

Rose admits that she used to be on autopilot with vaping, and the first few days after she quit, she found herself instinctively reaching for her device. Because vaping can help release a person’s anxiety, making them feel better, it can quickly become a habit, Rose says. The challenge is unlearning this habit, which is a deliberate process, she emphasizes.

Similar to See’s tracking activity, Rose has clients journal to help them become more mindful about how and why they vape. She asks clients to write down (or at least notice) what was going on before they vaped, including their thoughts and feelings and their environmental and internal cues. She tells clients not to judge or change the situation. She simply wants them to notice it and make note of it.

“That awareness makes it more difficult to continue engaging in the same self-destructive pattern, and that pain and discomfort lead us to eventually stop the pattern,” Rose says.

Meditation is another effective way for clients to practice nonjudgmental awareness. “Yoga essentially saved me from smoking because it forced me to be still in my own body, and my cravings started to decrease the more I did yoga and the more I got comfortable with myself,” Rose says. “Any kind of mindfulness practice in any capacity can really help calm that craving because it forces you to … pause and be aware instead of act on impulse.”

“When you’re trying to quit vaping, it’s likely to unmask other anxieties,” Lalk says. The trick is to find healthy ways to process this underlying anxiety. Lalk finds patterning techniques helpful for her clients in this regard.

Lalk uses the common technique of deep breathing to illustrate patterning. Counselors often tell clients to breathe in a numerical pattern: Breathe in for four seconds, hold for six seconds, and breathe out for eight seconds, for example. This technique works because of the counting pattern, Lalk says. “Once you start trying to do [this patterning], your brain shifts and it calms you down,” she explains.

Lalk encourages clients to find a patterning technique that works for them. It could be doing beats with their hands, taking deep breathes and counting, writing poetry, or going for a walk and looking for patterns (counting every orange object that they see, for example). The key is to be mindful while doing the activity, Lalk explains. “Running is a beautiful way to pattern because you can count your steps. Just running for the sake of running if you aren’t being mindful about it isn’t nearly as helpful,” she adds.

With the help of a relaxation patterning activity, clients can calm themselves as they discuss their underlying anxiety or other issue with a counselor. Lalk points out that people often hide from whatever makes them anxious. Counselors can work with clients to instead address and acknowledge their anxiety and move toward it, not away from it, she says. Lalk says one of her clients can do four different beats with each of his hands and feet. Once he starts doing his beats, he relaxes and starts talking about his underlying issues.

See also helps clients find mindful replacements for vaping. One of her clients tracked her vaping behavior and discovered that she mostly vaped in her car — a place she spent a significant amount of time driving to school, work and other activities. Together, See and the client reviewed various alternatives that she could engage in while in her car: Would playing music help? Did she need something to do with her hands, such as squeezing a stress ball or play dough or twirling a pen in her fingers? Was her vaping habit the result of an oral fixation?

They finally decided the client would keep a water bottle in her car, and every time she wanted to vape, she would take a sip of water instead. In many cases, it’s about figuring out what clients can do so that vaping is not at the forefront of their minds, See says.

Changing the narrative

Lalk points out that people who vape are not strangers to negative, shame-based and judgmental comments from others. But this sends the wrong message, she says. The person may have tried vaping at a party and, in a short time, become addicted. This doesn’t make them a bad person; it just means they are struggling, she says.

Counseling can help clients manage negative internal and external comments. Rose has her clients practice nonjudgmental awareness. For example, a client might set a goal of not vaping all week, but at the next session, he confesses that he did vape, which in his eyes, makes him a “horrible person.” Rose helps the client separate shame (“I am a bad person because I vaped this week”) from guilt (“I feel bad for relapsing and using nicotine”). Whereas feelings of guilt can be healthy, shame and negative thinking aren’t productive, Rose says. Clients can’t shame themselves into quitting, even though they often try to do just that, she adds.

Rose frequently uses narrative therapy to help clients identify and change these harmful thoughts. She asks clients to write down all of the thoughts they have about themselves at the end of each day. Maybe they vaped that day and feel like a failure, or maybe they went the entire day without vaping and feel good about themselves.

Rose encourages clients to be mindful of the story they are creating with their words and thoughts. She asks clients, “What is the narrative you have created about yourself and your vaping?” Sometimes clients have internalized a narrative of “I’m a smoker,” and the more they say this, the more it becomes true, Rose says. So, if a client states, “I’m a smoker who quit two months ago,” Rose works with the person to change the story to an empowering one, such as, “I don’t vape. I’m not a smoker.”

“Those narratives are going to illuminate some more core issues like self-esteem or a lack of self-worth,” she adds.

Focus on the wins

See suggests that counselors can also help clients focus on their small victories. “Every time you don’t [vape] is a win,” See says. “And if a day didn’t go as great as you wanted it to, then just press that reset button and start over. You can start over at any point in the day. You don’t have to wait until tomorrow.”

See collaborates with clients to identify rewards and motivations that would work best for them. That could be buying new shoes with the money saved from not vaping that week or not allowing themselves to watch a Netflix show until they make it one day without vaping. The goal is to have clients build up their toolboxes, so she has them come up with a list of about 25 things that aren’t substances that make them feel good, such as running or going out to eat at a favorite restaurant.

Having a sufficient stockpile of motivators in their toolboxes ensures that clients will have an alternative to turn to when the craving to vape hits, See notes. Having only a few options — even if they are strong motivators — can backfire because not every tool will work in every situation. For instance, if a client is stuck in class and can’t go running when the urge to vape arises, he or she will need another tool to use in that moment. Clients should also make their goal visible to help motivate them, See adds. For example, they can put the goal on their mirror so that they see it every day.

Rose recommends the app Smoke Free because it focuses on positive reinforcement, not consequences. “It’s very strength based,” she notes. The app doesn’t show a picture of an unhealthy lung or treat the user as naive. Instead, it focuses on the benefits of not smoking and the progress people are making toward their goals.

Upon opening the Smoke Free app, users see a dashboard displaying how long (down to the hour) they have been smoke free. It calculates the degree to which the person’s health is being restored with icons that display improvements (by percentage) for pulse rate, oxygen levels, and risk of heart attack and lung cancer. It also shows users how much money they have saved by not vaping. The app includes a journal component where users can note their cravings and identify their triggers. To further encourage users, it includes progress made such as life regained in days and time not spent smoking.

“A knowledge of consequences does not dissipate the problem,” Rose says. “We absolutely know that smoking is highly correlated with lung cancer, and yet millions of people still smoke.” Younger generations often feel invincible, so focusing only on the consequences of vaping isn’t a sufficient motivator, she adds.

Forming alliances

Counselors must take steps to reach children and parents even earlier because vaping is increasingly making its way into elementary and middle schools, says See, who wrote the article “The dangers of vaping” for the website CollegiateParent. With parents, it is also helpful to educate them on what to look for because vaping devices, which can resemble a flash drive or pen, are often hidden in plain sight and are easily overlooked, See adds.

Lalk recommends that counselors also take the time to learn from their clients. Through her alliance with some of her seventh- and eighth-grade clients, she found out which local stores were selling e-cigarettes to underage patrons. These clients also confided that one store owner said he knew the kids were underage but that the possibility of getting caught and having to pay a $250 fine was worth it because each vape sold for $60.

This knowledge helped Lalk take action in her community, including writing an article on how the shops, rather than the children, should be prosecuted, and participating in a movement to create ordinances setting new rules for establishments that sell vapes to minors. The businesses in her town now have to secure permits to sell vaping products, part of which requires acknowledging that they will not sell to minors. If store owners are found in violation of their permits, they risk losing their businesses.

Rose used to facilitate two hours of group counseling at a rehabilitation center five days a week, and she regularly witnessed the shame reduction and healing that can happen in groups. “I believe the opposite of addiction is not just abstinence,” she says. “The opposite of addiction is connection.”

Accountability is another big piece in quitting, Rose says. She often tells clients who are struggling to call a friend with whom they can be honest or to find another way to keep themselves accountable to their goal of quitting or reducing the amount of time they vape.

Rose personally found that documenting her journey of quitting in a blog post kept her accountable. Others reached out and told her that her post made them feel less alone and motivated them to quit too. In turn, she thought twice before using her vape again because she wanted to respond to incoming emails by confirming that she was still vape free.

See agrees that accountability and healthy rewards are smart strategies for helping clients who want to quit vaping. Peer pressure can become a big issue, especially for teenagers who don’t want to feel like the odd person out when seemingly everyone else in their crowd is vaping, she says. She advises clients to let people know they are quitting and to surround themselves with people who will empower and support them in their decision.

Accountability becomes even more important with adults, See points out, because they have more freedom and don’t automatically have someone watching over or checking in with them. That’s why having a support system is so important, she says. When clients feel like vaping, they can reach out to someone they trust and ask them for five reasons not to, See says.

See says clients might also consider posting on social media that they are quitting and openly ask for support, or they could participate in a 30-day challenge. One of Lalk’s clients participated in a challenge the person referred to as “No-Nic November.” These positive challenges can provide a good counterbalance to the vaping challenges that are so popular on social media currently.

When See dropped one of her children off at college, she noticed the dorm had placed a whiteboard with the words “Healthy Ways to Deal With Stress” written at the top. The students were adding their own suggestions, such as going to a pet store and petting a cat or going for a run. See loved this self-empowering technique and plans to incorporate it into her own practice by adding a Post-it wall where clients can add their own healthy ways of coping or their own words of encouragement.

Taking the first step

Quitting can be overwhelming, and sometimes clients don’t know where to start. See advises these clients to begin by taking small steps. Harm reduction can be a particularly effective early strategy because it empowers clients, See says. “Once they see they can harm reduce, then maybe [they] can harm reduce all the way to zero use,” she explains. “But putting them at the bottom of Mount Kilimanjaro and saying ‘get up to the top right now’ is daunting.” Instead, she asks clients what their “climb” to being vape free looks like for them. Do they want to climb fast, or do they want to climb slow?

Recently, See worked with a teenager who had been vaping for three years. She had been scared by the recent health reports related to vaping and wanted to quit. See asked this client about her motivators, and the client said she wanted to quit to protect her health, for her parents who were pressuring her to quit, and because of the monetary costs associated with vaping.

See asked the client, “What does 30 days without vaping look like?” The client’s eyes bulged. The thought of it was too much for her. So, instead, See and the teen client talked and decided she would remove e-cigarettes from just one place in her life.

By tracking her habits, the client learned she vaped mostly in her car. So, See suggested she remove the vape only from her car and also not allow her friends to vape there. See also instructed the client to notice and write down how it felt not having the vape in her car. Did she miss it? Did she reach for it without thinking? Together, they also made a list of possible replacements she could keep in her car, including a pen, candy flavored like her favorite vape juice, and a stress ball.

“That was one part of the mountain that she could climb,” See says. Feeling empowered by her success, the teenager eventually decided that she was ready to tackle the prospect of no longer vaping in her room at home.

Others, such as Rose, decide to take a faster approach and quit cold turkey. She notes that counseling can bring a level of mindful awareness to quitting and help clients figure out the underlying reasons they turn to vaping to fill an internal void. “The nicotine [and] physical addiction is a part of it, but that’s not the core issue,” she asserts.

Since she stopped vaping, Rose’s mindfulness practice has increased. She has trained herself to pause before acting on impulse. “The mental aspect is infinitely more difficult to unlearn than the physical addiction — ‘I’m sad, I’m going to vape. I’m happy, I’m going to vape. I’m bored’ — that’s the most common — ‘I’m going to vape.’ It’s something to do, something to reach for, essentially something to [help] avoid just sitting with [one’s] self in one’s own skin,” she says.

As Rose opens her Smoke Free app, her dashboard proudly displays that she hasn’t vaped for six months, 16 days and 13 hours.

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Multicultural encounters

Compiled by Bethany Bray November 21, 2019

The 2014 ACA Code of Ethics calls counseling professionals to “gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population.”

At face value, this is easy enough to understand. But when it comes to multicultural competence, what does it look like to put this “head” knowledge into practical action?

For Letitia Browne-James, a licensed mental health counselor (LMHC) who owns a counseling practice in the Orlando, Florida, area, this endeavor once involved bringing a client’s family into session to better understand how his cultural background, and its views on the role of family, were affecting his mental health.

The client was from a collectivist, Caribbean culture that placed greater importance on the family unit than on its individual members. Family approval was paramount to this client, she explains.

Browne-James also has Caribbean roots, but “I come from a culture where individualism is encouraged and celebrated,” she says. Connecting with this client — and fully understanding his cultural perspective — came via openness, flexibility and creativity on the part of Browne-James, who has a doctorate in counselor education and supervision with a specialization in counseling and social change.

“I invited the client to bring in his family for a few sessions so I could learn more about the family’s views and assess how I could help him individually by helping the entire family system understand mental illness and how to treat it with familial support successfully,” says Browne-James, a core faculty member in the Adler Graduate School’s online program. “We learned that [involving family] was the fastest and most effective way to help the client achieve his counseling goals and live a healthier and productive life in society.”

Browne-James encourages counselors to fully explore each client’s culture, whether that involves doing research, consulting with colleagues, or meeting with a client’s family. It is also helpful to invite clients to speak in sessions about what their cultural identity means to them, how they apply that identity to their life, and how they’d like it to inform their goals and work in counseling.

“I encourage professional counselors to think of multicultural competence as the basics of being a professional and ethical counselor — [to] view their help-seeking behaviors to expand their cultural knowledge as a professional strength rather than a weakness,” says Browne-James, president-elect of the Florida Counseling Association and treasurer of the Association for Multicultural Counseling and Development (AMCD). “I would also encourage them to be patient with themselves, with colleagues and with clients who are at different stages in their cultural journey, while remembering that cultural competence cannot be separated from ethical practice.”

Striving toward multicultural competence

Counseling Today recently reached out to American Counseling Association members of varied backgrounds and practice settings and asked them to share some of their case examples and insights regarding multicultural counseling.

We encourage readers to add their own thoughts to this discussion by posting comments at the bottom of this article, below.

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Multicultural competence is a never-ending journey that involves risk, adventure and discovery. Culturally competent counselors strive to enhance their awareness, knowledge and skills to work with others who are culturally different from themselves in meaningful ways. This includes deconstructing long-held assumptions, values, beliefs and biases that do not foster cross-cultural sensitivity. Furthermore, multicultural competence includes the ability to recover from cultural errors and to tolerate, manage and resolve intercultural conflict, no matter the setting.

Every cross-cultural interaction creates learning opportunities for counselors and counselor educators to enhance their awareness, knowledge and skills in multicultural counseling. One way clinicians can create opportunities to gain cultural awareness is by focusing on an art form (e.g., music, film, painting, photography) that interests the client. Counselors can use this information as a pathway to identify the constellation of values and assumptions that impact and inform their client’s worldview.

I remember working with an adolescent client who was in the midst of working through her cultural identity development. The client was born in Nicaragua and adopted at 6 months old by a white upper-middle-class family. She struggled with her racial and ethnic identity since she did not feel tied to her Nicaraguan roots and she did not identify as white. Initially, she was not very expressive, but I was able to reduce the cultural distance between the two of us by focusing on her interest in music.

Even though our identities (age, race, ethnicity, socioeconomic status) and developmental stages were completely different, I used music as a window into her worldview. In one of our first sessions together, the client mentioned that a popular rock band (Twenty One Pilots) was her favorite music artist. I had never heard of that [band] before, but I used this information to spark a conversation about her identity-formation process. I asked the client, “What’s your favorite song [from this band]?” She responded, and I asked her for permission to listen to the song and discuss the lyrics during the session. She agreed, and we dissected the lyrics line by line.

This activity created an environment that allowed the client to feel safe and supported as she opened up about her struggles with her racial and ethnic identity, low self-esteem, and desire to engage in self-harm behaviors. The underlying message in the song also gave me additional information regarding the client’s presenting concerns that she had not previously disclosed.

Fortunately, this cross-cultural encounter facilitated a strong working alliance that led to therapeutic change. I took a risk that proved to be beneficial for the client and created an opportunity to enhance my multicultural competence.

— Whitney McLaughlin is a licensed professional counselor (LPC) and a doctoral candidate at North Carolina State University.

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The term multicultural competence can feel vast or intangible. I do my best to embody multicultural competence by remembering that life and counseling are centered around people interacting with people, existing within a system. Every person is different, and understanding that these differences are central to our human experiences is essential.

Beginning with self-exploration of who I am and my worldview is imperative. Models such as Pamela Hays’ approach from her book Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy can be helpful in the process of understanding who and what I represent within counseling and society. Additionally, every identity I hold and the intersection of my many identities have different meaning in different contexts.

For example, when working with an adolescent [client] who self-identified as black, cisgender and queer, I asked myself, “What may I represent within the context of this counseling relationship?” To the client, my identities as black and cisgender may place me as an insider or safe to speak with, but my identity as heterosexual may place me as an outsider or an oppressor. I had to consider the spectrum of my humanity, the intersections of my various identities, the meaning that can be derived from who I am and what I may represent to my client, and intentionally make space for it all within the counseling relationship.

Then, all the same considerations needed to be made for my client’s identities while also accounting for systemic factors. For example, considering how systemic white privilege, racism, homophobia and heterosexism affected my client’s lived experiences as a black queer male assisted in understanding my client’s needs. Urie Bronfenbrenner’s model can be helpful in conceptualizing the levels and roles of systems (see Counseling Today’s April 2013 cover article “Building a more complete client picture” for additional information).

I recognize this sounds like a lot (and it is), but this can be accomplished through intentionality.

1) Do your homework: This refers to doing your personal work, such as understanding who you are and what you represent. I participate in my own therapy and have frequent conversations with trusted, critical thinkers to stay grounded and aware.

2) Work for your client: This refers to being receptive to understanding your client’s experiences while not requiring that they educate you on every aspect of their identities. For example, when working with the client mentioned above, I made sure I knew how queer was defined broadly while also allowing the client to express what being queer meant to him and his experiences.

3) Have an open dialogue: This refers to not shying away from discussing our identities and the effects of the systems we exist in. This also means not putting the responsibility on our client to broach the topic. With my client, acknowledging the interplay of his many identities across the multiple systems he existed within allowed us to examine the depth and variety of his lived experiences.

— Tyce Nadrich is an LMHC, supervisor and assistant professor of clinical mental health counseling at Molloy College. He also has a private practice in Huntington, New York, where he supervises counseling trainees and works predominantly with adolescents and young adults of color.

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There are two things that I impress upon all counselors I train. The first is that Caucasians are not devoid of culture, and the comparative practice of juxtaposing the lived experiences of nonwhite persons to their white counterparts is oppressive. Second, to be a culturally competent counselor, one must first have a deep understanding of [one’s self] as a cultural being.

I specialize in African American mental health, and this has required a great deal of study in black and liberation psychologies, culturally responsive psychotherapies, and culturally congruent treatments and frameworks. This also means always being willing to critique and ask questions about the worldviews and assumptions embedded in the many trainings and presentations I attend each year, to better understand their utility or lack thereof to the populations I serve.

Multiculturalism is a central tenet of my clinical work as well as my work as a counselor educator. As an African American woman being trained in predominantly white settings, most of my clients [when I was] a trainee and in my early career were racially/ethnically and culturally different from me. But the client who stands out most was an African American woman in her mid-40s [who was] accessing care through a hospital-based trauma treatment program for abused and suicidal African American women. She had an extensive trauma history, which included a long history of sexual abuse and intimate partner violence. While she had extensive contact with health care providers in the past, she’d never had a health care provider who looked like her. Despite being racially, ethnically and even culturally similar [to me, her counselor], she expressed a desire and preference for a white-identified counselor.

Oftentimes, we limit our understanding of multiculturalism and cultural competence to working with those who are dissimilar. What this client highlighted for me was how people of color, race, culture, ethnicity and other social locations exist in a complicated relationship to the systemic oppressive forces of racism, sexism, classism, ableism, etc., experienced in the day-to-day lives of people of color. And sometimes you can’t disentangle them, and they create additional barriers to accessing care.

Fast-forward nearly a decade, and though the majority of my clients identify as African American, I am always intentional about exploring the racial and cultural similarities and differences [between myself and] all clients.

— Delishia Pittman is an LPC and a licensed psychologist in Washington, D.C., and director of the clinical mental health counseling program at George Washington University.

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I work at one of the largest community colleges in the United States. We currently have about 65,000 students, and I work at one of the largest campuses. Our students are permitted to walk in for “counseling,” which is academic-based and similar to school counseling rather than mental health therapy. Our students are diverse in age, ability, learning, experience, race, nationality, language, citizenship and gender, just to name a few.

A simple request from a student to change their major puts my multicultural counseling and social justice skills [into] action. Very rarely is changing a major merely transactional, which is why it’s not a task that can be done by the student themselves. It requires coming in to meet with an adviser or counselor. [When this occurs], I want to have a conversation with the student about how they arrived at their program of study. As an immigrant, first-generation college student, and marginalized counselor, I’m aware of the environmental influences [that affected my choice of] my first major and how that evolved to my current career.

Most students at my college, but not all, are also first-generation college students, fully Pell [Grant] eligible (low socioeconomic status), immigrants, or first-generation Americans, which impacts their decision on what they should study. I ask what assessments they used, what they have learned about their major/career of choice, and what influences they have in their life to help them decide.

Since my students are so diverse and have so many intersecting identities, I never want to assume that they are also coming from a marginalized background. Some of my students are coming from a place of greater privilege than I had as a student or [have] even now as a professional.

Students sometimes confide that they are studying a major that does not interest them, and we investigate what is pressuring them to study that major, usually in science, technology, engineering or mathematics. I assess if the student has the privilege to change their major to their preferred major. This is important to understand, as not all students are in a place to choose. We assess if we can find additional resources, find integrative programs of study or minors to sneak into their curriculum, and I even offer my support to help advocate to their stakeholders about the possibility of changing their major. Regardless of whether they change majors or not, we come up with an academic plan.

I think it’s important for our profession to understand that in all types of counseling, even in school, career and vocational, where the work seems more transactional, there is an opportunity to implement our multicultural and social justice competencies. We must understand that our clients or students are diverse and have intersecting identities. They are influenced by family, culture, environment, media, peers and even our systems. We need to take all that into consideration to give them the best possible service.

— Margarita Martinez is an academic success counselor and curriculum chair for student development at Northern Virginia Community College. In addition, they serve as vice president for Latinx concerns for AMCD, as secretary for the Virginia Counselors Association, and as co-chair of the strategic plan committee for the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC).

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As a black woman in a suburb of Georgia, I have had numerous clients contact me simply because I am black. Georgia is one of those states that is known for having been a part of the Confederacy and having many small cities that are still dangerous for people of color.

I live and work in what is statistically the most diverse city in Georgia. My county is considered one of the most diverse counties in the nation. I am learning more, now than ever, the differences between myself and those with whom I work. I’ve been in academia for about five years without seeing clients and assumed that when I [returned to counseling and] joined a group practice, I would be seeing the “worried well.” But issues surrounding racial trauma and perception are not as commonly addressed as some other daily worries.

I recall one client, a darker-skinned African American male in his early 60s. He’d lived through the civil rights movement in Georgia, retired from one career, and raised all of his children. However, he was experiencing distress because of the way people viewed him as a “large, black, heavy-voiced man.” He felt that whenever he wasn’t whispering, others would assume that he was mad and say that he was yelling.

He also felt that this view of him was useful in his previous career as a prison guard, but once he completed his degree and attempted to start his next career as an elementary school teacher, his colleagues (mostly white women) reported that he was “aggressive, loud and scary,” and his contract wasn’t renewed. This man had struggled to get out of poverty and earn a degree, and in the year 2019, [he] was still experiencing discrimination based on others’ unfair perception of intent. He also felt like his family was telling him to change who he was rather than understanding his predicament.

I understand that my African American experience does not necessarily mirror [that of] other African Americans. Essentially, the only things that my client and I had in common were that we were African American, heterosexual and Georgia residents. He was almost twice my age; I am not a first-generation college student and have not experienced living in poverty. Even with these cultural differences, I know what it is like to be unfairly described as aggressive.

In relation to multicultural competence, there is a lot of attention given to race, ethnicity, sexual orientation and identity. [Yet] there are so many other things that we must consider. The best course of action is to allow our clients to express which aspects of their culture they believe most affect their day-to-day lives. Never assume that [just] because you have one or two things in common, that you’re adequately prepared to address your client’s issues.

— Asha Dickerson is an LPC in Lilburn, Georgia, and a professor at Adler Graduate School. She also serves as AMCD’s Southern Region representative and as president-elect of ACA of Georgia.

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Sharpening our multicultural competence requires that counselors enter the experience and suffering of those who are different from us. When we allow the other person to lead us into their unique reality, we may confront fear and anxiety. There is a chance that we may begin questioning our own values and worldview.

An example that comes to mind was an invitation made by a co-worker to join an initiation ritual from the religious tradition of Santeria [a religion brought to Cuba by slaves from western Africa and eventually to the United States by Cuban immigrants]. In this ceremony, my co-worker’s adolescent daughter was being inducted as a priestess. The ceremony was characterized by constant drumming, humming, walking in a circle, and minimal dialogue. Initially, I did not feel comfortable, as the ceremony was very different from my own religious tradition. In addition, I grew up listening to negative comments about santeros within my own culture.

After recognizing my fear of the unknown, I chose to gain knowledge about Santeria. This is a religion that helps its members gain balance and unity of the body, mind and spirit. The priest, or santero, invokes all sources of intelligence (conscious and unconscious, physical and metaphysical, individual and collective) in addressing [a person’s] suffering.

I rejoiced that my initial fear did not stop me from becoming better informed about this person’s religious beliefs [and the religion’s] ancient, holistic healing practices. By studying the ancestral beliefs of Santeria, I found much commonality between this African-based spirituality and modern counseling. Both traditions would like to empower clients in living with meaning and purpose. As [psychologist] Alberto Villoldo said, “Reclaim the courage of our ancestors, and bring that forward into the future.”

Multicultural competence is necessary when interacting with every client, not just clients of color. All clients are multifaceted and deserve that we honor their multiple dimensions of identity and how they shape their mental health and coping skills.

Multicultural competence is fundamental in establishing an effective relationship with our clients. It also invigorates and empowers us in developing a genuine relationship with our clients. It allows us to go beyond surface impressions and helps us discover the client’s deepest values, past and current sources of oppression/survival, and their hidden strengths so that they can creatively manage life’s challenges and opportunities.

— Maria del Carmen Rodriguez is an assistant professor in the Department of Counselor Education in the Nathan Weiss Graduate College at Kean University in New Jersey and president-elect-elect of the New Jersey Counseling Association.

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In 1992, I moved from the Midwest and became a professor at Appalachian State University in Boone, North Carolina. Shortly after moving to the Appalachian Mountains, I became a volunteer counselor at the local health department and served in that role for 25 years. My clientele primarily consisted of women who had little opportunity for jobs or education and who experienced barriers of poverty such as [lack of] transportation. My typical clients were women who came from traditional Appalachian mountain culture and were raising children in single-parent families. Therefore, from the onset, my counseling was inherently a multicultural practice because it involved numerous cultural differences between me and my clients — educational, economic, spiritual, etc.

I needed to remember that the therapeutic alliance was critical and consider their cultural beliefs and values. Generally, I focused on welcoming clients and inviting hope. For example, at times I would ask when they had last eaten and made sure I offered them food and beverage before we started the counseling session. Specifically, through readings and professional consultations, I learned the following Appalachian values:

Egalitarianism: Be an authority without being authoritarian.
Personalism: Use simple, direct, honest, straightforward and respectful speech. Be accessible.
Familism: Remember that blood is thicker than water and family structure is resilient.
Religious worldview: Explore religion as a possible resource.
Sense of place: Explore how clients view being economically deprived [and their view of] the importance of land.
Avoidance of conflict: Be respectful toward clients.

However, I also needed to examine each client’s unique pattern of values. For example, one client explicitly stated that I could counsel her for depression, but I could never discuss her Christian religion with her because I was not a religious leader. We agreed to this limit and, over one year, successfully resolved her depression.

I found that multicultural competence is not a result of “magic formulas” or the use of “politically correct terms.” [Rather, it] requires adapting recommended standards to the individual client. Such adaptation within Appalachian culture included:

Listening to their story. Explore “Who are they?” Be in their story, and reserve judgment.
Being aware of client tendencies to be “street smart,” be dependent on systems due to poverty, and value survival at all costs.
Using subtle techniques such as stages of change to understand context, motivational interviewing to invite dialogue, and solution-focused brief therapy to provide practical solutions.
Introducing concepts long term. Revisit important concepts repeatedly.

Finally, I found I needed to be brave, risk making mistakes, and learn how to recover from mistakes. I needed to be cautious of being so politically correct that counseling stopped us from being human and real with each other and instead turned the process into an assembly line.

My clients needed me to always remain human, real and compassionate with them so they felt safe and cared for, thereby inviting a genuine, healing dialogue.

— Geri Miller is an LPC, supervisor, licensed psychologist and licensed clinical addictions specialist. She is a professor in the Human Development and Psychological Counseling Department (clinical mental health counseling track) at Appalachian State University.

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As an Asian counselor and counselor educator who specializes in play therapy, working with clients who are from a culturally different background than my own happens regularly. Though this difference felt like a burden at first, now I appreciate the lens that I developed because of the intersectionality and complexity of each client’s cultural identity. This lens helps me cultivate my cultural humility, which embraces an interpersonal stance that is other-oriented and open to the other in relation to aspects of cultural identity.

I recall when I was at the beginning of my graduate program training in Texas and still in the beginning stage of my racial and cultural identity development, I experienced unsettling emotional reactions when child clients in play therapy bluntly commented on my appearance or accent such as “You talk funny”; “Are you from China?” [and] “You have black hair!” Because of the great supervision I received, in which I felt safe enough to explore my cultural identity, those reactions gradually dissipated, and I was able to be more fully present with children even when they made some cultural remarks.

I believe working with clients from various cultural backgrounds requires a counselor to have continued openness, self-refection, growth and development over time. Therefore, it requires absolute lifelong commitment from a counselor.

Recently, I began a project in collaboration with immigration lawyers to provide play therapy to unaccompanied and undocumented minors who are in the process of applying for asylum [in the United States]. Although I have extensive experience in providing play therapy to children with trauma and adverse experiences, I realized that I possessed limited knowledge on the historical and political context of some of the countries from which those clients came, particularly in the Northern Triangle of Central America, and on the ever-shifting immigration policies in the U.S. The actions that I am partaking in to educate myself to gain more knowledge in those areas are reading, taking webinars/workshops on immigration policies, joining a state-level immigration emergency action group, and consulting immigration lawyers and paralegals in this project.

I work for a university which is a Hispanic-serving institution and where the majority of the students hold a minority status. I love dedicating my time to conversations with my graduate students from those [Central American] countries and being educated by them about their cultures. Those conversations have helped me be a more culturally informed counselor and counselor educator.

In addition, I have been fortunate in learning from professionals outside of the counseling field who are also providing services to clients with diverse backgrounds. This provides me with a more holistic sense of my clients’ strengths and struggles. I hope collaborative work beyond the boundaries of separate professions becomes more common.

— Yumiko Ogawa is an LPC, counselor supervisor, play therapist supervisor, and associate professor at New Jersey City University.

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As many before have said, multicultural competence is an ongoing endeavor. Much of the work
is subtle and nuanced. Many counselors are eager to try out their newly learned advocacy skills. When counselors who hold dominant identities work with minoritized populations, advocacy without self-awareness can cause harm. Actions should not replace deep personal, introspective, multicultural work.

Often, counselors are not aware when clients or students do not regard them as a safe or affirming person. Clients or students may not pursue a counselor’s services if they hear from members of their own cultural groups and communities that the counselor has been unaffirming or has avoided discussing important aspects of a client’s or student’s race, culture or identity. Clients or students may come increasingly late to sessions, cancel, or terminate early without giving a reason. Counselors can brush [this] off or identify an alternative explanation for these occurrences, but these situations may indicate that counselors need more work on developing their own multicultural competence.

Counselors should also consider which clients they tend to have an easier rapport with and which they do not and reflect upon the reasons. We need to move away from intellectual understandings of racism, sexism, classism, ableism, transphobia, etc., and move toward considering how these injustices show up in our lives. For instance, cisgender counselors might ask themselves, “How might I be making my transgender client/student feel invisible by subtly avoiding discussing their trans identity, or am I focusing too much on their trans identity and not listening to their presenting concerns?”

Excelling at wielding social justice language is not a substitute for making authentic connections and fostering ongoing relationships with individuals who hold different identities and life experiences. These relationships outside the office can help counselors connect better with their clients and students.

— Rafe McCullough is an LPC, a licensed professional school counselor, and an assistant professor at Lewis & Clark College in Portland, Oregon. He was a member of the AMCD committee that developed the Multicultural and Social Justice Counseling Competencies endorsed by ACA.

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As a visibly identifiable Muslim woman, cultural differences in religious and spiritual practice come into my work in different ways. While some practitioners might choose not to disclose and broach their faith, my hijab serves as an indicator of my religious practice. What this often means is that clients make assumptions about who I am, what I believe, my level of religiosity, and how I practice based on their expectations of who I might be as a Muslim counselor and what society has taught them about my religion.

I can remember a time when I picked up a client assigned to my caseload from the waiting area. I introduced myself briefly in the main lobby and walked her to my private counseling office. As soon as we sat down, before I had a chance to say anything, she looked at me and said, “This isn’t going to work. I’m a very Christian lady, and I’m not going to work with a Muslim.” Because of the personal awareness work that I do as a clinician, I was able to notice and acknowledge my personal reactions and respond appropriately. For example, a few of those immediate reactions and assumptions were:

“This client has no idea who I am or how I practice.”
“I’m so tired of having to defend my faith and undo the unjust and vilifying narratives of Muslims in the media.”
“People who look like her have oppressed people who look like me. I wonder if I’m safe in this room.”
“She might feel unsafe in this room because of who she believes I might be.”

Through my personal work and practice of multicultural concepts of awareness, I was able to ground myself and attend to the client. [I reminded] myself that although such an incident may trigger some of my own trauma experiences as a black Muslim woman in a society that attempts to diminish people who look like me, my role in this counseling space was to prioritize the wellness of my client — and to do so with compassion and unconditional empathy and regard. I reminded myself that although she had made some assumptions about me, I had made assumptions about her based on my worldview as well.

Multicultural competence doesn’t just happen naturally. It isn’t something I just choose to have in a moment because it seems relevant. It’s a constant practice and requires deep reflection, critical insight, and a willingness to engage in developing my personal awareness and taking the needed actions to make sure that when I’m in the privileged role of counselor, my clients are valued, honored and respected. That was a very difficult process early on as a beginning counselor with many marginalized identities and experiences that can be triggered by some of the beliefs that my clients hold about me. It’s hard work.

But because of that continuous process of reflection and my own personal work, I was able to hear this client say that she couldn’t work with me because of my faith, and respond by compassionately broaching differences in our cultural identities and allowing her space to share her worldview.

I have had many clients see my hijab and tell me that they can’t work with me because of it, but they all decide to continue working with me after spending our first hour together. I came to realize over time that being a counselor with a cultural identity different than the majority culture was a subtle but powerful form of advocacy. I have been able to build deep, trusting relationships with individuals who had never had a personal interaction with someone who identifies as Muslim. [I] challenged their biases about who Muslims are simply by doing my job and putting in the time and effort to develop my awareness as a clinician.

My visible indicator of religion has also come up many times in various other ways with clients. For example, I have learned that clients who similarly identify as Muslim may also have hesitations about working with me because my hijab serves as an indicator of some form of religiosity that has negatively impacted them in some way. I learned, for instance, the importance of intentionally broaching when working with clients with LGBTQ+ identities because of my knowledge of the oppression and trauma they may have faced specific to religion and the intersection of their cultural identities. For one of my past clients, for example, seeing my hijab for the first time at intake served as a trigger for the trauma [the individual had] experienced in their religious community, and it made them hesitant to work with me. I wouldn’t have known that if I hadn’t taken the time to broach with them.

While some counselors may choose not to broach their religious identities, my practice of wearing a hijab changes that. My role as a competent counselor is to make sure that my clients are empowered and affirmed in their identities when working with me, and that can’t happen if I’m not willing to put the knowledge and awareness that I have into action. I’ve had to recognize how my intersectional privileged and marginalized identities influence the counseling process and take the steps needed to do justice to my clients.

— Zobaida Laota is an LPC associate in North Carolina who recently completed a doctorate in counseling and counselor education at the University of North Carolina at Greensboro.

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I think there is value in reading and studying about various cultures, but I think it is more effective when supplemented by building relationships, exploring new insights with colleagues, and engaging in cultural immersion experiences. Learning through relationships and engaging directly in a new culture provide a more authentic experience [for] gaining awareness, sensitivity, knowledge and appreciation.

One specific example from my own journey as a school counselor [who is white] involved seeking out a colleague from Iran to help me understand more about the culture of a student who had just moved to the United States from her country of origin [also in the Middle East]. Being aware that I needed more information about my student’s background (religion, country of origin) and [was] out of my comfort zone, my colleague provided new insights about her [own] faith, life experiences, and the impact of world events/discrimination that provided me a glimpse into her worldview. Although this student’s experience was not identical to my colleague’s, [my colleague’s] knowledge of common experiences, values and cultural strengths provided me needed insights to support this student in a culturally sensitive way.

Other ways that I gain knowledge, awareness and skills include attending counseling conference sessions focused on multicultural counseling topics. Having the opportunity to learn from other colleagues, reflect on my own biases, and explore multiple perspectives has been invaluable in my own development as a counselor. There is also tremendous value in participating in advocacy and social justice efforts with those directly impacted by discrimination, racism and injustice.

Multicultural competence is a lifelong journey. Staying aware of how we are feeling in uncomfortable moments and identifying new blind spots that highlight our personal biases are necessary in our work as counselors. If we begin to adopt a mindset that we are “experts” and have achieved multicultural competence, I fear we will overestimate our competence and not strive for new understanding, which is a disservice to our clients.

I think we have to work diligently and intentionally to seek out supervision, consultation and mentoring from colleagues of various cultural backgrounds. There is value in surrounding yourself with colleagues who can provide different perspectives and identify, as well as challenge, blind spots. I think we sometimes underestimate the value of having a network of diverse colleagues who can keep us honest and challenge us when needed.

— Kimberlee Ratliff is an LMHC and certified school counselor in Washington state, a professor in the American Public University System, and an adjunct faculty member at the University of Puget Sound and the City University of Seattle.

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Additional resources

To learn more about the topics discussed in this article, take advantage of the
following select resources offered by the American Counseling Association:

ACA Code of Ethics (counseling.org/knowledge-center/ethics)

ACA-endorsed competencies (counseling.org/knowledge-center/competencies)

Multicultural and Social Justice Counseling Competencies
Competencies for Counseling the Multiracial Population
ALGBTIC Competencies for Counseling LGBQIQA Individuals
ALGBTIC Competencies for Counseling Transgender Clients
American Rehabilitation Counseling Association Disability-Related Counseling Competencies

Books (counseling.org/publications/bookstore)

Multicultural Issues in Counseling: New Approaches to Diversity, Fifth Edition, edited by Courtland C. Lee
Counseling for Multiculturalism and Social Justice by Manivong J. Ratts and Paul B. Pedersen
Understanding People in Context: The Ecological Perspective in Counseling edited by Ellen P. Cook
Experiential Activities for Teaching Multicultural Competence in Counseling edited by Mark Pope, Joseph S. Pangelinan and Angela D. Coker
Counseling for Social Justice, Third Edition, edited by Courtland C. Lee

Counseling Today (ct.counseling.org)

“Multicultural and Social Justice Counseling Competencies: Practical applications in counseling” by Manivong J. Ratts, Anneliese A. Singh, S. Kent Butler, Sylvia Nassar-McMillan and Julian Rafferty McCullough
“Making the counseling profession more diverse” compiled by Laurie Meyers
“Counseling in the land of religious liberty” by Cebrail Karayigit and Jason Kushner
“Counseling individuals of African descent” by Malik Aqueel Raheem and Kimberly A. Hart
“Practicing cultural humility” by Sidney Shaw
“Five points of discussion for conversations about racial injustice” by Amanda L. Giordano
“Breaking the silence” by Charmayne Adams, Jillian Blueford, Nancy Thacker, Kertesha B. Riley, Jennifer Hightower and Marlon Johnson
“Addressing ethnic self-hatred in Latinx undergraduates” by Carlos P. Hipolito-Delgado
“Culturally competent end-of-life counseling” by Ashley C. Overman-Goldsmith
“The use of evidence-based practices with oppressed populations” by Geri Miller, Glenda S. Johnson, Mx. Tuesday Feral, William Luckett, Kelsey Fish and Madison Ericksen
“Advancing multicultural and social justice competence in counseling research” by Cirecie West-Olatunji and Jeff D. Wolfgang

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Voice of Experience: Diagnosing and its future impact

By Gregory K. Moffatt

Sitting in my office, I carefully filled out the insurance form in front of me. My client had requested third-party billing, and I was just learning to navigate the insurance system. In the space dedicated to the DSM-III-R diagnosis (yes, this was a long time ago), I carefully read and reread the criteria to be certain I had correctly diagnosed my client.

In graduate school, I had been drilled on the risks of labeling, so I made sure I was careful not only about the diagnosis but also about how the diagnosis might affect my client. Labels, as we all learn, have built-in hazards.

I am certain, even all these years later, that my diagnosis was correct and that I covered the issue effectively with my client. What I didn’t think about in those days, however, was how the diagnosis might affect my client 10, 20 or even 30 years in the future. This oversight makes me shudder. This is something I was NOT taught in graduate school or residency.

Regardless of the diagnosis, once we have written a number from the ICD-10 or DSM-5 on a piece of paper, that label will follow the client forever. Teachers, psychologists, licensing agencies and employers may end up viewing the person through the lens of those diagnoses well into the future, even when those diagnoses may no longer apply. Just as distressing, the client may view himself or herself through that lens too — in many cases, long after the diagnosis is no longer pertinent.

One of my clients was struggling through a serious family crisis. She was on the verge of suicide and was prescribed an antidepressant by her physician. After a brief hospital stay, she began to improve. In assisting her through that crisis, I was relieved not to have to add to her financial struggles. I filed with insurance, which paid for all of her session costs.

Little did I know how much this action would complicate her future. Fifteen years later, my former client, long since healed and healthy, completed school as a nurse practitioner. But when she submitted her paperwork for her medical license, she was denied because of her “suicidal” history. Unable to get even an entry-level position in the field, she decided to take a part-time job as a school bus driver. But, again, because of her mental health history, she was denied a commercial driver’s license.

My diagnosis and her hospitalization followed her almost two decades into the future and seriously interrupted her life, haunting her with memories of a very troubled time.

For this reason, I’ve talked more people out of hospitalization than into it. I now am aware of the potential long-term effects of hospitalization — something most of my clients have no way of knowing. I also stopped taking insurance payments years ago, in part for this same reason.

I’m not suggesting that we refrain from using diagnostic codes or that we don’t hospitalize. Sometimes we must. Likewise, I’m not suggesting that professional counselors stop taking insurance payments. I have had that luxury, but many clinicians do not. What I am suggesting is that, at a minimum, we take the time to think about the potential ramifications of these diagnoses 10 or 20 years into the future. We can’t know every possible outcome, of course, but some things are predictable.

When clients ask if I take insurance, my answer is always no. I explain that even though it may cost them more out of pocket at the moment, the upside is that there will be no permanent record of their visit other than what is confidentially maintained in my office. It is rare that any future organization could have access to their information. Exceptions would be related to a subpoena or a security clearance for government jobs, but in three decades of practice, that has happened to me only a few times (other than in cases that were highly likely to go to court from the beginning of the therapeutic relationship).

So, when considering whether to diagnose a child with attention-deficit/hyperactivity disorder or a learning disability, keep in mind that the diagnosis could have dramatic effects for that individual in college or even in future jobs. Likewise, diagnosing a client with a personality disorder is, by definition, stating that the person has an “enduring condition.” This might have detrimental effects when the client applies for a job in law enforcement, when working with children, or when pursuing a career in other potentially sensitive fields. Although a diagnosis may sometimes be necessary, we owe our clients our best look into the future before making a final determination.

Image via Flickr http://bit.ly/2lfWuka

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Human Rights 101: Implications for counselors and the counseling profession

By Michael P. Chaney, Carman Gill and John Super November 19, 2019

On April 30, an on-campus shooting at the University of North Carolina at Charlotte left two people dead and four others injured.

On January 6, Dana Martin, a 31-year-old, transgender woman of color was found in her vehicle—which had crashed into a ditch—with a fatal gunshot wound to the head, in Hope Hull, Alabama.

In 2017, two doctors and a clinic manager in the Detroit area were accused of performing or facilitating female genital mutilation (FGM) on nine girls—at least two of whom were only 7 years old.

Since 2017, the Chinese government has been detaining at least one million and perhaps as many as three million Uighur and other ethnic Muslims in internment camps in the Xinjiang region. The camps are a part of a years-long effort to wipe out the ethnic and religious traditions of the Uighur and other Muslim ethnic groups. Former prisoners describe torture and constant political indoctrination designed to force detainees to give up their religious beliefs, language and ethnic identity.

At first glance, these incidents seem to have little in common with each other; however, the link that bonds them together is that they are all human rights violations. A next logical question some might ask is what do these issues have to do with counselors and the counseling profession? Many professional counselors do not think human rights issues are related to or comfortably fit within the counseling profession and/or are outside of the traditional job description of counselors. This is partially due to the difficulty of separating human rights issues from political issues, which may create values conflicts for some counselors. Second, many counselors may not have a clear understanding of what human rights are beyond the rights that people know about, particularly if the rights directly impact them. Thus, values conflicts and lack of understanding often lead to professional counselors’ cautious involvement with human rights.

We are past and current members of the American Counseling Association’s Human Rights Committee (HRC) whose stated mission is to bring awareness to human rights and social issues that impact the counseling profession and to address barriers that impede human rights. We believe that human rights issues are inextricably linked to both the practice of counseling and the overall profession. We’ve developed this two part series, consisting of two separate articles that explores why human rights issues are important to counselors and counselors-in-training. This first article provides a general background of human rights issues and its relevance to practitioners, whereas the second article is solely focused on human rights issues and counseling students and counselor training.

We start with a question: What are human rights?

The concept of human rights entered the international realm with the founding of the United Nations (UN) in 1945. The term “human rights” was mentioned seven times in the UN’s founding charter, establishing that the promotion and protection of human rights is a key purpose and guiding principle of the organization. In 1948 the UN issued a document drafted by representatives from all regions of the world — The Universal Declaration of Human Rights — which for the first time set out fundamental human rights recognizing the inherent dignity and equal and inalienable rights of all humans regardless of race, gender, nationality, religion, language, social status, place of birth or other factors (such as sexual orientation, which is not specifically mentioned in the declaration). Human rights may include civil, political and cultural rights. Simply, human rights are freedoms and liberties that are due to people solely based on their status as human beings. The foundation of human rights is built upon respect for the individual, which aligns with counselors’ primary ethical responsibility to respect the dignity of our clients and students. According to the UN, everyone is entitled to basic human rights.

Although it is impossible to list all human rights issues in this series, there are defined categories. The first category pertains to the right to personal and physical safety, which includes freedom from slavery or unwilling servitude; torture; and inhuman, cruel or degrading treatment or punishment. From a counseling perspective, issues that may fall under this category include but are not limited to mental health consequences associated with interpersonal and domestic violence, gender-based harassment, human trafficking, and community gun violence. The second category includes political rights and civil liberties such as the right to express one’s ideas and beliefs freely and to fair treatment in the judicial system. For counselors, examples of this dimension include addressing mental health consequences associated with racial disparities in incarceration rates and forced treatment of mentally ill offenders. The third category of human rights centers on social and economic rights, which include the right to quality education, gainful employment, housing, health and an adequate standard of living. This dimension has implications for counselors who provide services to clients or students who live in poverty, are unemployed, struggle with health concerns or experience psychological distress as a result of systemic oppression. These examples demonstrate that human rights issues can potentially affect anyone. Therefore, human rights have a seat at the counseling table.

Human rights in the helping professions

Because human rights violations impact mental wellbeing, several of the member organizations affiliated with helping professionals specifically name human rights in their mission or vision statements. For example, one of the five general ethical principles included in the American Psychological Association’s code of ethics is respect for peoples’ rights and dignity. The Society for the Psychological Study of Social Issues describes itself as an organization that promotes research and education on psychological aspects of critical social issues and brings science and evidence to human problems. The statement of ethical principles created by the International Federation of Social Workers–the global body for the social work profession– states that members and the profession as a whole strive for social justice, human rights, and inclusive, sustainable social development.

Although the American Counseling Association (ACA) is in a unique position to be a leader at the intersection of counseling and human rights, presently, it does not name human rights in its vision and mission statements. However, ACA’s recently developed strategic plan includes social justice and empowerment as a core value, whose guiding principles can be summarized with the catch phrase: Human rights are right.

Because counselors are often on the front lines treating the mental health consequences of human rights violations in the lives of clients and students, we should have a clear understanding of our professional responsibilities as it pertains to human rights issues. First, we have a responsibility not to violate the human rights of other people including our clients and students. Second, we should work to build a culture where human rights are respected.

Why human rights are relevant to counselors and the counseling profession

As counselors, we must recognize the crucial role human rights play in mental health and wellness. Human rights violations often result in serious emotional consequences for individuals, families and communities. We began this article by giving recent examples of brutal human rights violations. Unfortunately, these incidents are just a snapshot — a mere fraction of the violations that entire groups targeted for their ethnicity, religion or political beliefs and individuals in marginalized populations experience daily. Many clients encounter multiple forms of harassment, bullying, restriction of freedoms, verbal abuse, threats of violence and life-threatening events.

The long-lasting physical and emotional consequences of exposure to these conditions cannot be understated. As a result of these violations, clients may experience a range of detrimental mental health consequences including but are not limited to — increased loss of dignity, ongoing stress, anxiety, sleep disturbances, physical distress, spiritual distress, increased substance use, decreased productivity, emotional dysregulation, severe depressive symptoms and suicidality. In addition to the impact on holistic wellness, individuals often experience post-trauma stress symptoms and are at risk of developing post-traumatic stress disorder (PTSD). Whether clients experience a single incident or have been subjected to chronic, ongoing human rights violations, their lives are impacted, as are the lives of loved ones, families, and communities. Collectively, we are all diminished as a result.

As counselors, it is incumbent upon us to identify human rights concerns and their impact, to uphold individual human rights and address the negative consequences associated with violating these rights.

The ACA Code of Ethics can serve as a guide to protecting and upholding human rights. In fact, the ethical principles defined in the code’s preamble to directly relate to human rights advocacy. Consider, for instance, the principle of autonomy, which states that counselors have a responsibility to foster an individual’s right to control their life. Control of one’s life pertains not only to the counseling setting, but extends to every life aspect and to all three of the human rights categories listed earlier in this article. Therefore, counselors should be cognizant not to intentionally or unintentionally violate the human rights of clients. This is consistent with an additional ethical principle, beneficence.

As counselors we have a responsibility to treat our clients with justice, equity and fairness. This responsibility incorporates human rights issues as well, as every human being has the right to basic freedoms, human decency and respect. Justice includes advocating on behalf of marginalized populations and treating clients and students fairly. Honoring others and keeping our commitments to those we serve and to the greater social community embodies the principle of fidelity and is in keeping with human rights principles. In doing so, we build trusting relationships with those around us, allowing for positive interactions and improved wellness, building healthier communities. Veracity, the last ethical principle listed in the preamble, bids counselors to deal truthfully with those they encounter professionally. Speaking the truth by identifying and exposing human rights violations creates awareness that can lead to change. Taken as a whole, these principles form a roadmap not just for the counseling-client relationship, but also for respecting the human rights of people not just in our communities but in society as a whole, which can help foster a healthier world.

Global human rights initiatives and mental health

As stated above, the UN’s Universal Declaration of Human Rights (UDHR) was originally adopted in 1948 and reinforces the ideals behind bettering our communities through endorsing fundamental human rights, understanding the mental health consequences of violating these rights and advocating. Consistent with ACA’s ethical principles, this declaration includes language such as autonomy, freedom and justice. This document heavily endorses the ideas of personhood, dignity and freedom for every human being, which complements the core values of the counseling profession.

Key to any discussion on human rights is the UN’s Commission on Human Rights (UNHRC) and its relationship to mental health and counseling. Established in 1946 for the purpose of incorporating legal responses into human rights problems globally, the UNHRC included 53 member states, whose delegates met at annual sessions in Geneva. The commission reviewed reports on specific human rights issues, adopted resolutions, issued statements and made decisions regarding human rights issues. It also provided a forum for countries, non-governmental organizations (NGOs) and human rights advocates to voice their concerns.

The UNHRC established the committee that drafted the UDHR and was tasked with upholding it until 2006 when the Human Rights Council replaced the commission. Currently, the council promotes and protects human rights worldwide. Consisting of 47 members, including the United States, the Human Rights Council meets three times per year in Geneva, but may also hold a special session as needed to address urgent human rights violations. The council focuses much of its work on pervasive issues such as cultural rights, adequate housing, the rights of indigenous people, the rights of people with disabilities, racism, slavery, human trafficking and violence against women.

Addressing human rights violations in counseling

Understanding the professional and clinical importance of human rights issues is valuable to the counseling profession in general and in clinicians specifically. Knowing how to assess and treat the negative effects of human rights violations is paramount to treating [client] symptoms in sessions. A counselor’s primary role is to help clients address the issues that brought them to counseling and to advocate on their behalf. In fact, the ACA Code of Ethics encourages us to advocate at individual, group, institutional and societal levels to address potential barriers and obstacles that inhibit access necessary to the growth and development of clients. For clinicians to effectively advocate on behalf of clients’ human rights, understanding how and why the issue affects clients, society, and the counseling relationship is a must.

For many counselors, human rights violations assessment was not likely taught in their respective counseling programs. Therefore, it is crucial that counselors hone their assessment skills by understanding how violations of human rights may manifest in clients. Identifying the words and behaviors hinting at trauma that may stem from human rights violations can help the counselor to further assess the client. Just as counselors should assess for histories of abuse, substance use and suicidal or homicidal ideation, gathering information about experiences of human rights violations is essential.

At the onset of clinical work with clients who have experienced trauma associated with human rights violations, we recommend four guiding principles with which to frame the therapeutic relationship. First, create a safe environment in which trauma symptoms can be stabilized and explored. Second, counselors would serve their clients well by asking direct, open-ended questions about potential human rights violations and exploring issues that help uncover related trauma. Third, do not discriminate, remain nonjudgmental and avoid victim-blaming as clients share their violation experiences. Fourth—and last—assist clients in empowering themselves. Once these fundamental principles are in place, the following counseling strategies may be effective in treating trauma symptoms associated with human rights violations.

Manage the level of emotional stimulation and expression in sessions. While avoiding overstimulation is beneficial, clients who limit their emotional expression may be resisting stepping outside of their comfort zone, which could prevent adequate processing and growth. In contrast, clients who are highly expressive emotionally may become overstimulated, which could cause trauma symptoms to get worse.
Mindfulness of emotions helps clients develop a level of awareness of their feelings and teaches clients how to examine the emotions they experience without judging whether or not they are “good” or “bad.”
Teach clients coping strategies for intense human rights violations, trauma symptoms and feelings. Techniques such as relaxation training, cognitive disputation and stress reduction can be helpful.
Educate clients on normal reactions to trauma. This includes validating and normalizing clients’ affective reactions to human rights violations.
Grounding techniques that make use of all the senses help clients to stay focused and in the present when processing distressful human rights violations. Three effective techniques include having the client listen to the counselor’s voice, have the client feel bare feet on the ground, and allow client to name 5 things they see, 4 things they feel, 3 things they hear, 2 things they smell, 1 thing they taste (5-4-3-2-1).
Eye movement desensitization and reprocessing (EMDR) has been shown to be effective for many clients to alleviate symptoms of trauma and distress such as those connected to human rights violations.
Group therapy for trauma survivors may be an effective complement to individual therapy.

The strategies mentioned above are by no means an exhaustive list of all potentially effective interventions at a counselor’s disposal for treating the mental health consequences of human rights violations. We encourage readers to consult professional literature for additional interventions.

ACA has done a phenomenal job of addressing the intersection of mental health and human rights — yet more can be done. As the counseling profession evolves and ACA continues to grow, we offer three recommendations that we believe would place it at the forefront of counseling and human rights issues. These recommendations stem from the World Health Organization, and we adapted them for the counseling profession.

ACA and the counseling profession should:

Continue to raise awareness and advocate for change by educating clients and advocating for targets of human rights violations.
Develop and support mental health policies and laws that promote human rights.
Train stakeholders on the human rights of people with mental health issues. Stakeholders include anyone who has an impact on people with mental health issues, including but not limited to counselors, law enforcement, schools and the judicial system.

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Michael P. Chaney is a licensed professional counselor, an approved clinical supervisor and an associate professor in the Department of Counseling at Oakland University in Rochester, Michigan. He is the immediate past co-chair of ACA’s Human Rights Committee and currently serves as the editor-in-chief of the Journal of LGBT Issues in Counseling. Contact him at chaney@oakland.edu.

Carman S. Gill is a licensed professional counselor, a national certified counselor and an approved clinical supervisor. She is also a professor and the doctoral program coordinator at Florida Atlantic University in Boca Raton, Florida. She is the immediate past co-chair of ACA’s Human Rights Committee and a past president of the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC). Contact her at carmangill@gmail.com

John T. Super is a faculty member in the University of Central Florida’s counselor education program. After receiving his master’s degree in marriage, couples and family counseling, he worked in and developed a clinical private practice with a focus on helping LGBTQ+ couples with relational issues. He is a national certified counselor and is also a licensed marriage and family therapist in the state of Florida. Contact him at jsuper@ucf.edu

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.