Tag Archives: immigration

Mental health implications of undocumented immigrant status

By Laura M. Gonzalez and Nathaniel N. Ivers April 6, 2017

The phrase undocumented immigrant, or its less charitable counterpart, illegal alien, tends to cause a stir in the media. The focus is on the paperwork, the lack of permission or legal status to be in the United States. However, for counselors to work effectively with this population, it is helpful to spend some time considering the second part of that phrase: immigrant.

For a person to decide to leave all that is known, familiar and comforting behind, he or she is likely in a state of considerable duress. Among the stressors that push immigrants to leave their homes are grinding poverty and starvation, threatened or actual violence, extortion from gangs, ethnic or religious discrimination and lack of hope that their situation will improve. Whether their journey involves hiding in a container in a cargo ship, clinging to the top of a moving train or walking through difficult terrain, it is not a decision to be taken lightly. Such a journey can last for months and be extremely perilous.

A person who decides to undertake such a journey as the “best available option” is already living in a state of physical, mental and emotional deprivation. We encourage counselors to consider the challenges posed by the pervasive stressors present in the person’s home country, the possible trauma encountered on the journey and the difficulty of living in the shadows in a new land where so much is strange and unfamiliar.

We have several goals with this article. We wish to clarify terminology and definitions to generate an accurate understanding of this population, describe some of the challenges facing families with undocumented members in the United States, outline some commonly occurring mental health issues among undocumented immigrants and provide counselors with some resources and ideas about how to respond to these clients. In addition to building individual capacity to respond among counselors, we hope to inspire advocates in our profession to consider systems-level responses or ways we can promote more equitable access to the support systems that undocumented immigrants often need. We are focusing on the undocumented portion of the immigrant population because of the severity of their needs and the relative scarcity of resources to meet those needs.

In terms of definitions, immigrants are people who leave their home country to live (temporarily or permanently) in a host country. They differ from refugees, which are defined as individuals fleeing persecution, war or natural disaster. The United Nations classifies refugees as a protected group, and if a host country offers these individuals asylum, it comes with automatic legal status. Immigrants can apply to receive temporary legal status based on a special function (such as a work visa or student visa), or they may become eligible for residency through a qualified family member who is a U.S. citizen. However, there are caps on each category (i.e., not every person who wishes to come to the U.S. to work or study may do so). Deferred Action for Childhood Arrivals (more commonly known as DACA) is a temporary permission to work that does not provide true legal standing in the U.S., and it can potentially be revoked by executive action.

It is important to have a trusted source for accurate information about immigration, especially when so much inaccurate information abounds in other public sources. In particular, counselors may wish to become familiar with eligibility for health and human services for undocumented immigrants. A helpful source for this information is the National Immigration Law Center website (nilc.org), which provides details about eligibility for health care services, education, workers’ rights, driver’s licenses, economic support programs and so on.

It also is important for counselors to be aware that differences exist between federal and state immigration policies and practices. Some states have created restrictive laws to govern activities such as enrolling an undocumented child in school, presenting for services in an emergency room and applying for a driver’s license. Thus, it is incumbent upon counselors to understand the climate and laws within their states and local communities. The current policy climate is changing rapidly, so staying up to date is essential.

Common challenges

Each immigrant family with at least one undocumented member is unique, but some typical challenges do exist. For adult immigrants who are undocumented, there are daily concerns about detection by the authorities, potential deportation and separation from other family members. Even an act as simple as driving to the grocery store can be perilous without a driver’s license, so undocumented immigrants may adopt the mantra “trust no one” and try to live in the shadows, undetected. The newest guidelines from the Department of Homeland Security (dhs.gov/executive-orders-protecting-homeland) include a broader definition of priorities for deportation. This change has generated enormous fear in the immigrant community.

Many undocumented immigrants must work jobs in which they are paid as part of the underground economy. Thus, they are not able to speak out against unsafe workplace conditions or unfair or discriminatory practices for fear of retribution. These jobs often pay poverty-level wages and involve hard manual labor. Some undocumented immigrants work more than one job to make ends meet.

Adults who are undocumented are also unlikely to have access to needed services such as health, legal, educational and other social support services, so they have unmet needs in terms of physical and mental health. In addition, it is common for these adults to have experienced some form of trauma — physical or sexual assault, robbery, threats, extortion, bearing witness to murder — during their journey to the U.S., so there is an accumulation of stressors that can become quite profound.

Youth living in a family with at least one undocumented member experience some of the same stressors — concerns about deportation of a family member, poverty, lack of services, etc. But some of their concerns are different. In most cases, these youth will have access to basic K-12 education, so they often acculturate to U.S. language and culture norms more quickly than do their parents. This can be difficult in the early phases of adjustment, but it does bring some benefit in terms of language proficiency, educational opportunity and socialization.

However, when their friends start moving through rites of passage such as getting a driver’s license, landing a first job or applying to college, youth who are undocumented or who have an undocumented parent have a strikingly divergent experience. Some are already aware of their legal status, but other youth first learn about their lack of documentation when they ask their parents to assist with these normative tasks. At this point, some youth become disillusioned and depressed, believing that all of their dreams and aspirations are now beyond their reach. Without a socially sanctioned way to participate in society, these youth may become involved in maladaptive coping strategies (e.g., gang involvement, substance abuse). Other undocumented youth become more determined and start fighting to achieve their goals, even if they have to create new systems outside of the defined legal structures.

In both cases, it is unlikely that their parents will be able to provide much assistance, so undocumented youth will almost always need advocates or champions from outside of their group to assist them. It is risky to identify oneself as undocumented in today’s hostile political climate, so finding an advocate is not a straightforward process. Adults who are familiar with the signs and signals that a youth (or a youth’s family member) may be undocumented — for example, not driving, not applying to college even with a good academic record, having many absences from school that are not typical — may find ways to reach out and indirectly inquire about the youth’s circumstances or offer resources. Counselors might wish to review websites such as the Department of Education’s Resource Guide: Supporting Undocumented Youth (www2.ed.gov/about/overview/focus/supporting-undocumented-youth.pdf) and the UCLA clearinghouse of resources on undocumented youth (smhp.psych.ucla.edu/qf/undoc.html).

Using ecological systems theory 

It is important that counselors understand the singular environmental factors and societal barriers that have the potential to affect the development and mental health of undocumented youth and families. This understanding can prepare counselors to apply more effective strategies when working with undocumented clients or families.

Urie Bronfenbrenner’s ecological systems theory may be a particularly helpful tool for counselors in this regard. Bronfenbrenner’s theory describes human development in terms of interactions between individuals’ personal characteristics and their environmental systems. The five environmental systems are the microsystem, mesosystem, exosystem, macrosystem and chronosystem.

The microsystem is the most immediate environment in which an individual interacts. For children, microsystems commonly consist of a small group of people, such as parents, siblings, schoolteachers, friends and classmates. The mesosystem is the interaction between microsystems, such as the communications between parents and teachers.

The exosystem is outside of one’s direct interaction but still has the potential to impact one’s mental health and development because it directly influences members of one’s microsystem. This might include a parent’s relationship with his or her boss or co-workers, or a teacher’s relationship with his or her principal. A common example of the influence of the exosystem on someone is that of a parent who feels unappreciated and disrespected at work and then displaces that anger and frustration onto his or her children.

The macrosystem is the largest ecological system. It includes cultural values and beliefs, and political and economic systems. The chronosystem, which includes constancy and change, reflects the influence of time on one’s development.

Undocumented immigrant status can influence all aspects of a person’s ecological system. In the microsystem, immigration may affect the relationships among and between family members. The combination of fewer community and financial resources plus the need to stay obscure or in the shadows may reduce the number of microsystems that undocumented youth and families have. For example, documented youth may engage in more extracurricular activities than do undocumented youth. This expands the microsystems of documented youth to include additional people, such as teammates, music teachers and coaches.

Immigration, and particularly undocumented immigration, may also change traditionally microsystemic relationships into exosystemic relationships. For example, it is common for undocumented families to immigrate to the United States in waves, with a parent initially leaving children with extended family members. This can lead to parents becoming part of their children’s exosystem for a period of time. Later, when children are able to immigrate to the United States to reunite with their parents, the relationship rapidly shifts back to one that is microsystemic. These sudden shifts in interactions can require an adjustment period and strain the relationships between undocumented youth and their parents. Changes in microsystems can also occur as the result of other factors such as deportation.

Undocumented immigration may also influence the mesosystem, or interactions between microsystems, particularly in reference to the quality and frequency of such interactions. One example is the relationship between a child’s schoolteacher and parents. Language differences between parents and teachers can affect the strength of this relationship, which can in turn reduce the ability of undocumented parents to be fully involved in their child’s school. This can prove particularly challenging when difficult and complicated situations such as discrimination or bullying occur.

The indirect aspect of the exosystem may be particularly pronounced with undocumented youth and families. Parents who are trying to make ends meet but who are not legally allowed to work in the United States may work long hours at very low-paying jobs and experience exploitation, prejudice and discrimination. Parents who experience financial stress and fear of potential deportation may inadvertently displace their preoccupations onto their children in the form of irritation and frustration. This can negatively impact the mental health and development of these youth.

The macrosystem also may have a profound effect on mental health and development. In particular, marginalized groups such as undocumented youth and families are particularly vulnerable to economic and political trends. This is certainly true in reference to the legislation and execution of laws associated with undocumented immigration. As previously mentioned, undocumented youth who learn of their undocumented status and the barriers associated with that status in terms of securing education, employment, a driver’s license and so on may be particularly susceptible to feelings of despair, hopelessness, helplessness, anxiety and fear.

Unique factors associated with the chronosystem also may be in play with individuals and families who are undocumented. In particular, the possibility of change, such as deportation, may constantly be on the minds of undocumented youth or members of their microsystems. Changes (or a lack thereof) in immigration policies and laws may also affect the mental health of undocumented individuals. For example, in 2010, Dreamers anxiously awaited the prospect of gaining citizenship through federal legislation (known as the Dream Act). However, this legislation was met with barriers and did not pass Congress. This was a huge blow to many who were leaning on this legislation for the prospect of stability, opportunities for education and careers, and other privileges of full citizenship.

More recently, political rhetoric and actions associated with securing the U.S. border and enforcing immigration laws more strictly have created a great deal of uncertainty and fear in undocumented immigrant communities.

Strategies for working with undocumented clients 

Counselors can do a number of things to help undocumented individuals and their families. With respect to the microsystem, counselors can provide a space for undocumented youth and families to vent their frustrations, fears, mistrust and sadness associated with their experiences of discrimination, exploitation and barriers. Helping parents to express their frustrations may reduce the chances of them displacing anger and frustration onto other members of the family unit. Counselors can also help parents problem-solve and cope with challenging aspects of their lives, such as dealing with disrespectful co-workers or prejudicial bosses. In addition, counselors can help parents prepare for worst-case scenarios, such as steps they could take in the event that one or both parents were detained or deported.

Concerning the mesosystem, counselors can help youth and families develop their relationships with other microsystems, such as teachers and other school personnel. In particular, it is important for counselors to help undocumented youth and parents brainstorm ways to respond to school personnel about school issues such as academic struggles, behavioral challenges, discrimination and bullying. With clients’ permission, counselors working with undocumented youth and families may also consider taking on an advocacy role with school systems, particularly when discrimination and unresolved bullying are occurring.

With respect to the macrosystem, counselors may consider advocating for changes in the law regarding illegal immigration. This may include advocating for pathways to citizenship, better access to community resources and so on. It also may take the form of advocating against movements or legislation that would be harmful to undocumented youth and their families.

Counselors can also help youth and families draw upon and cultivate resilience. This may take the form of helping clients to remember the struggles and obstacles they have already been through and rediscover the strengths they possess that have helped them navigate these trials.

Case study

The following is a brief case study of a counseling experience that one of the article authors had with an undocumented family. Specific names and circumstances have been changed to protect the family’s identity. Many of the details of this case are common experiences that undocumented families face.


Marcus, an undocumented immigrant who is 14 and speaks Spanish, was referred to you by the school social worker. Marcus attends the first session with his 45-year-old mother, Elizabeth, who also speaks Spanish and is undocumented. Elizabeth shares with you that she immigrated alone to the United States 10 years ago. Because of financial difficulties, she had to leave Marcus with her parents in her country of origin. A few months before this first session, Marcus was able to join his mother in the U.S. Elizabeth shares that Marcus refuses to call her “mom” and acts very standoffish toward her.

Marcus shares that he doesn’t know why he had to come to the United States. He says that he was happy in his country of origin and misses his friends, grandparents and cousins. He also says that he doesn’t like school, that English is difficult for him to learn and that students at the school pick on him. He says he can understand the names the other kids call him and the mean things they say. He doesn’t have enough command of English to fight back with his words, however, so he uses his fists. Marcus has used his fists to fend off verbal attacks a number of times and, on each occasion, he has been suspended from school.


In this case example, Marcus’ microsystem changed suddenly. He was uprooted from the only life he had known, where he had friends and close connections to extended family. Using Bronfenbrenner’s model as a reference, we see that Marcus was separated from his ecological system — a system in which he knew the explicit and implicit cultural beliefs, values and rules and interacted with people who looked like him and shared his language. His microsystem changed from that of friends, grandparents, uncles, aunts and cousins to that of his mother and a schoolteacher.

Furthermore, Marcus’ mother, who for many years had been part of his exosystem — someone who influenced his life indirectly but didn’t interact with him outside of an occasional phone call and letter — became his primary microsystem. Elizabeth, who missed her son dearly and felt guilty for not being there to raise him, wanted desperately to pick up where they had left off before she immigrated to the United States. Marcus was not able to reciprocate her feelings, which hurt Elizabeth deeply.

Although Elizabeth had lived in the United States for a decade, she had interacted primarily with other Spanish speakers and largely remained in the shadows to avoid detection. Therefore, she struggled to communicate with school personnel at Marcus’ school and did not know how to help her son deal with the bullying that he experienced.

The counselor should take into account a number of factors when conceptualizing and treating this family. Systemically, it is important to recognize the changes (chronosystem) that have occurred in the lives of both Elizabeth and Marcus and how they are adjusting to those changes. The counselor might help Elizabeth recognize the adjustments that Marcus is experiencing and assist her in developing realistic expectations regarding their relationship. It also would be beneficial to further assess her relationship and interactions with Marcus’ school (mesosystem) and co-construct strategies to help her figure out what is going on in school and how to advocate for her son. The counselor also might consider ways that he or she can advocate appropriately on behalf of the family.

The counselor also might assess Marcus’ exosystem by understanding the stressors that Elizabeth faces in her daily life. These include working multiple jobs, experiencing pressure from family members in her country of origin to help out financially and dealing with ongoing fears of deportation. If Elizabeth is facing a great deal of stress and anxiety, the counselor could take care to validate Elizabeth’s emotions and provide her with stress-reduction tools.

The counselor can work with Marcus to develop healthy strategies for dealing with the verbal abuse he reports experiencing at school. The counselor also might work to broaden Marcus’ microsystem by looking into community programs in which Marcus might be interested, including sports programs, after-school programs or a mentorship program.

Conclusion and resources

Seemingly insurmountable barriers exist for undocumented children and families, but counselors can take a number of steps to facilitate the mental health of these clients. It can be particularly helpful to conceptualize undocumented families’ circumstances from a systemic perspective, such as Bronfenbrenner’s ecological systems theory. It also is helpful to validate clients’ experiences while drawing upon their resources, including the resilience and skills they have used to overcome past trials and struggles.

Finally, it is important for counselors to be aware of the resources that exist to help undocumented families. The following resources will get you started.

In addition, we recommend the following books for those who wish to deepen their personal understanding of the narratives of undocumented immigrants:

  • Enrique’s Journey: The Story of a Boy’s Dangerous Odyssey to Reunite With His Mother by Sonia Nazario
  • Underground America: Narratives of Undocumented Lives compiled and edited by Peter Orner




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

Laura M. Gonzalez is an associate professor in the School of Education at the University of North Carolina at Greensboro, having received a Ph.D. in counselor education from North Carolina State University and an M.Ed. in college counseling from the University of Delaware. In addition, she has conducted research and outreach to the Latino immigrant community with the goal of enhancing educational access. Contact her at lmgonza2@uncg.edu.

Nathaniel N. Ivers is an assistant professor in the Department of Counseling at Wake Forest University. He received his master’s in counseling from Wake Forest University and a Ph.D. in counseling and counselor education from the University of North Carolina at Greensboro. He has published research and conceptual papers related to Latino immigrants and has provided counseling to the Spanish-speaking immigrant population in North Carolina. Contact him at iversnn@wfu.edu.

Letters to the editor: ct@counseling.org




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.

Counseling interns get firsthand exposure to immigrant experience

By Bethany Bray September 26, 2016

An innovative partnership in North Carolina is pairing counseling graduate students from the University of North Carolina at Charlotte with clients of a free medical clinic nearby. Many of these clients are recent immigrants.

According to those involved with the effort, the partnership provides the student interns with a chance to hone their counseling skills while also offering them a firsthand lesson in advocacy and social justice issues.

The Bethesda Health Center (BHC) provides free primary care, diabetes and hypertension management, and health education for low-income and uninsured residents of Charlotte and the surrounding county. The UNC Charlotte counseling interns offer mental health care alongside these physical health services.

The partnership provides much-needed care to minority populations who are, statistically, the least likely to seek or access mental health services, says Daniel Gutierrez, an assistant professor of counseling at UNC Charlotte, as well as a licensed professional counselor, licensed mental health counselor and member of the American Counseling Association.

It has also provided counseling students with some valuable learning that transcends the typical textbook lessons, says Katherine Wilkin, an ACA member and clinical mental health counseling student at UNC Charlotte. Wilkin, who was born in Venezuela, is able to offer counseling to BHC clients in Spanish and English.

The experience has opened Wilkin’s eyes to the cultural factors that often increase risks for mental health struggles, including the stress of navigating a language barrier and acculturation to a new location.

“My experience at Bethesda Health Clinic has enriched my training and has strengthened my passion for providing mental health services to the Hispanic population in their native language of Spanish,” Wilkin says. “… This program exposes counselors and students to a diverse population with unique issues. The [U.S.’s] growing Hispanic population calls for mental health professionals to be sensitive and aware of the cultural considerations when working with this population.”

UNC Charlotte’s work at BHC was highlighted recently by National Public Radio (NPR). CT Online reached out to Gutierrez for a Q+A to find out more.


CT: In your own words, how does this program meet a need?

DG: Latinos are the fastest-growing and largest minority in the U.S., and they experience mental health disorders at the same rate — some argue at higher rates — as the majority culture. Yet, when compared to the majority culture, they are the least likely to access mental health treatment. They, on average, receive a lower quality of care and end up presenting with more severe symptoms.

There is no doubt that there is a great need for effective and accessible mental health care for this population. However, there are numerous barriers that keep Latinos from accessing mental health treatment, such as language difficulties, a lack of appropriately trained mental health workers, stigma and an overall difficulty trusting providers.

On the other hand, counselor educators everywhere preach the importance of teaching our students to work with underserved and vulnerable populations, but we don’t always have the opportunity to give our students quality learning experiences doing this work. This program meets two needs: a) it creates access to appropriate mental health services for an underserved population; and b) it creates a diverse and dynamic learning experience for our students.


What have you learned from this program?

I don’t think you have enough room [in this article] to describe what I’ve learned. I learned how complicated it is to set up a program like this. I learned the importance of doing work with the I_learnedcommunity and not just in the community. This program has also reaffirmed my belief that understanding people is more important than understanding illness.



Talk about the logistics of how this program came together. What did it take to get started?

First off, the real credit goes to people like Wendy Mateo, the executive director of the Bethesda Health Center. Before all the publicity from NPR, and with limited resources and under some very challenging circumstances, Wendy was wholeheartedly serving the Latino community by providing medical care and chronic health management to the low-income and uninsured immigrant families in Charlotte. She does an amazing job and is an inspiration to helpers everywhere.

When we met with Wendy, she expressed that although they were making considerable strides in improving the physical health of Latinos in Charlotte, there was a great need for mental health services for their patients. We quickly realized that serving at a clinic that helps the underserved in Charlotte would be an amazing opportunity for our counseling students, and that our counseling students could provide the services that Bethesda truly needed. So, we brought together a team of faculty from different departments and began conversations about building counseling capacity at this free clinic.

We began by first evaluating the mental health needs for the current patients. We conducted chart reviews, spoke with staff at Bethesda and began to develop an understanding of what kind of mental health needs they were facing. We then had a series of meetings evaluating space needs; developing the right type of forms; discussing issues related to supervision, ethics, confidentiality, HIPPA compliance, how to manage interpreters; and examining the whole process for providing services.

I think we were all very aware that starting this program had many moving parts and that it wasn’t going to be as easy as just putting two chairs in a corner and assigning clients to students. It was a long and complex process, if we were going to do this right. These clients are already underserved by the community and are statistically more likely to receive substandard quality of care. It was important that we gave them the best care we could and that our students were going to have a positive experience.

After establishing a format and structure for the services, we recruited two doctoral-level counseling students who were licensed professional counselors to begin seeing clients. We called this our pilot study. We evaluated the progress of these initial students and used this data to inform the placement of master’s students. That following semester, we began placing master’s counseling students in their internships and practicums at the site. Thus far, the clients and the students both consider this program a great success.


Based on your experience, what advice would you give to counselors who might want to get involved in something similar in their local area?

One of the key members of our team, Mark DeHaven, is known for saying, “Collaboration is good, but partnership is better.” Too often we try to collaborate with community sites because they are great places to get data or place students, and that has merit. However, when you partner with a community agency, you begin to share responsibility and work together toward common goals, and that’s a whole other wonderfully beautiful thing.

I invite those who want to start these kinds of programs to begin by building strong community partnerships. It is complicated and sometimes cumbersome to partner with community agencies, but it has to be less about you and your agenda, and more about the needs of the people you are serving.

It’s also important that you develop a strong team of like-minded people [who are] willing to not just talk the talk but also walk the walk. I am lucky to work along some great and passionate people from different departments. Our team consists of Edward Wierzalis, a fellow Department of Counseling faculty member and the UNCC counseling program clinical coordinator; Mark DeHaven, a distinguished professor in public health science; Roger Suclupe, a lecturer from social work; Amy Peterman, an associate professor and director of clinical training in the Health Psychology Department; and a counseling Ph.D. student, Carolina Benitez.

This team made this project come together. So, my second piece of advice for future counselors is to build a good team.


The NPR piece says this came about because you were “looking to get more involved in the community.” Can you elaborate? Why is that important to you?

Well, I think this is probably a pretty personal question. I think everyone on our team serves in the community for different reasons. For me, I am driven by the spiritual ideas of welcoming the stranger, reaching out to those deemed the least and doing justice. I was also mentored by people who continually stated that in a world with so many health disparities, economic disparities and so much need, counselor educators should strive to go beyond mere talk and do impactful work.

After the NPR story went national, the first words from my mentor’s mouth were, “Some people got help — and that is the important thing.” I hang that email by my desk at work because it keeps me focused. Those of us with counseling training are equipped to do good in this world. Doing nothing seems like a mistake to me.


What type of nontextbook lessons have you seen your students learning?

Probably what I’ve enjoyed the most about this process is the surprising reactions I’ve seen from students. Our program has an emphasis on multiculturalism and diversity, so the students are well-versed in textbook knowledge. However, the internship experience [at BHC] offeredtears_in_eyes them a real quality experience working with a population that was culturally different from their own.

I have had students come to me during their experience and sit in my office with tears in their eyes, and say things like “I just didn’t know” and “I love working with these people.” I think it raised student awareness to some of the struggles Latino immigrants face, such as having to cope with the traumas they experienced before entering the U.S., the stress and anxiety of leaving loved ones behind, and trying to care for family with limited resources. They also expressed new levels of multicultural awareness and realized that there was much they had taken for granted, such as the ability to speak the same language as their clients.

At the end of the most recent semester, we had students describe their experiences, and most stated that what [they had] learned most form the program was “working with people who are culturally different from you,” “understanding that most Latinos are very different and come from different countries, even though they are all labeled as Latino” and “learning the challenges of working with translators and the importance of tuning into body language.” Students also stated that this site [BHC] provided them with experiences that many of the other sites could not.


What do you want counselors to know about this program and your experience with it?

I would want my colleagues across the country to know one thing: This is worth doing. Latinos and other racial ethnic minorities are not receiving services at the same rates as the majority population. There is a need for helping professionals willing to reach out to our communities.

This kind of work might be complicated to set up and require more energy than you want to expend, but it’s good work and it is worth doing. It’s a great experience for the students and the community. It’s not simple work; you will most likely make a lot of mistakes getting this kind of a program off the ground – I know we did – but it is so much better to dance and miss a few steps than to never dance at all.




From NPR: “Students Fill a Gap in Mental Health Care for Immigrants

Find out more about the Bethesda Health Center at caminocommunitycenter.org


Contact Daniel Gutierrez at DGutierrez@uncc.edu




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


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




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.

Counseling and Russian culture

By Anton Ivanov and Clifton Mitchell April 27, 2016

In Russia, counseling is often not considered a substantial profession. Unfortunately, the same is true for any country that used to be a part of the USSR. A very limited number of nonmedical-model counseling centers exist, particularly in rural parts of the country. The sad truth, however, is that most Branding-Images_Russiaof the Russian population doesn’t even know about such services.

Anton Ivanov (this article’s first author) grew up in Russia. After five years in the United States, and as a second-year student in a counseling program, he has become acutely aware of the substantial contrasts between the two countries when it comes to their perspective and practice of counseling. He has a desire to educate American counselors about his country and people.

Historical context: Residue of the Soviet regime

To grasp fully the mentality of the Russian people regarding counseling, one needs to look deep into the country’s history. In the Soviet era (1922–1991), counseling and psychological services were either not available or were rejected by the government and people. Thus, such services were extremely rare. Lacking counseling services, Russians with mental health problems or drug and alcohol addictions were historically treated by medical doctors through the use of medications.

Sigmund Freud’s works were translated into Russian during the Soviet era and were one of the few sources of learning about psychotherapy for Soviet therapists. However, his works were soon forbidden, as were many works of other Western practitioners. For those seeking a more thorough review of the history and current development of counseling in Russia, we suggest reading Christine L. Currie, Marina V. Kuzmina and Ruslan I. Nadyuk’s article, “The Counseling Profession in Russia: Historical Roots, Current Trends and Future Perspectives,” in the October 2012 Journal of Counseling & Development.

Historically, people diagnosed with severe mental health issues in Russia were often sent to medically oriented psychiatric hospitals where confidentiality rights were not generally considered. When records were disclosed, citizens were often stigmatized and disgraced, which limited their opportunities for employment and minimized their chances of living a life without scrutiny. In many Russian communities, simply mentioning that parents were seeking mental health services for their children or themselves could have negative consequences. When such information became public knowledge, families’ reputations were jeopardized, and they were often stigmatized as “dysfunctional.” Unfortunately, these attitudes remain prevalent today.

Further compounding the stigma, the government used psychiatry as a tool to suppress ideas that were different from the accepted ideology by labeling rebels as “mentally unstable.” Because the specter of mental health problems were used to dissuade dissent, terms such as psychology, psychiatry and psychotherapy came to arouse fear among the population.

To complicate matters further, the idea that social or environmental factors could cause certain mental health issues was strictly rejected; the only allowed stance was that all psychiatric disorders had a biological cause. As a result, people suffering from psychological issues often minimized their symptoms in an effort not to see a doctor. When Russian people are sick, they often quip that “the issue will disappear by itself” or “it is already too late to treat the issue; it is incurable.”

Throughout Russian history, its people have commonly sought counseling and psychological help from “healers” who are believed to possess “good” energy, holy powers, skills to fix people’s issues and the ability to foresee events. Healers often prescribe herbs that are believed to be helpful. Russians also practice balneotherapy, take mud baths and schedule spa visits to reduce their stress levels and treat physiological issues. Most Russians rarely see a doctor about their mental health issues. Instead, many Russians prefer to talk about their problems with their friends in the kitchen while sharing a bottle of vodka.

Both historically and today, Russians respect and trust the army, the church and the national leader. In times of crisis, the Russian people have been inspired and united through the hope that they place in their leaders and the church. People still rely on the Russian Orthodox Church to “solve” their issues. People go to the church to have all their questions answered by priests and in hopes of magically ridding themselves of their mental health issues by either drinking holy water or attending public worship. Russians view priests as authority figures and trust them much more so than they do mental health therapists. Unfortunately, priests have little or no training in counseling and rely on their own knowledge to assist people who are dealing with mental health issues.

Counseling challenges and concerns

Russians’ mental health problems are similar to those found in other countries, but these problems are exacerbated by deeply ingrained political policies and social attitudes that are coupled with severe socioeconomic hardship. High rates of depression, anxiety, drug and alcohol use, eating disorders, divorce, suicide and unemployment are all present. Other lifestyle factors contribute to high rates of cancer and AIDS, leading to a decline in the average life expectancy. Racism, local and international wars, and religious discrimination further add to the stress. In a country where much of the population lives below the poverty level, it appears little might be done to thwart the high levels of depression and apathy. Recent economic sanctions have intensified these problems.

In Russian culture, many men view marriage as a loss of freedom, whereas women generally see marriage as a significant step toward a happy life. Women are often viewed as an inferior gender that prefers dependency and dreams only of having a family, whereas men conduct themselves assertively and prefer independence. Many male children are raised in Spartan conditions under which displays of emotion and the questioning of parents are rarely allowed. Unfortunately, acting in an aggressive manner is too often reinforced. These factors, in combination, have resulted in high rates of domestic violence and an overall hostile culture throughout Russia, making family counseling an urgent need.

Although sexuality is widely discussed among Russians, parents, teachers and priests are skeptical about sex education and hesitate to utilize it. Unplanned pregnancies have resulted in high abortion rates. In a 2001 article in the Canadian Medical Association Journal, Barbara Sibbald noted that Russian women had six abortions on average during their lifetimes. The prevalence of unplanned pregnancies has also resulted in overflowing orphanages that house abandoned children and those taken away from their parents because of drug and alcohol addiction. Understandably, a substantial need exists for access to birth control, sex education, family counseling services and drug and alcohol treatment.

Current status and foundational needs

Generally speaking, counseling in Russia is decades behind the United States in terms of acceptance, education and theoretical development. Yet, as Currie, Kuzmina and Nadyuk noted, counseling has been recognized as a branch of social work and is starting to gain a presence in Russia. Still, counselor education programs such as those commonly found in U.S. colleges are extremely rare in Russia. Counseling is still several steps away from becoming a viable profession in Russia, and various issues need to be addressed before it is viewed as a legitimate, functioning entity.

For instance, the requirements for training and certification vary across the country and are not established or consistently regulated by any governing body. Unfortunately, this has resulted in numerous charlatans and unqualified practitioners claiming to provide “counseling.” Currently, very few facilities consider offering practicums or internships to students. This leaves many beginning counselors poorly prepared for real-life practice. In addition, outstanding students with college degrees are offered no assurance of employment unless they have the aid of social and administrative connections. In addition, the low income of counselors does not attract many students to the field.

After an American Counseling Association delegation visited Russia in 2006, a Counseling Today article reported that Russian counselors were prone to learning one theory and using it exclusively. There appears to be a limited amount of training across theories. Thus, the idea of counselors adapting approaches to the client’s individual personality and problems is not commonly practiced. It is apparent that expanded training in a wider array of approaches is strongly needed.

In a country where corruption is too often the norm and where ethical codes are not viewed as essential, adherence to the strict ethical standards present in the United States is not emphasized. In her article, Sibbald noted that sexual relationships between medical practitioners and clients are common, and ethical standards regarding such relationships are not enforced. In particular because of Russians’ historical distrust of mental health services, it is essential that formal ethical guidelines be established, taught and monitored. Until the Russian public learns to trust that its counselors will protect confidentiality, mental health services will not gain a foothold in Russia.

Potential counseling needs of Russian immigrants 

Many Russian immigrants would benefit from the counseling services offered in the United States, but counselors who underestimate the significance of cultural differences could inhibit the process. In a chapter in the 2004 book Culturally Competent Practice With Immigrant and Refugee Children and Families, Tamar Green described some of the primary psychological challenges that Russians encounter when coming to the United States. These challenges include cultural shock, which involves transitioning from a socialistic to a capitalistic society and from a nonreligious or Russian Orthodox atmosphere to the American spiritual environment. In addition, immigrants must manage language barriers, unemployment, basic shopping knowledge, navigation of the medical system, loneliness and isolation.

Although children adapt to the American environment faster, they still experience issues such as feeling neglected by parents, getting help with schoolwork and not feeling protected in a new environment. When going through the adjustment process, these youth can be psychologically traumatized. Green noted that they are searching for their new selves in an environment in which they have distinctly different names and accents. In addition, they are struggling to find new friends, striving to match American clothing styles and trying to develop new hobbies and interests, all of which are quite different from what they knew back home in Russia. At the same time, Russian parents adapting to this new environment are equally overwhelmed and cannot attend to children as much as they might wish. Yet, by virtue of possessing strong and persistent survival skills, Russians have learned to preserve their culture and identity while managing change and settling in other countries.

Russians usually view doctors as authority figures and readily hand their problems over to them. Similarly, if Russian clients decide to try counseling, they may expect the counselor to take responsibility for their problems and are likely to follow the counselor’s advice without question. Because of these characteristics, person-centered approaches to counseling are not likely to be suitable for these clients.

In addition, because of the harsh nature of Russian culture, empathy is not readily understood by most Russians. Olga Bondarenko, an associate professor of psychology at Nizhni Novgorod State University in Russia, points out in an article that Russians frequently mistake empathy in therapy for sympathy or pity, which is less acceptable to them (see bit.ly/23eZEZj). For this reason, directive techniques are much more suitable.

It might also be noted that Russian culture tends to be very philosophical, and Russians like to approach problems from philosophical perspectives. Existential approaches in counseling might best accommodate this cultural feature.

Another feature of Russian culture is a reluctance to wait. Hence, pacing in counseling can become a challenge because Russians expect immediate results. In addition, many immigrants simply cannot afford long-term treatment because of financial constraints. Likewise, the mindset of many Russians is that money should be invested in something tangible, such as electronics, clothes, cars or houses. Investing in counseling will likely seem foreign and even useless to them because of their inability to grasp its benefits and see the results immediately. Counselors will need to explain to Russian immigrants that counseling in the United States is a slower, more deliberate process.

Russian culture is communistic and collectivistic, and because a large percentage of the population lives in extended households, family is likely to be an integral part of these clients’ lives. In Russian schools and institutions, children are called by their last names, thus further promoting the ideology
that family comes first. In stark contrast to American culture, the familial emphasis of Russian culture strongly limits the idea of individuality, if not eliminating it altogether. Counselors should remain cognizant of this when attempting to construct problem solutions for Russian clients.

To better understand these clients, practitioners should bear in mind that Russians may appear to be grumpy, closed, secretive, suspicious, quiet, anxious and rather shy because they have often lived in a state of uncertainty. Many elders were traumatized by the division of the Soviet Union, which resulted in a loss of country, land, currency, political leaders and, most important, identity. It is not uncommon to encounter Russian elders who still hope and dream of one day again living in a socialistic society similar to the former USSR.

Because of a lack of experience with and understanding about counseling, counseling interventions remain novel to most Russian immigrants. If they were court ordered to attend counseling, they would likely find the process strange and present as exceptionally skeptical about its helpfulness. In addition, historical cultural attitudes toward mental health services may be ingrained in these clients, which might make them seem resistant to the process. Counselors should be aware of and prepared to manage this aspect of counseling Russians.

Similar to other cultures, Russians like to criticize and complain about the opposing mindsets and attitudes they encounter in other Russians and the Russian government. Incongruously, counselors may discover that some Russian immigrants are not close to or do not speak positively of other Russian immigrants. If such sentiments arise in counseling sessions, however, counselors should be careful in aligning with these perspectives in an effort to join with the client. Ironically, Russian immigrants might feel offended and disrespected by an American counselor who aligns with a negative attitude toward Russians and their motherland.

Overwhelming contrasts

To comprehend the essence of Russian culture and meet Russians’ counseling needs, one must understand the country’s history and the unique features of its people. This article was written to provide a glimpse into this often misunderstood world.

Being in the United States for five years has given me (Anton) an increased understanding of the usefulness of counseling and its eventual benefits for Russians. Being in a counseling program has intensified my desire to see the counseling field grow in Russia and be used by Russian immigrants. I believe that some information described in this article may also be applicable when working with immigrants from the countries of the former USSR or other Russian-speaking immigrants.

Yet counselors in the United States need to understand that counseling is foreign to most Russians. It is not something that meets the needs of those who come from or exist in a society in which the primary focus is survival, not personal growth. It is our hope that counseling services will progress in Russia and that through an understanding of Russian culture, counselors in this country will be better prepared to educate and counsel Russians.




Anton Ivanov is from Orel, Russia, and is a second-year student in the clinical mental health counseling program at East Tennessee State University (ETSU). He hopes to seek residence in the United States, promote awareness of Russian culture among Americans and help Russian immigrants acclimate to American culture. Contact him at ivanova@goldmail.etsu.edu.

Clifton Mitchell is professor emeritus at ETSU and author of Effective Techniques for Dealing With Highly Resistant Clients. He travels the country giving seminars on the management of resistance in therapy and providing legal and ethical training in a game-show format. Contact him at cliftmitch@comcast.net, and visit his website at cliftonmitchell.com.


Letters to the editor: ct@counseling.org


Immigration’s growing impact on counseling

By Laurie Meyers January 27, 2016

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

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

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

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

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

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

Strange new world

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Communicate to advocate

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

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

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

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

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

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

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

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

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

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

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

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

Connecting with the community

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

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

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

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

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

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

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

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

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

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

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

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

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

Undocumented and disadvantaged

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

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

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

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

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

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

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

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

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

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

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

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

Working toward the future

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

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

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

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

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

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

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

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

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

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

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

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




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




Additional resources

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

Books (counseling.org/bookstore)

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

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

From ACA’s trauma webinar series:

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




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

Letters to the editorct@counseling.org

Voices unheard

By Krystle Dorsey August 14, 2013

Photo: Flickr/ FrauSchütze

Photo: Flickr/ FrauSchütze

There’s this guy I know, let’s call him “Javier.” When he was 15, he had a life in Peru that he was not willing to leave. In Peru, Javier was surrounded by his family and friends. He was part of a community that spoke the same language he did and shared his values. Nonetheless, Javier’s mother felt her family could achieve more in the United States. She left for this country and then moved Javier here a year later. Javier had to say goodbye to his homeland where he was perfectly happy and come to a country that made him feel alone.

His loneliness was the result of a weekly, sometimes even daily, routine on his way to attend his American high school. He prepared himself to fight if one of the White kids randomly pushed him again in the hallway, despite Javier minding his own business. It could be the skinny one who had called him a “spic” the day before while he was waiting in the lunch line. Then again, Javier wouldn’t be surprised if he ended up having to fight the curly-haired kid who stood in front of his classroom doorway the week before and said, “Go back to where you came from. You don’t belong here.” He responded to the ignorance of these kids with his fists because he could not speak enough English to respond verbally. These situations, in addition to his loneliness, made Javier hate life here in America and everything associated with it. He wanted to go home.

Eventually, however, he made it through. Despite his resistance to American culture in the beginning, a final encounter with the law made it too risky for Javier to use his fists to communicate his anger and frustration any longer. He loved his mom, and he knew she wanted him safe in the United States. He got a night shift after school washing dishes to renew a green card his mother could not afford for him. Through soccer, he made more and more friends with whom he felt comfortable practicing English. He finished high school, continued to work other jobs and even took a couple of college classes. Today, he has a life he loves.

We go through life every day speaking the language of our environments. Sometimes we notice who isn’t speaking; a lot of times we don’t. Even when we do notice who isn’t speaking, we rarely consider the reasons why. We’re quick to say they are shy or simply not talkative. Some of us even think they’re dumb, lazy or lack the desire to speak our language. There are those who are even frustrated with these individuals’ accents; there are others who make fun of it.

Javier is a friend of mine. When we first got to know each other, I would listen to his stories about how hard it was for him to adapt to the United States, and I would wonder how he could have received more help. I wondered if there was truly something more that could have been done. What happened to Javier happened about 15 years ago. Although he’s all right now, I wonder about the many other immigrant and international students who slip through the cracks each day in cities all over the United States, especially in predominantly Caucasian, English-speaking communities.

Various social movements in the United States have made most Americans more aware and accepting of cultural differences. The consideration of these differences and how they can be used to better serve members of various cultural groups is called “multiculturalism” within helping professions such as counseling and social work. Multiculturalism traditionally comprises race, ethnicity, gender and religion. It has provided great insight to individuals in workplaces and schools about how people of different racial, ethnic and religious backgrounds have different values and needs in these environments. Nonetheless, other facets of diversity go relatively ignored within the scope of culturally competent services or social justice. Language is one of these topics.

Language is a social skill. Proficiency in a new language requires one to use it often and in different social contexts. In addition, one must receive the encouragement and possess the confidence to take risks without fear or worry of ridicule from others. Unfortunately, this may not always be available for immigrant youth in grade school such as Javier or for international students at colleges and universities. Although one might make the effort to acquire English through formal education, this is not always enough. For example, Javier was placed in English as a second language (ESL) classes when he arrived in the United States and stayed in them until he graduated high school, but he did not feel comfortable speaking the language until he found friends who would not make fun of him.

Language barriers experienced by immigrants and international students exacerbate normal challenges typical to most individuals when adjusting to a new environment, including homesickness and the inability or lack of opportunity to make new friends in the United States. I’m sure you’re thinking, “Isn’t that obvious?” but the connection between acknowledging what makes sense and putting prevention or intervention programs into action may not always be on the priority list for policy makers and school administrators. Some multicultural researchers have thus tried to shed some light on the language difficulties faced by immigrant youth in the United States so communities will be aware of specific risks that need to be addressed.

For example, Christine J. Yeh, a researcher on Asian immigrant cultural adjustment for the National Institute of Mental Health, and Marc Atkins, a leading researcher at the University of Illinois at Chicago on mental health services for grade school students, observed in 2008 the problems Chinese immigrant youth have with expressing themselves adequately in English. These researchers conducted intense focus groups with immigrant youth and were able to provide reasons why language difficulties made pursuing friendships an additional challenge. These students had pressing family, school and work responsibilities that gave them little time for social interactions that would help them improve their English skills. Furthermore, their decreased opportunities for practice made them particularly uncomfortable in social situations. Although seemingly commonsense information, these types of studies are important to educators and others who advocate for these students. The concrete, scientific reasons behind how language barriers inhibit bright students from doing well shows policy makers why these students need additional services — for example, special social interaction groups during the school day, which they are more likely able to attend versus afterschool programs.

Furthermore, providing scientific research allows advocates to show just how serious the consequences of language difficulties can be. Senel Poyrazli and Kamini Grahame, two researchers at Penn State Capital College who specialize in immigrant and international student experiences, found in 2008 that the lack of opportunity to meet new people left international students of various racial and ethnic backgrounds feeling socially isolated. These students were at particular risk for depression and anxiety. Strong proof for why social isolation was a serious concern for these students allowed these researchers to suggest meaningful solutions to university officials and others who familiarized themselves with the study. Thanks to these researchers, and those like them, we now know that increasing social support for immigrant students with low English proficiency can be the make-or-break factor in salvaging their overall educational experience and healthy development.

For example, I have another friend named “Ines” who emigrated from the Dominican Republic to the United States during her childhood, similar to Javier. However, Ines moved with her entire family to a predominantly Hispanic community. She was supported not only by her family, but also by an abundance of friends, teachers and members of a strong church community who spoke her native language. Ines had a completely positive experience as a Hispanic immigrant youth in the United States. Javier and Ines have nearly the same strong level of English proficiency today, but very different experiences to achieve it.

With the growing globalization of the world, language will become increasingly important in our environments. Group counseling literature with a linguistic focus shows that group interventions can be an important tool in helping immigrant and international students develop a bicultural/linguistic identity. With a broader view of multicultural competence, the human services and education fields will expand to serve populations in great need of their services, along with the help of others who are willing to advocate for them.




Krystle Dorsey earned her Master of Education in Counseling and Development from George Mason University. She currently works for the university’s college access program. Krystle advocates for the educational success, leadership potential, and career development of at-risk youth. Contact her at kdorsey757@gmail.com.