Monthly Archives: January 2020

CEO’s Message: You make the world a much better place

Richard Yep January 31, 2020

Richard Yep, ACA CEO

When I think about the embodiment of a true leader, I use descriptors such as inspirational, compassionate, caring, humble, willing to sacrifice, committed to listening, putting the good of the people above personal gain. Before anyone assumes that this is a column bashing the current U.S. president (although I suppose it could be), let me clarify. I am actually speaking in reference to each of you working in the counseling profession. You are the leaders who inspire me with the outstanding work you do each and every day for clients, students, families and communities.

Professional counselors are among the most vital professionals when it comes to how this nation, and, in fact, the world, will heal moving forward. It’s no secret that we are being confronted by issues such as poverty, hunger, homelessness, opioid addiction, gun violence, climate change, discrimination, and natural and human-made disasters. The work that you do as professional counselors and counselor educators can make all of the difference in whether we overcome things such as dissension, racism and the growing economic divide. I know that you can’t do it all as individual counselors, but when you add yourselves to the number of colleagues you have around the globe, we can see how the movement to bring counseling to thousands of communities could have a dynamic impact. You and your colleagues have the opportunity to make this world just a little fairer, more equitable and more inclusive.

I’m aware that accepting and acting on such a responsibility can be daunting, especially in the midst of taking on more clients, being tasked with paperwork that often doesn’t get completed until “after hours,” or facing a counselor-to-student ratio of 1-to-1,000. But you are good with “daunting.” You are a special breed of human, and I have such confidence in what you are doing to make this earth, my earth, our world, so much better.

Here in the United States, we will have elections this year at the national, state and local levels of government. I would never tell you for whom you should vote. But I will say that my hope is that those who serve in government positions will be the types of leaders who possess the characteristics I referred to at the beginning of this column. Let’s make sure that our elected officials understand the importance of counseling and how their support of such services really can make this country even better, more productive and more welcoming than what we are currently experiencing.

Let’s make sure that those who choose public service understand that they will be measured by their commitment to, and success in, improving people’s lives. For example, last month, Chesa Boudin was sworn in as San Francisco’s new district attorney. Boudin, who had actually served as a public defender in San Francisco, had a lived experience that compelled him to run on a platform of restorative justice. He believes in criminal justice reform that includes eliminating the discriminatory cash bail system, protecting immigrants from deportation, and creating a pretrial release program that would allow defendants to keep their jobs and homes. What I found especially interesting was Boudin’s commitment to ensuring mental health treatment for those charged with crimes because he knows that incarceration does not properly address the issue of those who have behavioral health needs.

In terms of lived experience, before Boudin was a Rhodes scholar and a Yale Law School graduate, he experienced the criminal justice system as one of its youngest victims — as the child of parents who were part of the Weather Underground. They were sent to prison when he was just 14 months old (his mother was released when he was 23, and his father continues to serve a sentence of 75 years to life).

I’d like to believe there are more Chesa Boudins out there who have declared they are running for public office in 2020. Folks, we are running out of time if we are truly committed to making this country and our world more compassionate and caring. My belief is that there needs to be a partnership that includes professional counselors and other behavioral health experts working with those in the public policy arena to successfully address the challenges that so many people are facing.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext. 231 or to email me at You can also follow me on Twitter: @Richyep.

Be well.

From the President: Connecting research to practice

Heather Trepal

Heather Trepal, the 68th president of the American Counseling Association

This month’s Counseling Today cover story is about obsessive-compulsive disorder (OCD) and obsessive behaviors. According to the National Institute of Mental Health, these behaviors occur across the life span for about 1 in 100 adults and may be as common in children as diabetes (see

I have my son’s permission to share a little about his story here. When my son was around 8 years old, he began taking a long time going to bed. He slowly developed an intricate routine of tapping and jumping from the steps, to his bedroom, to the bathroom and back. He also developed some other obsessive behaviors and repetitive movements. If there were any deviations from this routine, he would have to begin the entire process over again before he could finally settle in for the evening.

One night, after going through a particularly difficult bedtime routine, my son came to my husband and me and said that he didn’t want to live that way anymore. His need to perform these rituals was interfering with his ability to function. We searched for a counselor and, fortunately, found one who specialized in working with children with anxiety, attention-deficit/hyperactivity disorder and obsessive behaviors.

The counselor took time to form a relationship with my son by getting to know him, asking about his favorite sport, his friends and his favorite subject area in school. The counselor also made an effort to accurately and thoroughly assess the impact of my son’s behaviors on various domains of his life, including school, friends, health and sports. The counselor let me know that he was a specialist in working with these behaviors and that his work with my son would be guided by research and evidence-based practice. My son worked with his counselor for quite some time and made substantial progress.

OCD and obsessive behaviors are complex and can be extraordinarily difficult to understand and treat. In addition, clients who struggle with these behaviors may feel isolated. One organization that supports education, advocacy, access to effective treatment, and the reduction of stigma around these behaviors is the International OCD Foundation ( In addition to being a national nonprofit, this organization maintains many state affiliate organizations. Such organizations create a sense of community and networking for those affected by these behaviors (and those who love them). In addition, the International OCD Foundation and its affiliates support researchers and mental health clinicians on the journey toward better understanding and treatment of OCD and obsessive behaviors.

Just as my son’s counselor helped assure me that his work would be guided by research, it is vital to understand the connection between research and effective practice. This year, we have an ACA task force, chaired by Kelly Wester, called the State of Counseling Research: Its Impact on the Profession and the Public. Working in conjunction with ACA’s Research and Knowledge Committee, this task force will examine the current state of counseling research, focusing on our strengths. The task force will recommend avenues for increasing counseling research connections and visibility throughout the profession and with the public. We need to know more about the impact of our counseling research so that we can continue to best serve our clients and communities.



Follow Heather on Twitter @HeatherTrepal

Cultivating social class awareness in the counseling profession

Derrick L. Shepard and Eva M. Gibson

As professional counselors, the two of us often engage in the  reflection process to gain an understanding of ourselves and our clients. As African Americans raised and living in the South, both of us have to navigate through our share of “isms.” Derrick, a black doctoral candidate and practitioner from an urban Southern community, has faced some striking experiences that draw attention to issues of intersectionality. Eva, a black counselor educator and former practitioner, has also acquired some interesting stories over the years.

In our discussions of similarities experienced due to our race and even differences due to our gender, an additional topic emerged that is not as apparent — issues of class. Whereas racism and sexism are subjects that receive much attention, classism is often overlooked in the counseling profession. Our goal is to start an intentional conversation by bringing attention to social class (outside of objective measures) in the therapeutic relationship. We initiate this conversation with our personal stories.   

Derrick’s story: My path to the counseling profession was unconventional. Raised with an older brother in a low-income, single-mother household, I understood and valued what the American dollar can do for an African American male. Even though we did not have substantial economic capital, my mother did possess the innate ability to move between social classes through hard work and education. As a child, I saw this, and it shaped my life moving forward.

After high school, I pursued a degree in business administration. As is often the case with others from lower-class backgrounds, I sought riches from a lucrative major. I did graduate with a degree in business administration; however, my dreams of financial security did not materialize. Instead, I struggled financially after college. I was able to ascend the social class ladder by obtaining a college degree and the cultural capital that comes with it, but I did not achieve the middle-class lifestyle I envisioned. For years after college, I relied on my lower-class knowledge to stretch a dollar to balance all of the financial debts I incurred while obtaining my degree. I, however, was not happy in the world of business.

As I eventually learned in researching the intricacies of social class, individuals from lower social class standing have a propensity to rely on one another for everyday needs and survival. With this propensity also comes a sense of serenity. For me, at that time, this was a natural way of living. So, I felt at home and at ease. In addition, others from similar backgrounds encouraged me to further my education. With this encouragement, I decided to pursue a graduate degree, but not in the world of business. Instead, I landed in the field of counseling.

My natural inclination to help others was an intuitive fit in the counseling world. Even so, I felt a sense of incongruence. As a doctoral candidate, others view me in a particular light — a light enhanced by the cultural capital associated with the aforementioned status, working in higher education, and networking with others who share similar values in education. And yet, when I return home, that cultural capital gets washed away by hometown acquaintances (and even some family members) because it does not have the same value as the American dollar. And at times, I tend to agree with them.

This experience has shaped my approach with clients. I engage clients with a sense of gentleness surrounding their unique social class identity while understanding the systemic barriers in place (e.g., transportation issues) that may prevent some of them from fully engaging in the therapeutic process.

Eva’s story: My husband and I decided to do premarital counseling before we got married. During that process, I came face-to-face with some of my classism issues. Although I was in graduate school at the time and knew the benefits of counseling, it felt different sitting in the client seat. I felt this urge to “put on my best face” because I did not want to present as a client with problems but rather as a responsible, proactive citizen. I felt as if the counselor needed to see the best of me, and because I fell in the middle-class, college-graduate category, I needed to behave accordingly.

To be completely honest, I am not sure to what degree these feelings were due to my identity as a middle-class client and to what degree they were due to my identity as an African American woman. As a professional black woman, I constantly feel as though I have to wear a mask. I fear letting my vulnerabilities and struggles show because I represent not only myself but also my people. Because I am often the minority in professional settings, I tend to stand out, and I feel a responsibility to showcase this positive, professional, accomplished representative to combat all of the other negative stereotypes that are often attributed to black women or to black people in general.

Let me tell you, this is exhausting. Paul Laurence Dunbar, Maya Angelou and W.E.B. Du Bois illustrate this concept so well in their analyses of the masks we wear and the double consciousness of black people. These efforts are draining but necessary for my survival.

As is often the case with intersecting identities, it is difficult for me to isolate the influence of social class pressures versus the influence of race-related stressors, but I am certain that both played a role in my response to counseling. Although the goal of premarital counseling is to explore issues that may affect the relationship, I was acutely aware that I would not dig too deep — not because I did not desire a strong marriage, but because I was concerned about how the counselor would view me. Although we completed four sessions, they were superficial because my issues with appearances (both as a middle-class woman and as a black woman) acted as a barrier and prevented any real work from being done. The process of sharing this story was difficult for me (again, I do not like to feel exposed), but I highlight it to bring attention to issues that we need to consider as clinicians.

Social class and counselor considerations

As we examine social class with a stronger lens, we discover this construct is shaped by one’s environment. Just as we cannot claim to be “colorblind” practitioners, neither can we claim “social class blindness” in working with our clients. In attending to the social class identities in the room, we develop a holistic view of the client, which leads to better outcomes. In contrast, if we do not value the intersectional identities of our clients, we are not providing the best care. In essence, we are arguing for the inclusion of social class in the therapeutic alliance.

At this point, we ask readers to do what counselors do best — reflect. How do you define your social class status? Do images of money, clothing and your home come to mind? Has your social class status changed over the years? Were you able to climb the social class ladder after completing a graduate degree? From that perspective, has your worldview of social class changed? Are you now less prone or more prone to noticing the social class microaggressions that take place every day? Counselor educators and researchers Caroline O’Hara and Jennifer Cook liken social class microaggressions to the racial microaggressions experienced by ethnic minority groups. How do you see this playing out in your professional practice?

You might also ask why such a reflection exercise is important. As counselors, it is our ethical responsibility to acknowledge and respect the multicultural identities of our clients in the counseling relationship. Equally important, we need to acknowledge our own multicultural identities. Acknowledging and respecting the various identities in the therapeutic relationship guides our decision-making process as it relates to diagnosis, treatment and interventions. However, it is not uncommon for counselors to bring middle-class bias into the room and to form negative impressions of clients on the basis of their lower-class social status.

The perception of social class differences between counselor and client could lead to a negative experience for the client, especially when the counselor lacks awareness surrounding social class issues. This often results in early termination or lower quality services. Ultimately, developing one’s multicultural competency as it relates to social class is an ethical responsibility of the practitioner. 

The social class worldview model

Humans live within systems. These systems can be as simple as one’s immediate family or as complex as working at a large university. Embedded in each of these systems is a unique economic culture with its own unique set of values, beliefs and expectations.

For instance, think about a prison black market for cigarettes. Within this system, the economics are not aligned with traditional forms of currency such as coins and dollar bills. In this environment, cigarettes, considered contraband, are highly valued and often sought during exchanges. However, outside of this system, the value of cigarettes is diminished because they can be easily purchased from a store.

To better understand subjective measures in economic cultures, William Ming Liu developed the social class worldview model (SCWM). The SCWM serves as a tool that counselors can use to understand social class from a systems perspective and on a more individual level instead of using objective measures such as education and salary. The SCWM considers saliency, consciousness, attitudes, relationships with material objects, behaviors and lifestyle. It also introduces the concept that individuals internalize class values on the basis of environmental feedback. In this process, clients and counselors bring sets of values that cannot be ignored into the therapy room.

Classism consciousness

Counselors have an ethical responsibility to have an awareness of their personal values and to avoid imposing these values on clients. With this responsibility in mind, the American Counseling Association continually educates its members on various “isms” through professional development and chartered divisions focused on various aspects of diversity. Even with the efforts ACA makes to promote diversity education, we believe awareness surrounding classism in the counseling profession can be enhanced.

Classism is the marginalization of an individual on the basis of his or her perceived social class identity, and it can be conceptualized into different forms. Consider the case of upward classism. This form of classism involves marginalization of individuals perceived to be in a higher social class. Now consider how this might materialize in your professional life. Do you have negative personal views of clients you perceive to be of a higher social class than you? Sometimes this might take the form of minimizing their presenting issues if you believe that their resources exceed those of your own. If you have struggled with similar experiences, take time to reflect on the impact this had on the therapeutic relationship.

What about lateral classism? How might this affect you? Lateral classism reinforces expectations of individuals perceived to be in a similar social class. Have you found yourself in situations in which you were attempting to portray a certain status in the professional setting? What might some potential negative consequences of those efforts be?

Downward classism is the most familiar form of classism and comprises prejudicial treatment of individuals perceived to be in a lower social class. This may also involve negative perceptions of clients due to physical appearance, an apparent lack of resources, or even differences in mannerisms and experiences. Although we seek to treat our clients in an equitable manner as counselors, we also must acknowledge and attend to any personal biases we may hold.

Finally, we must internally examine the potential of internalized classism, which is not as frequently discussed. Internalized classism manifests itself in negative feelings (e.g., depression, anger) related to not being able to keep up with one’s economic culture. This can affect clinicians’ feelings of competence or “worthiness.”

All things considered, have your “ism” issues ever unintentionally affected the counseling relationship from a social class perspective? Now put yourself in the client’s shoes regarding upward, lateral, downward and internalized classism. How might the client’s experience of these issues affect the therapeutic relationship? Although we are highly trained professionals who are well-equipped with specialized clinical skills, we must use intentional techniques that adequately integrate the individual, social and environmental factors within this context.

Suggestions for practice

After engaging in reflection centered on your and your clients’ social class, it is time to consider how to implement this newfound knowledge into practice. The following suggestions are not all-inclusive, but they can serve as guideposts to assist you along your journey. It is imperative that we incorporate social class considerations from the beginning of the therapeutic relationship and continue to integrate this lens throughout the therapeutic process.

When we first meet clients, we often make assumptions about their visible identities, including race. Even so, we are trained to inquire about how clients view themselves in relation to race. On the other hand, we are less inclined to have open conversations regarding social class with our clients even though we often make assumptions about our clients on the basis of their dress, income and material resources. How can we rectify this?

Start by asking clients how they perceive their current class standing. Do they consider themselves financially fortunate, even though they may reside in an economically distressed neighborhood? Or might they consider themselves impoverished, even though their income is higher than that of most of their peers? By gauging clients’ social class worldviews during the intake process, counselors gain a better understanding of how clients conceptualize their economic culture. This serves as a first step in developing a deeper therapeutic alliance that appreciates each client’s unique social class lens.

As the therapeutic relationship continues to advance, counselors’ intentionality in understanding and respecting all aspects of clients’ worldviews is paramount in providing culturally competent services. But how do counselors intentionally address clients’ social class worldviews in the therapeutic alliance?

Let’s return to the stories offered at the beginning of this article. In our stories, we described the expectations associated with our socioeconomic worldviews. We both shared an awareness surrounding our social class identities. We became conscious of the impact of addressing (or not addressing) the expectations associated with our social class worldviews. It is from this consciousness that we learned to value our social class identities and the impact these identities have on providing services to a diverse clientele. We believe this is an important consideration because our goal is to provide culturally competent counseling. To accomplish this, we need to be aware of our personal values as practitioners.

Now is a good time to return to the reflection questions posed earlier. From those questions, what values were you able to identify as a practitioner? Although it is second nature to examine constructs from our own lens, we may miss critical aspects because our personal experience guides our interpretation. The use of concrete interventions may be a helpful strategy to engage. For example, goal exploration is a good starting point. What is your goal as a counselor? What is your client’s goal? Do the goals complement or conflict with one another?

Value exploration is another important part of this endeavor. Write down a list of your values, and compare those values with your client’s perceived social class status. Do they match up? Are there incongruences that you could address?

Need more ideas? Let’s say that you have a client who comes from a lower socioeconomic status. You notice that the client’s value of acquiring material possessions constantly strains their finances, yet they are not willing to make concessions. Even so, they continue to express concern about their financial situation. This conflicts with your values. Although intentions can be noble, they can also lead to a rupture in the therapeutic relationship.

We recommend engaging in the supervision process with an intentional lens on social class to process this dissonance. A practical intervention is for the supervisor to create notecards with various identities (e.g., race, gender, social class) in the supervision triad and as the supervisor and supervisee conceptualize the client. By using this intervention, both parties intentionally bring social class into the room.

Our next recommendation might be a heavier lift, but we believe the effort will bear fruit. As practitioners, it is our ethical responsibility to engage in continuing education to maintain our skills and to learn new best practices to serve diverse clients. With that in mind, we encourage readers to submit and present on issues related to social class and the counseling profession. These presentations can be given at the local, regional or national level. Regardless of how the continuing education process occurs, we need to see more social class awareness within the counseling profession.

As counselors, we serve a diverse clientele. To improve our service to them, we should be engaging in a reflective process to better understand ourselves and, in turn, to better understand our clients. We challenge our counseling colleagues after reading this piece to take the time to examine their own social class values, backgrounds and histories. From there, contemplate how your social class identity affects your work with clients. Finally, we encourage you to continue developing an understanding of social class and the counseling profession. Yes, what we call for is challenging. But as African American icon Cicely Tyson notes, “Challenges make you discover things about yourself that you never really knew.”



Derrick L. Shepard is a doctoral candidate and TRIO counselor at the University of Tennessee, Knoxville. His research focuses on social stratification issues in society and the impact these societal issues have on the therapeutic alliance. Contact him at

Eva M. Gibson is a counselor educator at Austin Peay State University in Clarksville, Tennessee. Her research focuses on marginalized populations. Contact her at or


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

Letters to the editor:


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.

From Combat to Counseling: Getting started in counseling military clients

By Duane France January 29, 2020

We want to help people. It’s a common reason many choose to become professional counselors. Maybe we’ve been told we’re good listeners. Maybe we have lived experience with overcoming mental health concerns. Whatever led us to counseling, we want to use our skills to help people. At some point, we may decide we want to help people in the military population: service members, veterans and their families. Perhaps we want to help military kids because we have a couple of our own, or we were one. Or, we want to support military spouses in post-military life because they’re an underserved and under-resourced population.

Having a clinical focus on serving the military population is admirable. More importantly, it’s necessary. With critical mental health access shortages in the Department of Veterans Affairs (VA) and Department of Defense (DOD), and studies that show that community providers are not as culturally competent with the military population as VA and DOD clinicians, it’s essential to increase the military population’s access to timely and competent mental health services.

Counselors often ask me: How do I do it? I may want to serve veterans and their families, but how do I get there from here?

Here are some critical points to consider if you’re interested in working with the military-affiliated population.


Know why you’re doing it

Understanding your motivation for serving veterans is critical. More importantly, it’s an ethical responsibility for counselors. In order to give the highest quality of service to those we work with, as well as to be true to ourselves, we need to understand what it is that got us into this work and why we want to do it.

What are your personal and professional motivations to serve this population? Like me, are you a veteran yourself, or (also like me) a child of a veteran? Are you a military spouse who has the lived experience of your partner’s service? Or do you have no prior direct affiliation with the military, but happened to work with the population during your clinical training? Regardless of your background, it’s essential to understand why you chose this particular population to serve.

Photo by U.S. Army Master Sgt. Alejandro Licea/

Understand your limitations

Along with why you’re doing it, it’s important to understand your limitations. This could mean that you may have some familiarity with one aspect of military culture but recognizing that you’re not an expert in all military culture. Or that you may come up against some things in your clinical work that you’re not prepared for, and you didn’t know would bother you. I remember several years ago when working with a veteran, a session in which they were recounting significant racial discrimination while they were in the military. This discrimination was the source of their depression rather than PTSD as most people (including the client) assumed. As I was listening to the veteran recount their story, I found myself getting angrier and angrier, to the point where I started to lose concentration and therapeutic objectivity. The former senior noncommissioned officer in me was offended at the experience.

What I didn’t realize was that this was a psychological reaction on my part to two different things: the blatant disregard for the military values that I hold dear shown by the veteran’s leadership, as well as my own unresolved emotional response to racial discrimination in my childhood. A classic example of countertransference. Counselors like me, who identify as military-affiliated, must assess for and address potential countertransference. Just because a counselor is a veteran doesn’t make them the best counselor for veterans, and we need to be aware of the limitations of our own personal experience.

Where do you start?

So understanding why we want to serve veterans is essential, and it’s also important to understand the limitations that we may face, but what about the practical aspects of serving this population? As in, specifically, how do you help? I often hear how difficult it is for professional counselors to serve in the VA (although the department is currently putting a lot of effort into creating more licensed professional mental health counselor positions). And if you’re not in the VA or DOD, but want to help veterans, where do you go? How do you find internships, post-graduate placement or positions for a fully licensed counselor?

There are several suggestions that I often give to those counselors who reach out to me, asking about how they find positions in the community that serve veterans. First, do some research in your area. Are there mental health clinics that primarily serve the military population? Organizations like the Cohen Veterans Network may be a useful resource for internships or to get your pre-licensure hours, or clinics like the one I work for, the Family Care Center, in Colorado Springs. Even if they are not currently taking interns, they may have some advice for you.

Another potential source for positions is to see if there are other veteran services in your community that would be willing to add a clinical component to them. For example, the Veterans Village of San Diego, a nationally recognized leader in serving homeless veterans since 1981, has 27 mental health interns as part of their staff. Organizations that provide employment, housing, legal and financial resources to veterans may be willing to include a mental health component to their services.

And finally, there is a national program that may be of some benefit. Give An Hour is a national network of volunteer clinicians who serve the military population. I often recommend it as a resource for those veterans and family members looking for support outside of my local area. It is also a way to connect with other like-minded professionals serving the military population. If you’re looking to serve veterans in your area, it’s a good idea to reach out to those who are already doing so and network with them. You can find a list of clinicians in your area who are working with the military by searching for providers in your zip code, and reaching out and connecting with them on LinkedIn or through email. It’s likely that you will find one or two who would be willing to sit down and talk and give some professional advice on what serving the military looks like in your location.

Serving those who served

Dedicating your professional career to serving those who served and those who care for them is admirable and not to be taken lightly. Like many other underserved populations, it is necessary to understand the unique culture of the military and how it impacts our clients. Through diligence in our preparation, we can make sure to provide the best care possible for those who sacrificed much on our behalf.



Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at Contact him at




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.

Fostering immigrant communities of healing

By Lindsey Phillips January 28, 2020

During the months surrounding the 2016 presidential election, the rhetoric around immigration was so charged that Daniel Gutierrez, a licensed professional counselor (LPC) and American Counseling Association member, noticed a substantial uptick in panic disorders at a free clinic in Charlotte, North Carolina. One therapist even told Gutierrez about a client who was having panic attacks every time that a political ad played on television.

Four years later, Gutierrez, an assistant professor in the counselor education program at William & Mary and coordinator of the addictions emphasis for the university’s clinical mental health counseling program, says he still encounters immigrants who are terrified and no longer understand the immigration process in the United States. Many worry about family members back in the countries they left. Some worry that if they visit these family members, they may not be able to easily return to the United States themselves. Some are confronted by people screaming “Go back home!” as they shop for groceries or walk down the street. Fear, guilt and worry are constant emotions for many immigrants, notes Gutierrez, who is also faculty director of the New Leaf Clinic at William & Mary in Williamsburg, Virginia.

In fact, Gutierrez says that providing counseling services to immigrant populations can sometimes feel like working in a hospital emergency room. “We’re just trying to stop the bleeding for a minute, and sometimes we don’t have time to look at some of the other concerns,” he says. “You don’t even know where to start. There’s so much trauma and anxiety.”

“They have such a history of past trauma that it overshadows everything,” Gutierrez continues. “They’ll have this experience on the border crossing or in their home country, and when they get here, that [experience] influences every relationship.” Gutierrez has seen cases in which a mother has difficulty connecting with her partner and children because of the guilt she feels about a trauma that happened while the family was crossing into the United States. For this reason, counselors often have to deal with larger presenting issues — trauma, anxiety, depression — before they can work on other concerns such as relationship issues, he explains.

Immigrants also face myriad stressors after migrating to a new country, and these stressors take a toll on their mental health. In fact, researchers have identified an immigrant paradox in which recent immigrants often outperform more established immigrants in areas of health, education, conduct and criminal justice.

This paradox illustrates how damaging acculturative stressors such as financial concerns, insufficient living conditions or food, cultural misunderstandings, an inability to communicate or speak a new language, lack of employment, and isolation can be to immigrants. Lotes Nelson, a clinical faculty member at Southern New Hampshire University who often presents on this topic, points out that these stressors can result in symptoms of anxiety, depression, posttraumatic stress disorder (PTSD), conduct disorders (especially for children) or substance abuse issues.

Isolation and the lack of a support system can cause immigrants to turn inward and internalize their symptoms, says Nelson, who lives in St. Augustine, Florida, and, as an LPC and approved clinical supervisor in North Carolina, offers distance counseling services. Her clients who are immigrants often report feeling that something isn’t right — their heart is racing all the time or they constantly feel sad, for example — but they can’t pinpoint what it is or why they feel this way. In addition, they frequently lack people they trust to talk to about their concerns.

One problem is that accessibility to counseling services is limited for immigrant populations. Gutierrez, author of the chapter “Counseling Latinx Immigrant Couples and Families in the USA” in the forthcoming book Intercultural Perspectives on Family Counseling, says that immigrants are less likely to receive mental health services, and when they do, the services are often lower quality than what the majority culture receives. “The counselors who are offering the care [to immigrant populations] are overwhelmed with large caseloads. They are about to hit burnout. … The immigrant stories of journeying over are [also] really difficult,” he explains.

In addition, Gutierrez finds that the counseling profession doesn’t have enough practitioners who understand the cultural implications and nuances of working with immigrants.

Nelson, a national certified counselor and a minority doctoral fellow of the National Board for Certified Counselors, also points out that immigrants may not voluntarily seek counseling because many have not been exposed to mental health care until reaching the United States. So, at least initially, she says, they may not consider counseling to be an acceptable service or treatment. When someone is not familiar with the mental health care process or if they question the validity of therapy, then they are not going to easily share their thoughts, concerns and fears in counseling, explains Nelson, a member of ACA.

Gutierrez and Nelson agree that to overcome some of the barriers that immigrants face in receiving mental health care, work must be done on the part of counselors to cultivate personal relationships and build trust with them. Counselors need to understand where each individual client is from and what that person’s transition to living in the United States has been like. Gutierrez also stresses that if they truly want to make a difference, counselors must enter into partnerships with immigrant populations and the communities that serve them.

Overcoming language barriers

Language is often a barrier when working with immigrant populations, and finding bilingual counselors can be a problem, according to Gutierrez. In 2009, when Gutierrez lived in Orlando, Florida, he sought his own mental health counselor but found only five who were Latinx and spoke both Spanish and English.

Gutierrez, co-founder of the annual Latinx Mental Health Summit, also points out that native Spanish speakers will sometimes use physiological terms to talk about psychological illness, which results in diagnoses being missed or lost in translation. For example, in some Latinx cultures, people may say, “My heart hurts” or “I have pain in my heart” to describe sadness.

Nelson has observed that immigrants who are experiencing anxiety also commonly describe their symptoms physiologically, such as having abdominal pains. Some clients may believe that a stomachache is purely physical and not related to mental health, she points out.

Counselors can overcome some language barriers by working with interpreters. Because of the complexity of translating mental health terms and concepts, Nelson cautions counselors to make sure they are working with qualified interpreters, not just individuals who happen to speak the language. With some clients, certain mental health terms or symptoms may not exist in their cultures, so their language may not even have a word to describe it, she adds.

Nelson invites interpreters to ask her questions to clarify and help them make sense of what they are translating. She also requests that they translate her words verbatim to the client to avoid potential misinterpretations.

Finding qualified interpreters can also be a challenge, Gutierrez points out. Nelson and Gutierrez have used interpreting agencies, hospitals and university language departments to find interpreters. Once counselors do find someone qualified, they then need to ensure that the translator will keep clients’ information confidential, Gutierrez adds. He recommends that counselors have interpreters sign confidentiality agreements. For him, the best-case scenario is working with interpreters in the helping fields (e.g., case management, nursing, health education) because they already understand the importance of client confidentiality.

There is also a danger of misinterpreting body language when working with clients from different cultures, Nelson notes. For example, whereas nodding in U.S. culture typically denotes comprehension, some clients raised in Asian cultures may nod because they are embarrassed about not fully understanding what is being communicated or don’t want to make the therapist feel bad that they don’t understand, Nelson explains.

Nelson has also had clients bring in their children to translate for them in session. When this happens, she explains to the client that even though the children may be capable of translating, the conversation may be beyond the child’s developmental age, so she would prefer working with a translator. However, some clients resist working with a translator and feel safe only when having someone inside their family unit translate their personal information. When this happens, Nelson respects the client’s preference but carefully explains the potential consequences of choosing that option.

Prioritizing family

Many immigrant populations place a high value on family, and this means that counselors should make it a priority too. “If a client has to choose between their child and being seen by [a therapist] … they always prioritize family. They always prioritize children,” Gutierrez says. “So, family cohesion is a stronger predictor of whether [immigrants] engage in services or benefit from services than [it is with] the majority culture.”

Gutierrez says counselors will be more successful engaging with immigrant populations if they offer family services, provide some form of child care, or help clients connect how their own well-being and mental health influence their children’s well-being.

Nelson agrees that counselors must find ways to incorporate the family if they are to be successful in reaching out to immigrant populations. Because child care can be a challenge for many of these clients, she suggests that counselors consider providing clients’ children with a separate room where they can color, watch movies or engage in other developmentally appropriate activities while their parents are in session. However, she acknowledges that this setup is not always possible, so counselors may have to find other ways to accommodate families.

Clients often come to see Sara Stanizai, a licensed marriage and family therapist and owner of Prospect Therapy in Long Beach, California, because they are navigating two conflicting messages: the individualist mindset widely embraced in the United States and the collectivist mindset often emphasized in their homes. Family was so central to one of Stanizai’s adult clients that the client’s mother had to speak with Stanizai before the client could work with her.

If clients come in discussing problems with their family and the therapist’s advice is to set better boundaries, this could work against the clients’ mental health and well-being because being with their family is a priority for them, Stanizai says.

Instead, she works with clients to reframe the issue with their families to find common ground. Rather than focusing on why a client is at odds with his or her parents, she helps the client think about the underlying motivations and values that they all agree on. For example, the client may agree with the parents’ desire for them to have more opportunities and to be successful, even if the client doesn’t fully agree with the parents’ high expectations or demands to get straight A’s.

Because of the stigma that often surrounds mental health within immigrant communities, some clients may not feel able to talk openly with their families about counseling. This is strange for them because they have such strong family units, Gutierrez points out. An inability to turn to their families can prevent these clients from going to counseling because they fear getting “caught,” he adds.

Thus, confidentiality becomes particularly important when working with immigrants whose communities may stigmatize counseling or whose experiences or undocumented status could prevent them from freely sharing their stories. For example, if an individual’s pastor refers the client to Nelson, she will make a point to say, “I know you came here because your pastor recommended counseling, but this does not mean that what you share here goes back to your pastor. This meeting is for you, and anything you say here will stay within this room.”

When working with clients who are immigrants, counselors should consider the individual’s overall support system, which can include family, friends, faith leaders, community elders, local organizations, medical doctors and other professional service providers, Nelson says. She reminds her clients that she is just one part of their support system. For example, if spirituality is important to a client, then she will say, “It sounds like you have great respect for your worship leader. I want you to continue to go to them while you are also coming to counseling. You have a whole host of support around you.”

“If you as a counselor [have] … tunnel vision — ‘this is me and my client’ — when working with immigrants, then it’s more than likely not going to be successful,” Nelson says. “Because if you only look at one of those resources, such as friends, [clients] are going to get a fraction of the treatment that they need.”

Partnering with the community

Gutierrez learned the value of community and partnerships when he worked as a counseling professor at the University of North Carolina at Charlotte (UNCC). Mark DeHaven, a distinguished professor in public health sciences at UNCC, taught Gutierrez about community work and connected him with Wendy Pascual, the former director of Camino Community Center, a local free clinic.

Through his partnership with Pascual, Gutierrez learned that the clinic had 85 people on a waiting list to receive mental health services. He also discovered that primary care was often a starting point for immigrants to receive services. The majority of people at the clinic had mental health issues related to depression, anxiety, stress or trauma, and these issues were often a significant driver of their physiological complaints (e.g., diabetes, high blood pressure). The physical illness was often just a symptom of a mental health concern — one that was going untreated because of a lack of qualified counselors and services.

Gutierrez worked with Pascual and a team of academics, including DeHaven, to fulfill this need and reduce mental health disparity within the immigrant Latinx community in Charlotte. Graduate counseling students at UNCC agreed to provide counseling services for the clinic, so the services remained free for the immigrant population and operated as part of the students’ counseling training.

Gutierrez notes that counselors need to enter into partnerships if they want to make a difference in immigrant communities. He stresses the word partnership. “There’s a difference between partnership and collaboration,” Gutierrez notes. “Collaborating with people in a community is OK; you do your stuff and then you go back home. But partnership [involves] … joining with people in the community and … adopting their mission and vision.”

Partnerships allow counselors to reach immigrant communities and better understand clients’ cultural values. For clients who are immigrants, it is often about the personal relationship and building confianza, or trust, Gutierrez says. But he notes that in Spanish, the word confianza goes further than just trust. “It’s confidence. It’s connection. It’s partnership. It’s someone who invites you in to break bread,” he explains.

Gutierrez cautions counselors not to assume that immigrant clients are going to come to them. Instead, he advises counselors to work within the communities they want to serve. He also recommends attending community events such as church celebrations or local festivals as a first step toward building these partnerships. By attending the annual Puerto Rican festival in Charlotte, he was able to foster relationships with individuals and learn more about what work was already being done to help immigrant communities.

Counselors should “just follow the crowd backward,” he advises. For example, they can look for people organizing food and backpack drives or voter registration efforts and connect with them because these people are the ones who are already doing great work in the community.

Partnerships have also assisted immigrants in finding Nelson, who notes that most of her clients come to see her because of referrals from religious leaders, resettlement agencies or other clients. She also agrees that immigrant families value seeing counselors out and about in their communities, including at events, festivals, fairs, their places of worship and so on.

Even so, counselors must remember to uphold their ethical obligations, such as protecting client confidentiality, during such community interactions, she notes. When a client brings Nelson a flyer for an upcoming event, she carefully weighs her ethical obligations with the needs of the client: Will attending the event harm or benefit her relationship with the client? Could it in any way interfere with the client’s treatment or the progress the client is making?

She also has conversations with the client about boundaries. They discuss how the client wants to handle this dual relationship and talk through scenarios concerning what could happen as a result of Nelson attending the event. Will the client acknowledge her (and vice versa) when they see each other? How does the client want to explain their relationship to family members and friends who may be at the event?

For Gutierrez, the faith-based community has been the biggest asset in working with immigrant populations. In churches and other spiritual communities, immigrants can typically use their own language, connect with others like them, and feel safe and heard, he explains. For this reason, Gutierrez advises counselors to work with pastors and other spiritual leaders to educate them about the benefits of professional counseling. Often, that is all practitioners need to do to increase the number of immigrants who seek counseling, he says.

Gutierrez tested the power of spirituality for immigrant communities by holding identical educational counseling courses (with the same curriculum and instructor) in a clinic and in a church. Whereas only 20-30% of immigrants completed the course at the clinic, 90% of those attending the class at the church stayed because they said they felt the class was closer to God and more aligned with their beliefs, Gutierrez says.

If clients value spirituality, counselors can integrate that into their sessions and adapt interventions to include spirituality (adhering to the competencies developed by the Association for Spiritual, Ethical and Religious Values in Counseling), Gutierrez says. For example, counselors might ask clients how they understand a situation from their own religious or spiritual perspective, or they could discuss the use and function of meditation and prayer, as appropriate, he explains.

Nelson has had immigrant clients with symptoms of depression or anxiety report that “I’m possessed by the devil because I feel this way.” Other clients have told her that in their home country, they would have been taken to church and prayed over for days or weeks for having such feelings. When this happens, she relates mental health needs to medical ones because the concept of medical health is often familiar to these clients, even if mental health is not. She asks them where they went when they had physical pain. When they respond that they went to see a doctor or a healer in their village, she compares that process to seeking a mental health professional to figure out why they feel sad or feel like something is not right with them emotionally, psychologically or socially.

Diagnosing the person, not the culture

“We’ve treated culture in counseling sometimes likes it’s a diagnosis,” Gutierrez asserts. He explains that practitioners sometimes try to adapt counseling approaches to fit specific cultures — for example, using cognitive behavior therapy (CBT) with all Latinx clients. But this method ignores the differences within cultures, he says. CBT may work well for one Latinx client, but another Latinx client may prefer psychoanalysis.

“Good cultural accommodation or adapting culturally responsive care starts with a good conversation about what the client needs and the services you provide,” Gutierrez says.

“There’s still a human being in that chair. … It’s less about the strategies you use and more about the person you’re working with … because they’re dealing with multiple layers of stress, challenges and stigmas. So, find out what their story is before making some assumptions,” he advises.

Being culturally responsive may mean adjusting the length of counseling sessions, Gutierrez notes. Even though a 50-minute clinical session is standard practice in the United States, shorter sessions may work better for some immigrants, he says. 

Likewise, Nelson says it is dangerous for counselors to quickly settle on a diagnosis without knowing the client’s overall picture. On the surface, it may look like an immigrant client is dealing with anxiety over moving to a new country, but counselors should consider everything the person has experienced in their life before, during and after migration, she explains. Past and ongoing traumas and adverse childhood experiences can shape a person’s development and can potentially lead to disruptive behaviors, PTSD, depression and anxiety, she adds.

To learn about clients’ immigration experiences, Nelson often says, “Tell me what you went through physically and mentally. What was the living situation when you were migrating, and what is it now? What kind of threats did you experience?”

Often, clients will resist answering these questions because they are not yet willing to focus on the traumatic experiences they went through, Nelson says. Many clients respond along the lines of “I don’t think about that. That’s over now. I want to focus on the here and now” or “That’s just what I had to do to get here and to get a better life.”

When clients dismiss their past experiences, Nelson respects where they’re at emotionally and cognitively and doesn’t push them to share more of their story in that moment. She admits that it is easy as a counselor to develop an unspoken agenda with clients, so she continually reminds herself that counseling is about allowing clients to tell their stories when and how they need to.

Both Gutierrez and Stanizai stress the importance of counselors educating themselves about different cultures and not placing the burden of this education on clients who are immigrants. Although multicultural training courses can be helpful, it is often equally (if not more) beneficial to learn from the community itself, Stanizai says. Gutierrez agrees that immersion is the best teacher, so he advises counselors to put themselves in settings where they are surrounded by people different from themselves.

Stanizai, who specializes in working with first-generation/bicultural Americans and runs an Adult Children of Tiger Moms support group, advises counselors to spend time reading books and watching media written for and by people in the culture they are working with. “Find a local news source, a radio station, novels or nonfiction that can educate you on not only specific topics but also cultural values and beliefs,” Stanizai says.

Cultural awareness helps counselors learn about privilege, avoid making assumptions or buying into stereotypes about groups of people, and better understand how being an immigrant within mainstream American culture can affect clients’ beliefs and mental health, Stanizai says. Most immigrants will not care whether counselors are familiar with every cultural custom, such as marriage contracts, but they will care, she says, if counselors have a surprised reaction — e.g., “What is that? That’s so different!” — to something they share about their culture.

No matter how much counselors educate themselves, they can never learn about all of their clients’ different experiences and cultures. Gutierrez finds that sometimes counselors are scared to talk about race and ethnicity out of concern about potentially making a mistake. This fear can turn into overcorrection and cause counselors not to ask important questions, he notes.

It is OK, Gutierrez says, for counselors to directly address the issue of a client’s race or ethnicity differing from that of the counselor. For example, a counselor could broach the topic by saying, “My family is Latinx. My parents came here from Cuba. You are Asian. I wonder how you feel about getting help from someone whose background is different from yours?” 

Gutierrez and Stanizai also advise counselors to take a tutorial stance when working with immigrant clients by asking questions about their unique experiences. Counselors could ask, “What was it like to grow up in your family? How much did culture play a part in your childhood? How is your family different from your best friend’s family? How is it the same?”

Counselors’ hubris can also be a barrier to working effectively with clients who are immigrants, Gutierrez warns. If counselors feel like they are going to be savior figures and fix all of the immigrant’s problems, then that mindset undercuts the progress of the client, he explains.

Stanizai agrees. “It’s easy for very well-meaning therapists to get caught up in trying to prove to their clients that they are good people,” she says. “You want to make sure that you’re not processing [clients’ stories] for your own benefit. … That’s really off-putting, and people can sense it a mile away.”

Clearing the way for immigrants

Counselors only have to sit and hear one immigrant’s story or journey to realize how resilient they are, Gutierrez notes. “I don’t give them solutions. They find them,” he says. “They’ve pulled themselves through all these difficulties and challenges, so there’s this amazing resilience in them.”

Often, the pressures and demands of life, of having to concoct strategies to get to work and home, weigh on them, so Gutierrez says he simply provides them with a safe, secure space where they don’t have to feel all of that extra pressure. “Usually I’m just clearing the way for them,” he says.

Providing this space can take many forms. One therapist Gutierrez knows often has clients sing old hymns or folk songs as a symbolic way of allowing them to recapture a piece of their soul that they may have lost during their journey. In this safe space, clients can grieve what they have lost or what worries them in their own way, Gutierrez explains.

Counselors might also consider simply sharing a cup of coffee with their clients. Gutierrez recalls one immigrant client from early in his counseling career who demonstrated his resourcefulness and taught him how to “break the rules.” The client brought Gutierrez a bag of coffee as a thank you, but Gutierrez explained that he couldn’t accept the client’s gift for ethical reasons. The client said, “Oh, so you can’t take it from me?” So, the client opened the bag, walked to the coffee machine and made two cups of coffee. The client then said, “Well, I’m going to drink a cup. We can share it together.”

This moment was a turning point for Gutierrez. Now, he often enjoys a cup of coffee with clients while they talk in session. This small gesture counters some of the hostility and challenges that immigrants face, especially in today’s environment. As Gutierrez points out, it also creates a comfortable counseling atmosphere that will help immigrant clients find peace and lets them know that “there’s room for [them] here.”



RELATED READING: See the online exclusive article “Straddling two worlds,” which explores the complex and critical issue of identity development among immigrant populations.

Also, check out Counseling Today‘s 2016 Q+A with Gutierrez, “Counseling interns get firsthand exposure to immigrant experience.”



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

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