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Addressing the invisibility of Arab American issues in higher education

By Souzan Naser February 5, 2021

COVID-19 has wreaked havoc in just about everyone’s life, and it is not lost on me that individuals are deeply feeling the cost of this pandemic. Too many people are grieving the loss of loved ones, recovering from their own illnesses, suffering from food and housing insecurity, and coping with depression, anxiety and isolation. As we begin to settle in with a new presidential administration, we can begin to have a glimmer of hope that our country will take a more aggressive approach to managing the spread and treatment of COVID-19.

For me, the impact of the pandemic has been less severe, and I feel especially fortunate. I was reaching the midpoint of my sabbatical when the virus took hold and shelter-in-place orders were issued. Like many of those reading this article, I was scheduled to attend the April 2020 American Counseling Association Conference in San Diego, and I was thrilled to have been given the opportunity to present and facilitate a workshop. My presentation, adapted from my doctoral research, was to examine the paucity of Arab American cultural competency training available for college counseling professionals. I also planned to unpack the contemporary needs of Arab American students, their expectations when meeting with a counselor, and the factors that increase their likelihood of engaging with a mental health provider. I am passionate about this research, especially given the lack of adequate mental health services for Arab American students and how this affects their success.

In this piece, my aim is to amplify the micro-level personal concerns of Arab American students who participated in focus group sessions that I led, those whom I counsel and teach, and those more broadly who live in the Arab American community of Chicagoland (Chicago proper and its adjoining suburbs). I will also provide recommendations, based on feedback from students, so that we can keep pace with the contemporary challenges of this population and confidently assist them when they call on us for support while experiencing psychological distress.

Study background

Since 2015, I have been studying the preparedness of community college counselors to effectively engage with Arab American college students. Pre- and post-tests were used to assess counselors’ levels of cultural competency with Arab students. The post-tests were administered after counselors participated in a 90-minute professional development program called Understanding the Arab American College Student.

My study also included Arab American college students, who through a series of focus group sessions offered a rich critique of how the political landscape shapes their experiences and identities. The information they shared also captured the essence of who they are culturally, socially and religiously, and how they navigate their identities at home and school. They also shared the importance of having mental health practitioners who understand their worldview and can be turned to for support.

Background on Arab Americans

Arab American identities are vast and complex, and the Arab American students with whom counselors interact in their offices are just as diverse as the 22 countries these students emigrated from or have ancestral ties to: Algeria, Bahrain, Comoros Islands, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen. Members of this community have been immigrating to the United States since the late 1800s and have long been a part of the fabric of American society, making significant economic, educational and political contributions. According to the Arab American Institute, which is one of the longest-standing Arab civic engagement organizations in the U.S., it is estimated that nearly 3.7 million Americans trace their roots to an Arab country. Although Arab Americans live in almost every part of the U.S., more than two-thirds of them reside in just 10 states: California, Michigan, New York, Florida, Texas, New Jersey, Illinois, Ohio, Pennsylvania and Virginia.

There are many assumptions about Arab Americans that can interfere with the therapeutic process and alliance. For instance, Arab and Muslim are not synonymous; in fact, over 60% of Arabs residing in the U.S. are Christian, not Muslim. Arab Americans may be first, second or third generation. Some are fluent in Arabic and English, whereas others may speak only one. Another commonly held misconception revolves around the citizenry status of Arabs. Of Arabs in the U.S., 82% are citizens, the majority of whom are native-born.

Misguided beliefs, stereotypes and popular assumptions may lead us to view members of this community as one-dimensional, but in fact, Arab American students are distinct, so each student should be regarded as an individual with unique experiences.

Political stress

Although we lack data on students who have an Arab background because they are expected to identify as white/Caucasian on most college and university admission forms, a few campuses such as the University of Illinois at Chicago have some data illustrating that Arab Americans make up a significant portion of the student body. Additionally, the college for which I work sits in a congressional district that has one of the largest concentrations of Palestinians in the U.S. It is clear that we also enroll a sizable number of other Arab American students. Because Arab American students constitute a significant percentage of the college population — while simultaneously facing targeting and various forms of racial/ethnic exclusion — it is imperative that our field incorporates a mental health framework that honors this population’s sociopolitical experiences and cultural and religious background.

In addition to facing many of the same challenges that college students generally encounter, such as navigating academic stress, negotiating relationships with friends, and deciding on a major, Arab students are subject to an ongoing and unrelentingly hostile political climate. These students, their families and their communities at large are dealing with the impact of anti-Arab and Islamophobic foreign and domestic policies such as the global war on terror, the Muslim travel ban, mass surveillance, and racial profiling programs promoted under the “countering violent extremism” framework. These policies and programs trickle down into Arab Americans’ everyday lives in the form of hate crimes, discrimination and a generalized sense of fear.

All of this can contribute to the development of mental health issues or exacerbate already-existing psychological disorders. Focus group participants shared how repressive policies shaped by the Trump administration (especially the Muslim travel ban executive order) translated into their everyday experiences of feeling anxious, alienated, intimidated and untrusting of institutions that are meant to be supportive. Several students at the time disclosed their feelings of uncertainty with comments such as, “Personally, I was scared during the election and when Trump became president,” “There’s still some fear that I have about what he can and cannot do to us as Arabs or Muslims,” and “The Muslim ban was very traumatizing, not just to me, but to people who could not come back to the States when they left for vacation.”

In failing to understand the political stress our Arab students are enduring, and by neglecting to engage in meaningful and elevated conversations about political issues that concern them, we run the risk of these students prematurely terminating sessions. Students in the focus group spent a considerable amount of time discussing the factors that would discourage them from returning to see a counselor. The following quotes highlight some of the factors mentioned:

  • “It has to be a judgment-free zone, and if it isn’t, then I wouldn’t return to counseling.”
  • “I don’t want to be judged or misunderstood based on what they’re hearing about Arab Americans in the media.”
  • “There has to be a connection. The counselor has to understand me as an Arab American.”

Culturally competent practitioners must be able to monitor their biases and examine how their own racial/ethnic backgrounds may play a role in forging an authentic relationship with Arab American students. One of the biases mental health professionals may hold that could influence their attitudes toward this population is associating all Arabs or all Muslims with a potentiality for criminality or terrorism. These associations are not held exclusively by professionals in our field. Rather, they are common misconceptions that are the product of government discourse, domestic policies and campaigns such as the global war on terror.

In my research, nearly 70% of the counselors surveyed agreed that many people may hold negative attitudes, stereotypes, preconceived notions and biases about Arab Americans. Other biases, steeped in corporate media, include the portrayal of Arab and Muslim women as docile and submissive — victims of a backward culture and religion from which they need to be rescued. A student who participated in the focus group sessions indicated that they “worry about how counselors get their information about us. Are they getting [it] from media outlets, and how does this impact the way counselors work with us?”

Despite our every attempt as professional counselors to be supportive of Arab and Muslim college students, applying a one-size-fits-all approach without critically examining our understanding of how anti-Arab racism and Islamophobia operate may not serve their best interests. While many counselors who are committed to diversity may have backgrounds in some social justice/racial issues, they usually lack training in the area of Arab American exclusion and discrimination.   

Cultural considerations

While social injustice is a factor to consider when working with Arab American students, they, like any other students, also need to sort through a wide range of micro-level challenges. Family issues, intergenerational dissonance, acculturative stress and identity confusion are just a few of the personal stressors that may compromise this population’s emotional well-being.

In Arab society, family is central. Family is the conduit through which cultural continuity is promoted and through which the rich traditions and values of the homeland are invoked. Both the immediate and extended family are heavily involved in the enculturation, upbringing and decision-making processes of the Arab American students you counsel. Counselors may find that even through adulthood, Arab American students will not make decisions in isolation. Rather, the expectation is that they will consult with members of their family before deciding on a course of action. Because they come from a collectivist society, in which the needs and wants of the group supersede those of the individual, these students may hesitate to act if a course of action or decision does not mirror the values of the family, does not benefit the collective or is considered shameful.

Whereas the dominant white middle-class U.S. values emphasize autonomy and freedom to make decisions without having to defer to others, cultural norms in Arab families dictate the opposite. As clinicians, we should consider how the practice of encouraging students to differentiate their individual identity from that of their family is antithetical to most Arab Americans. When our Arab American students are feeling obligated by their family to make a decision that does not necessarily satisfy their own desires, we should explore how we can assist them in negotiating an outcome that meets their need without being seen as a betrayal to their family.

Rather than viewing these distinct cultural forms as dysfunctional or expecting our Arab American students to align with Euro-North American-centric ideals in order to be healthy and feel supported, I propose that we use the inherent strengths of their own heritage, culture and values. By doing so, we are demonstrating an appreciation for their background and worldviews. Focus group participants shared the importance of integrating their cultural heritage when implementing therapeutic techniques. One participant stated, “Non-Arab counselors need a better understanding of who their Arab students are and the mechanisms our parents use to raise us.” Another suggested, “Counselors shouldn’t assume things about us; they should ask us about our values, beliefs and customs.”

Although it cannot be emphasized enough that family represents a core aspect of Arab culture, we also come to learn that honor, respect, morality, hospitality and generosity are other dominant features of this group. When working alongside Arab American students, it is useful to keep these cultural norms in mind so that these students will feel heard, understood and appreciated.

Intergenerational dissonance — another common source of stress for Arab American students — can arise when students are feeling pressured to hold steadfastly onto traditions of cultural heritage or religious values with which they no longer identify. Students shared the stress of negotiating relationships with their parents, and the acculturation differences between them, with these types of responses:

  • “Our parents worry about us becoming ‘Americanized’ and disregarding our traditions and religious practices.”
  • “I think there are a lot of struggles that Arab Americans face, especially if they were born in America but their families were not.”
  • “We feel obligated to do what our families expect of us.”

Students also candidly shared how intergenerational dissonance leads to other points of contention, including students wanting more freedom than the parents are willing to give, and the negotiation of romantic relationships, marriage and career choice.

Often in immigrant families, the children adopt dominant white middle-class U.S. values at a much faster pace than their parents do. This can cause disharmony and disruption in family functioning. According to psychologist and scholar John Berry, a number of factors, including age at immigration, language fluency and the reason for leaving the home country, determine the ease and comfort with which individuals adjust upon immigrating to the U.S.

During the course of my research and my years spent counseling Arab American students, I have learned that some of these students have assimilated with ease into mainstream U.S. life but have determined that it is equally important to them to maintain the richness and beauty of who they are as Arabs. They view themselves as members of a collectivist people with a strong extended family network, a rich heritage and culture that informs their way of living, and (for some) a religious framework from which they draw strength and guidance. These students have learned how to effectively and strategically weave in and out of the American and Arab in them; they have found a way to manage the conflicts associated with intergenerational dissonance.

Students who are struggling with identity confusion, and pushing back against familial pressures, want to explore the facets of their identity on their own terms. Focus group participants explained the challenges of trying to live “on the hyphen” (as in Arab-American) and navigating the contradictory worlds in which they live:

  • “I feel like Arab students are lost and don’t know how to act. They’re like in between and unsure if they are more Arab or more American.”
  • “Our families struggle with understanding what it’s like for their child to be an Arab living in America. We struggle with being American at school, and we struggle with being Arab at home.”
  • “I live both the Arab and American life, but I feel like non-Arabs see me as the other.”

Arab American students face ongoing angst caused by trying to live out their hyphen, which involves modifying and massaging the parts of their heritage that they want to maintain and embrace and discarding those that are no longer meaningful to them. Negotiating the complexities of their identity is further complicated by living in a hostile political landscape in which they are generally made to feel unwelcome and marginalized.

During the time of my study, Arab American students were in the thick of grappling with the realities of a newly elected president who was targeting members of their community with a travel ban and threats of deportation. Students spent considerable time processing how the election cycle and rhetoric from Donald Trump left them feeling vulnerable and affected their sense of belonging on campus. One student stated that Trump’s jingoistic sentiments during the election period “[bred] all kinds of hostility and hate, not just toward Arabs, but all other minorities, and the results have been disastrous.” According to a 2017 report by the Southern Poverty Law Center, hate crimes against Muslims grew by 67% in 2015, the year that Trump launched his campaign for president.

Arab American students’ sense of security has been punctured by a hostile climate that criminalizes and scrutinizes them. Students are telling us that it is a complicated time to be Arab or Muslim, and they need counseling professionals to have an understanding of how their identities are being shaped by the political landscape. Considering these conditions, how do we establish safety in the therapeutic encounter? How do we affirm these students’ humanity and obviate their concerns?

Counseling considerations

To establish culturally responsive care to Arab American students, we need to consider both the macro-level political stress that is causing these students harm and the micro-level challenges that affect their psychological well-being. As counselors, we have a unique opportunity to strengthen understanding of the contemporary challenges Arab American students face and the therapeutic measures we use to address them.

These students are informing us that they will benefit from counselors who are familiar with family dynamics, intergenerational dissonance and identity confusion. As counselors trained in Euro-North American counseling theory and technique, we need to critically examine the applicability of these models to the Arab American student and modify the strategies we use so that they complement the worldview of this population. If we fail to do so, we may mischaracterize cultural norms, beliefs, values and traditions as oppressive or primitive, which could inadvertently shame the students with whom we are working. We may also construe or unfairly judge these students’ family interactions as unhealthy with blurred boundaries, or consider them enmeshed and fused, interfering with individuation and differentiation of self.

These terms, inherent in Western models of family therapy, are incongruent with the Arab American family system. Applying these concepts may unknowingly leave these students feeling judged, misunderstood or misheard and could lead to premature termination of therapy. Instead, we should consider reframing our understanding of Arab American family dynamics by viewing these interactions as loving, caring and uplifting, and meant to provide unconditional support.

In addition to the factors previously mentioned, students shared other elements that would discourage them from returning to see a counselor:

  • “I had a counselor who would advise me or come up with solutions that were more appropriate for non-Arabs.”
  • “I was given solutions from counselors that do not match what I am looking for or who I am.”

Those who participated in the focus group also explicitly let us know that it is a trying time to be an Arab American student. They are traversing a hostile political climate that is causing them psychological distress. Being well-meaning and using the compassion that called us to this field may not suffice. As counselors, it is our duty to intentionally address any gaps in our knowledge base concerning the roles that culture, racism and oppression play in impeding these students’ abilities to function academically and personally. If we neglect to do so — and if misguided beliefs, popular assumptions or personal biases go unchecked — we may unintentionally revictimize these students. To eliminate the potential for harm, we can monitor our sensitivity to the historical and current oppressions that Arab American students experience. This can be accomplished in part by attending professional development opportunities that increase our understanding of this population’s sociopolitical, cultural and religious needs.

Finally, we can help these students re-create and reimagine the world they live in by acting as agents of change who advocate for and work alongside them to eliminate institutional discrimination. This includes having conversations with administrators to critically examine our campus communities to determine whether we are taking the necessary steps to promote a sense of belonging for this population.

Institutional responsibility includes counting Arab American students on admission forms and monitoring any inequities that could leave these students feeling vulnerable and paralyzed. Our institutions of higher education should also take intentional steps to diversify the recruitment and hiring of faculty and staff to complement the demographics of their respective student body populations. Ultimately, the question that counselors and institutions of higher education should be asking is, “How do we help Arab American students feel safe, understood and integrated?”

 

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Souzan Naser is an associate professor and counselor at Moraine Valley Community College in Palos Hills, Illinois, where she has won awards for her work on increasing diversity on campus. Her doctoral dissertation addressed the paucity of Arab American cultural competency training available for counseling professionals. She was born in Palestine and raised on the southwest side of Chicago, in the heart of one of the largest concentrated Arab American communities in the U.S. Contact her at nasers2@morainevalley.edu.

 

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

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

Wanted: Bilingual and bicultural counselors

By Lindsey Phillips February 3, 2021

Successful therapeutic relationships are built on trust and understanding, so counselors can ill afford to have words and phrases become “lost in translation.” Cultural competency on the part of counselors is also crucial, especially as clients are becoming more linguistically and culturally diverse.

According to the 2019 American Community Survey conducted by the U.S. Census Bureau, 22% of U.S. households speak a language other than English at home, with 13.5% speaking Spanish. And this number will only increase in the years ahead. The Instituto Cervantes, in its Yearbook of Spanish in the World 2019, estimates that nearly 1 in every 3 Americans will be Hispanic by 2060, making the United States the second-largest Spanish-speaking country in the world after Mexico. The Pew Research Center projects that 19% of Americans will be foreign born by 2050, up from 12% in 2005. It also estimates that 82% of U.S. population growth will come from immigrants and their descendants.

The counseling profession emphasizes cultural competency, but evidence suggests that the mental health field as a whole isn’t keeping up with the rising demand for bilingual and bicultural services. According to survey results released by the American Psychological Association in 2016, approximately 10.8% of U.S. psychologists reported being able to provide services in a language other than English, with only 5.5% able to provide services in Spanish.

This lack of culturally competent services can take a toll on people’s mental health. “When clients can’t find a bilingual counselor, they become more isolated. Often, they don’t talk about their emotional issues because they don’t feel that they can be seen or understood on a linguistic or cultural level,” says Ingrid Ramos, a licensed professional counselor (LPC) and the director of the Bienestar (wellness) and Resilience programs at The Women’s Initiative in Charlottesville, Virginia. “Then, you see a worsening of symptoms.”

To better meet the needs of bilingual and bicultural clients, mental health professionals must become more culturally competent themselves. That goes beyond simply speaking another language or being aware of cultural difference. Clinicians need to be prepared to offer bilingual services and practice cultural humility, which requires better bicultural/bilingual training opportunities and supervision.

Finding the right words

Language is central to counseling because it allows clinicians to build rapport and better understand clients’ life experiences, thoughts and behaviors. But fluency in the client’s native language is often not enough to make a counselor linguistically competent in session. Olga Mejía, an associate professor of counseling at California State University, Fullerton (CSUF), acknowledges that mental health terminology doesn’t always translate. She often tells her counseling students, “There’s Spanish, and then there’s therapeutic Spanish.”

Although Spanish is Mejía’s first language, she admits she felt lost during her first clinical position after completing her doctoral program. Her clients and colleagues alike assumed that she could easily offer mental health sessions in Spanish, but she struggled to translate certain technical terms commonly used in the field such as confidentiality and the cycle of violence.

That’s because the process isn’t as straightforward as translating the words and phrases directly, Mejía explains. A direct translation often doesn’t take into account the cultural context and nuance between languages. Therefore, she advises her counseling students to translate the idea behind the terms rather than searching for the perfect word. For example, even if there isn’t a word-for-word match for boundaries in the client’s language, a counselor can explain that people often set rules or limits in relationships.

According to Ye (Agnes) Luo, an assistant professor of counseling at the University of North Texas, even explaining what a counselor is and how that differs from a psychologist can be challenging because some languages, such as Mandarin, use the same word to describe both professions. And certain countries may not distinguish between these roles the way that the United States does, she adds.

Luo, an American Counseling Association member and LPC in Texas who speaks both Mandarin and English, has learned that she can’t simply ask clients if they understand what counseling is because the client’s understanding of counseling may differ from her own. For example, she has worked with clients from Asian countries who expect counselors to prescribe something to “fix” their presenting issues. These clients viewed her as an authority figure rather than perceiving therapy as a collaborative process, she notes.

Interpreters must also be aware of the nuances involved in the way mental health professionals speak. Ramos advises counselors who use interpreters to discuss the therapeutic process with them before going into session. “Our communication is our tool,” Ramos says. “How we say things, how we ask questions, how we reflect back to the client — that’s the counseling intervention.” Therefore, it is important that interpreters also understand how to communicate in this way when translating for clients, she points out. For example, an interpreter could accidentally misrepresent a counselor’s reflective statement by telling the client, “The counselor is repeating what you just said,” rather than translating the reflective statement.

Medical interpretation can feel more transactional, but because counseling involves emotional disclosure and vulnerability, it requires a certain tone and set of communication skills, continues Ramos, who serves on the board of Creciendo Juntos, an organization that provides support and resources for Latinx families and Latinx-serving organizations in the city of Charlottesville and Albemarle County. For this reason, the Virginia Department of Behavioral Health and Developmental Services distinguishes between medical and mental health interpreting, she says. For example, the agency underscores the importance of mental health counselors and interpreters meeting before a session, while acknowledging this is not always necessary in medical settings.

Counselors also have to be upfront with clients about their bilingual language proficiency, advises Luo, a counselor at C2 Counseling in Corpus Christi, Texas. When searching for her own personal counselor, she found a clinician who advertised herself as bilingual in Mandarin and English. But in their first session together, the counselor asked Luo if it was OK if she spoke in English, not Mandarin, because she had never used Mandarin in a clinical setting. Luo acquiesced, but it was not the experience she had desired or expected.

Cultural competency and humility

Counselors must consider the client’s country of origin, not just the client’s language. “Language is essential,” notes Mejía, a bilingual and bicultural licensed psychologist. “But [clinicians] have to have the language with the cultural competency or cultural sensitivity, along with the cultural humility.” For example, in Spanish, knowing when and how to use tu and usted (both words for you) changes depending on age, gender, seniority and familiarity. If counselors don’t have the cultural understanding of that distinction, then they could hurt their relationship with the client, and the client will not feel seen or heard, she says. 

As Alaina Hanks, a licensed professional counselor-in-training at the Gerald L. Ignace Indian Health Center in Milwaukee, points out, a lack of cultural competency can also have serious repercussions, including potential misdiagnoses. Some of Hanks’ Native American clients have told her that other mental health professionals previously misdiagnosed them as having schizophrenia or depression with psychotic features because they mentioned seeing spirits or receiving guidance from ancestors during a traditional ceremony. Counselors must listen to the client and learn about their culture to accurately determine what is connected to culture and what is clinically significant, she stresses.

“A huge part of [cultural humility] is understanding the history of where you are and what that means,” says Hanks, an ACA member who helped co-author the article “A collective voice: Indigenous resilience and a call for advocacy,” published on CT Online in February 2020. She advises counselors to start by learning the histories of the places where they live and work because these histories, in combination with current policies, affect clients.

Because Ramos, who is from the Dominican Republic, often works with clients from Mexico and Central America, she brings a sense of cultural humility and curiosity into session with her. Sometimes, her clients assume that she understands everything they say just because she speaks Spanish. She knows not to make that assumption. Instead, she routinely asks, “What does that phrase mean in your country?” If she still doesn’t fully grasp what the client is trying to convey, she will dig deeper and ask what the phrase means in their community or family.

“As a bicultural counselor, it’s important to remember that every culture has its own way of speaking about symptoms, illness and treatment,” Ramos says. To gain a better understanding of the presenting issue, she asks clients how they understand or see the problem and how their culture views their symptoms or behaviors. She also asks how people in their culture typically cope with these symptoms or behaviors.

Because Native American approaches to wellness are often about gaining balance, Hanks, who is Anishinaabeg and enrolled in the White Earth Nation in Minnesota, sometimes incorporates the medicine wheel when working with Native American clients. The medicine wheel is a sacred symbol used by many Indigenous tribes to represent all knowledge of the universe. It consists of a circle, divided by a horizontal and vertical line, with four colors (black, white, yellow and red). Each tribe interprets the medicine wheel differently.

In Hanks’ traditional teachings from her Ojibwe tribe, the medicine wheel operates as a way for Indigenous people to understand the world and their roles within it. “I have used it similar to a wellness wheel in helping clients identify where they need balance in their lives or finding ways to reconnect counseling concepts in a cultural framework,” she says. She also uses it to initiate conversations about grief and the cycles of life.

Although the medicine wheel is widely recognized among Native American populations, its use varies from tribe to tribe, Hanks says. For that reason, she cautions counselors to practice cultural humility and get training before incorporating the medicine wheel in their clinical practice. The same can be said about the use of any intervention that might speak more fully to a client’s culture but with which the counselor is largely unfamiliar.

Mejía urges counselors to be curious and culturally humble to ensure that they don’t fall prey to assumptions or black-and-white thinking about a culture. For example, in working with a teenage Latinx client, counselors shouldn’t automatically assume that the client is going to leave home to attend college. Instead, Mejía advises clinicians to slow down and consider: Why wouldn’t the client go away to college? What cultural factors might encourage the client to choose a college closer to home? What would it be like if the client did attend school away from home?

Striving to cultivate cross-cultural relationships

Ramos often uses narrative therapy to incorporate a client’s culture, family context and worldview — including their sense of spirituality — into treatment. She frequently uses Latinx cultural references, such as dichos y refranes (i.e., Spanish proverbs and sayings), to engage clients and make their culture and stories central to the session. For example, in a group format, Ramos may ask clients to share popular sayings used in their family, community or culture that relate to the dynamic the group is discussing. In the past, clients have mentioned dichos such as “El tiempo lo cura todo” (which is similar to “Time heals all wounds”) and “Dios aprieta, pero no ahorca” (which is similar to “When God shuts a door, he always opens a window”). This technique can help clients reconsider how they view themselves and their personal journeys, Ramos says.

Ramos doesn’t believe that counselors have to be proficient in Spanish to incorporate Spanish sayings into their practice. “The main point is always to use invitational language in the counseling setting to elicit the dichos and reflections from the client as a way to honor the cultural meaning the dichos might have for them,” she explains.

Ramos also focuses on cultivating the relationship from the second the client enters her office. In the United States, people have grown accustomed to filling out forms as soon as they enter a health facility, but that isn’t true for all cultures. Ramos points out that many Latinx cultures value personalism (i.e., person-to-person contact). So, she first gets to know her clients and discusses the forms with them rather than simply handing them the forms without any explanation.

Ramos has noticed that if she clearly explains the intake process to her clients who are immigrants or refugees, they are more willing to engage with the steps needed to get services. On the other hand, if she just hands these clients a form, they may hesitate to answer questions because they don’t fully know or trust her yet. Simply saying, “Welcome to the office. How did you find us?” or “How can we serve you today?” can be a nonthreatening way to start the conversation, Ramos suggests. “It doesn’t have to be a 30-minute intervention. It can be five to 10 minutes of explaining why they are here and what the process is,” she adds. 

Counselors also need to be sensitive to literacy levels. Asking clients to fill out forms may cause anxiety or shame if they don’t know how to read or write in their native language, Ramos points out. Cultivating that relationship for the first 10 minutes before having them fill out forms can help put clients at ease. Ramos then asks clients whether they feel comfortable filling out the forms themselves or might prefer her support in doing that. This is a simple way to dismantle the shame around any literacy issues so that focus can be put on clients’ needs, she explains.

Recognizing the need for bilingual/bicultural training

Given the increased demand for counselors who are bilingual/bicultural, there is a corresponding need for counselor education to include more programs aimed at preparing counselors to be linguistically and culturally competent. Unfortunately, says Mejía, an ACA member whose research focuses on immigration and the training of bilingual/bicultural therapists, there are not many programs like this currently in the United States, and for the ones that do exist, there are no standards for this type of training.

Mejía noticed that many of the bilingual counseling students at CSUF lacked the support they needed during their practicum training. They rarely had bilingual/bicultural supervisors, and they often had to translate documents, forms and counseling terms on their own without any guidance, she recalls. “They’ve been learning all the [counseling] skills in English, and all of a sudden, they are expected to do it in a different language,” which was intimidating and challenging, she says.

In response, Mejía started and serves as the director of the Ánimo Latinx Counseling Emphasis program at CSUF. The program consists of five master’s-level courses focused on helping students become self-aware as bilingual and bicultural counselors, knowledgeable of Latinx cultures and therapeutic Spanish, and familiar with interventions appropriate to Latinx and Spanish-speaking clients. It also teaches counseling students about social justice advocacy for issues relevant to the Latinx community and allows students, depending on their proficiency, to practice speaking Spanish in a clinical setting. 

Ánimo, which loosely translates to encouragement or spirit, is in its third year, and Mejía can already see the positive impact the program is having on the counseling students at CSUF. She frequently gets inquiries from students about the program, which speaks to the need for such training. But behind the program’s success is a harsh reality: It took 10 years of determination and dedication on the part of Mejía and her colleagues to receive the institutional support needed to bring the program to fruition.

Bilingual/bicultural training programs such as Ánimo also allow counseling students to support and learn from each other. The students in the program recently decided that they want to establish an Ánimo student group to build a supportive community for bilingual/bicultural counselors, which Mejía thinks is a wonderful idea.

Challenges faced by bilingual/bicultural counselors

Often, there is a cultural “tax” associated with being a bilingual or bicultural counselor. Mejía started the Ánimo program to help counseling students, but she doesn’t get consistent faculty release time (i.e., reduced teaching responsibilities to work on other projects) to fulfill duties related to the program, including training faculty, promoting the program, interviewing prospective students, attending meetings, and conducting exit interviews with graduating students. In addition, prospective and current students often seek her out — as director of the program — for advising and mentoring. Still, she finds a way to balance it all because as a first-generation college graduate herself, she knows how important these connections are and how valuable the program is to other bilingual/bicultural counselors. 

Sometimes, colleagues and agencies may expect bilingual counselors to take on additional roles — including ones that might be outside their scope of knowledge or training. When Ramos was an in-home counselor, she would support clients by attending school or social services meetings with them. Those agencies didn’t always schedule an interpreter because they assumed she would operate as both the client’s interpreter and therapist. “That put me in a situation where my mind that I wanted to use for the emotional support of this family now had to be used for interpreting,” Ramos recalls. Interpreting itself can be taxing, she adds, so she had to set boundaries and assert that she needed an interpreter in certain situations so that she could successfully perform her true job as a counselor.

Luo says some of her bicultural counseling students find it difficult to establish boundaries in session. If a counselor feels personally connected to a client because they share a language or similar culture, a danger exists that the counselor could overidentify and self-disclose too much, she cautions.

Isolation can also be an issue for counselors who find themselves in a region or clinical practice in which they are the only ones who are bicultural or bilingual. All counselors can benefit from participating in support groups with other helping professionals, but bilingual/bicultural counselors have unique challenges that may require them to find support groups with clinicians who also share these struggles, Ramos says. For example, a bicultural counselor may have high caseloads of people whose immigration or socioeconomic status affects their ability to access the resources they need, which in turn may affect their well-being.

Of course, it may not be easy to find this support if counselors live in an area without much diversity. Ramos offers the following suggestions for connecting with other bilingual/bicultural professionals:

  • Reach out to agencies within the community that provide mental health services to see if they have bilingual counselors on staff.
  • Find organizations that provide services to immigrants and refugees and that focus on education and advocacy. Although these organizations may not concentrate solely on mental health, they do work to identify the needs and gaps in services for these populations, Ramos says. And counselors could collaborate with these organizations to build a resource network.
  • Check with the counseling or social work departments at local universities and colleges to find alliances of refugees, immigrants or other minority groups.
  • Attend online webinars and trainings, which are more widely available now because of the COVID-19 pandemic. These events will help counselors connect with other bilingual and bicultural providers.

Improving supervision for bilingual/bicultural trainees

One of Mejía’s motivations for starting the Ánimo program was the lack of available supervisors who are culturally and linguistically competent. A supervisor’s lack of cultural competency is a barrier for counselors-in-training, Mejía asserts. Students often tell her they feel unheard or overlooked when their supervisor doesn’t understand an issue they have as a bicultural counselor or as a counselor working with a client from a different culture.

Mejía also gets frustrated when supervisors ask their trainees to translate another colleague’s session or the clinic’s forms or to answer the phones because they are bilingual. Trainees are not compensated for this work, and these tasks don’t count toward their clinical hours, she points out. Mejía often asks supervisors, “Would an English-speaking trainee be required to do this?”

Ramos has noticed that bilingual/bicultural counselors-in-training tend to dismiss their own feelings and challenges when they don’t have a supervisor who is culturally competent. They may think that they are the only ones dealing with an issue and hesitate to bring up their concerns with their supervisor. “Having a supervisor who can relate culturally with the population you are serving can fill the gap needed in support for the counselor,” she says.

As Hanks observes, it can be challenging for supervisors and counseling professionals who have been in the field for a long time to admit that they don’t know something. But taking a reflective and humble approach to supervision helps bicultural counselors to feel seen and heard, she says.

Hanks recalls a positive experience she had with a supervisor who was curious and didn’t make assumptions. While working in a youth shelter, Hanks was approached by a Native American child because she assumed that Hanks, who is also Native American, would better understand her. Hanks’ supervisor didn’t address the situation by telling her to set better boundaries. Instead, the supervisor said, “I noticed this one child is really close to you. Tell me more about it. Tell me what you think is going on. What do you think about it clinically?” Those questions led to a productive conversation about Hanks’ therapeutic relationship with the client.

Luo has always had supervisors who were culturally different from her, and none of them asked about how their cultural difference affected the dynamics of supervision. Luo encourages supervisors to be the ones to initiate these conversations rather than waiting for trainees to bring up the topic. Now as a supervisor herself, Luo makes a point to always address culture with her supervisees. For example, she might say, “As you have probably noticed, we come from different cultural backgrounds. Do you want to talk about how these cultural factors affect our relationship?”

Bridging cultural differences

In Milwaukee, Mark Denning of the Oneida Nation created the program Unity Fire to address challenges related to the COVID-19 pandemic and social justice struggles. The program is open to the public and uses Native American customs to help unite communities during a time when many people feel isolated, unheard and unsafe.

Hanks attended a unity fire held during the protest over the killing of George Floyd and remembers it being heavy with emotion. The firekeepers taught those attending how to offer a prayer into the fire using traditional sacred medicines. “There’s space at these fires for [cross-cultural] connection,” Hanks says. “That’s why they call it the ‘unity fire.’ It’s all about people uniting again.” 

Ramos’ agency — The Women’s Initiative — aims to create community partnerships. Its Bienestar program provides counseling in Spanish to Latinas and connects Latinx children and men with bilingual providers in the community. It also offers workshops and presentations centered on Latinx cultural values and resiliency, mental health issues, and cultural barriers that this population often faces.

Staff members at The Women’s Initiative also offer support groups for immigrant and refugee women. For example, Ramos led a basket weaving group, which for many clients was a way to connect a culturally significant craft with emotionally relevant concepts such as change, disappointment and resilience.

The Women’s Initiative also partnered with the International Rescue Committee and Hyojin Im, an associate professor in the School of Social Work at Virginia Commonwealth University and an expert on mental health services and refugee communities, to host trauma-informed cross-cultural psychoeducation (TICCP) leadership training for immigrant and refugee communities in Charlottesville. The TICCP program offers a series of workshops that teach bilingual leaders in these communities about the mental health impact of refugee and immigrant trauma and cultural adjustments to a new country.

TICCP has been a way to bring immigrant and refugee communities together and to create leaders within those communities from which others can learn about mental health, Ramos notes. These leaders “can help to make referrals and to deal with the stigma around mental health,” she adds.

Ramos loves connecting bilingual/bicultural therapists with immigrant and refugee communities and empowering these communities to be active participants in their own mental health. “Whenever I can bridge that gap [between cultures], I like to do it,” she says, “because I know it means a client or family will receive a better service.”

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

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

Fostering immigrant communities of healing

By Lindsey Phillips January 28, 2020

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

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

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

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

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

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

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

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

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

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

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

Overcoming language barriers

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

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

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

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

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

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

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

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

Prioritizing family

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

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

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

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

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

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

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

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

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

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

Partnering with the community

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagnosing the person, not the culture

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clearing the way for immigrants

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

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

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

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

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

 

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

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

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

Letters to the editor: ct@counseling.org

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

Straddling two worlds

By Lindsey Phillips January 23, 2020

Because immigrants often feel like they are straddling two worlds — their origin country and their new one — identity development is complex and critical for this population. Immigrant clients often tell Sara Stanizai, a licensed marriage and family therapist and owner of Prospect Therapy in Long Beach, California, that they have one foot in each culture and don’t fully fit into either one.

When people feel like they don’t fully belong to any one community and are constantly hiding one or more aspects of themselves to try to fit in, they question their identity and choices, Stanizai explains. She finds this is especially true for emerging adults who are figuring out their careers. Immigrants may be successful at their jobs, but they often feel like they are failing because they are hiding or ignoring a part of their identity in the process, she says.

Daniel Gutierrez, an assistant professor in the counselor education program and coordinator of the addictions emphasis for the clinical mental health counseling program at William & Mary, points out that straddling two worlds involves code switching between language and cultures: People alter their behavior and speech to accommodate different cultural norms. They may act and speak one way at home and another way when they are at school or work or out with friends. “You can’t be who you are naturally. You have to switch depending on the social context or you have to abandon your home culture to succeed, and then you feel guilty all the time,” says Gutierrez, who is also faculty director of the New Leaf Clinic at William & Mary.

Gutierrez finds that many immigrants question their identity (for example, “Am I Korean enough? Am I white enough?”). Immigrants may feel that they need to reject their home culture to fit in with their new one, so Gutierrez recommends asking clients, “How do you identify? Whom do you connect with? What does your social network look like now? How do you make sense of what’s home?”

Immigration can also cause intergenerational conflict because family members acclimate to the new country and culture at different rates. The expectation that even after immigrating, children will continue to behave as they did in their origin country can lead to conflict, says Lotes Nelson, a clinical faculty member at Southern New Hampshire University. She often hears clients say that their children are “behaving like Americans” because they are being disrespectful to them or dressing and behaving in a way that is embarrassing to the family. These clients often ask her, “What do I need to do to make sure our children follow our culture and behaviors?”

Nelson, a licensed professional counselor and approved clinical supervisor in North Carolina, acknowledges that this isn’t an easy conversation to have, but she invites families to talk through their feelings. One framework that she finds helpful is the ABCDE model (which is part of rational emotive behavior therapy) because it helps clients reflect and reframe their thinking about a certain situation or emotion.

Nelson, a member of the American Counseling Association, briefly illustrates how this model works: Take a 13-year-old child who is no longer interested in going to church (the “A” or activating event). The parents may interpret this change as a sign that coming to the United States was a mistake (the “B” or belief), Nelson says. They may feel responsible for their child no longer practicing their spiritual values, and these emotions may manifest as anger at the child (yelling or physically punishing the child; the “C” or consequence).

To help parents challenge their interpretations of the event and their emotional response to it (the “D” or disputing), Nelson may say, “Let’s explore your impression about what has occurred for your child. Tell me more about this belief that coming to America might have been a mistake for you and your family. I wonder how else you might view this new experience.”

Closely examining the situation with a new perspective often helps clients navigate their emotions and thoughts more effectively and helps them find a way to move forward, she explains. In this example, the parents may realize how living in the United States has exposed their child to different beliefs and how their child now has friends who don’t go to church. So, the parents make a new plan: They will continue discussing the significance that religion plays in their culture in the hope that the child’s rejection of church is not permanent (the “E” or effects).

Younger generations of immigrants may also feel indebted to their parents for their sacrifices, such as moving to a new country to provide them with better opportunities or paying for their education. As a result, they may choose a career path — one they don’t want — just to honor their parent’s wishes, says Gutierrez, a licensed professional counselor in North Carolina and Virginia and an ACA member.

He recalls working with a family who possessed conflicting notions of academic success and happiness. The mother thought her children were not doing well in school, but the kids said they were doing fine. Success for the mother meant her children getting straight A’s and becoming successful medical doctors. Her children resented the added pressure because they didn’t value straight A’s in the same way.

Gutierrez says his role as a counselor is not to wave his finger at family members but to teach them how to communicate with one another. In a sense, he operates as a referee, making sure each person pauses and clearly states back what they heard the other person say.

With this particular family, Gutierrez asked the son, “What do you think your mom is going to say this week?”

The son said, “She’ll scream at me about not finishing my homework or about getting a B on my last math test.”

Gutierrez asked, “What do you think she wants from you? What do you think she means by always bringing up school and grades?”

The son replied, “She only cares about grades and about me becoming a doctor. She doesn’t care about what I want out of life.”

The mother was in the room and heard her son’s perspective. Later in the session, she had the chance to share her side of the story. She expressed how yelling over her son’s grades was the way she expressed her love for him because she didn’t want him to struggle the way she had. This exchange caused the mother and son to become emotional because they both gained a deeper understanding of the other’s feelings and the underlying motivations of the mother’s actions, Gutierrez shares.

Stanizai finds that immigrants are often used to having external validation or external measures of success, so in therapy, she helps clients move to internal ones. For example, a client might be getting pressure from their family to get straight A’s and become a lawyer or doctor, and this pressure is affecting the client’s mental health. Stanizai would help the client identify the internal qualities and strengths that they possess that are not dependent on the expectations or circumstances of others. For example, she might help the client realize that they will succeed in whatever career they choose — even if it’s a different career from what the family wants — because they possess a good work ethic.

“A lot of anxiety comes from feeling overwhelmed and feeling responsible for so many people other than [themselves],” Stanizai says. “If people feel they have no other choice than to cut people or cultures out of their life, then that can make people feel disconnected and depressed.” Feeling “othered” or isolated can exacerbate symptoms of mental health issues such as depression and anxiety, she adds.

Because it is so isolating to not fully fit into any one group, Stanizai started an Adult Children of Tiger Moms support group to give immigrant children a safe space to talk about these issues and find others who have similar experiences. She has noticed that the group, which has people from various types of cultures, has become its own culture — one that is validating and healing to its members.

Groups are often more accessible for people who may not be able to commit to weekly individual counseling sessions. In addition, they tend to help people overcome any stigmas they have about therapy because when participating in a group, individuals often feel like they are taking a class, not going to counseling, she adds.

Stanizai has noticed that a common thread often emerges in her group sessions: No matter how successful the participants are, they all feel like they are letting their families down. Many group members report feeling unhappy at their jobs, yet they feel that they have to stay because of family expectations. They also note feeling guilty because their parents often assume they will move back home — either to their hometown or into their parents’ house — after they graduate.

Stanizai had one client who graduated and found a job in a city that was far away from her parents. The client felt so guilty that she went back to visit them every weekend. Stanizai asked the client, “Why do you think your parents want you to move back home? Why is that so important to them?” The client said, “My parents worry about me, and they want to stay connected.”

Stanizai worked with the client to brainstorm ways that she could connect with her parents without having to go home every weekend, such as using a video chatting app or inviting them to her apartment for dinner. The client decided to email her parents more often, and she found that doing this actually helped her and her father grow closer, Stanizai says. They would exchange long emails, and in writing each other, they were sharing more details about their lives than they did when the client went home and sat quietly watching TV with her father.

“Parents really want [their children] to be successful and happy, Stanizai says. “The framework for what that looks like might be different from [the client’s], but they can respect and honor that and also open their [parents’] eyes to what is important to them without completely turning their backs on [their family] so they can both coexist.”

This intergenerational conflict serves as a microcosm of the constant struggle between identities that immigrants often face. With counseling, these clients can come to terms with these identities and finally find their footing.

 

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For more on working with clients who are immigrants, read the in-depth feature article “Fostering immigrant communities of healing” in the February issue of Counseling Today.

 

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

 

Letters to the editor: ct@counseling.org

 

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

Should we talk about politics? What we are missing in counseling sessions

By Cebrail Karayigit and Donna M. Nesbitt April 8, 2019

The 21st century has become a period of widespread refugee crisis. The Department of Homeland Security defines refugee as “a person outside his or her country of nationality who is unable or unwilling to return to his or her country of nationality because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.”

According to The Guardian, in 2017, the number of people forced to flee their homes rose to a record high of 16.2 million. In recent years, individuals migrating from authoritarian countries has mainly been motivated by political instability. These countries are often structured in ways that allow the government to hold a majority of the power, while their citizens have restricted political freedoms.

Although there are many such countries, the failed coup attempt on July 15, 2016, in Turkey illustrates a worrisome example of deteriorating stability in a country that just a few years prior was being promoted as a model of democracy. The failed coup resulted in many academics, doctors, teachers and journalists becoming targets of persecution in their home country. Many of them fled to survive or to seek better lives, and in the process, they experienced extremely stressful events — e.g., losing their jobs, lost socioeconomic status — because of political oppression.

It is important to acknowledge the deep need these individuals have for freedom of thought and speech, especially knowing that they come out of a culture of silence and fear. As professional counselors, however, we have a natural tendency to avoid talking about political issues in our practices. We need to become aware that refugees who discuss these issues are not often looking to engage in a political debate; rather, they want to have their words and thoughts validated in a safe space.

Given that the lives of many refugees are complicated by the political turmoil in their home countries, avoiding political conversation with them in counseling would not seem to be genuine or authentic practice. In fact, allowing them to discuss how they have been affected by those political factors can offer a deeper understanding of their presenting problems.

As Elie Wiesel, the Romanian-born Jewish writer who eventually became a U.S. citizen, once stated, “Wherever men and women are persecuted because of their race, religion or political views, that place must — at that moment — become the center of the universe.” Thus, as counselors, we should understand that these struggles are a significant part of refugees’ lives and should be given the attention and respect they deserve.

 

Why this topic matters to Cebrail

While completing my internship at one of the largest public universities in the eastern part of Turkey, I encountered a client of Kurdish descent. In our first session, this client identified her issues with experiencing political oppression on campus and with being Kurdish in Turkey, especially given the oppressive political climate that continues even today.

My internship supervisor advised me to discontinue our session when this topic was broached, because at that time, it was considered unwise to discuss such political matters with a client in such an environment where some tension has always been apparent regarding Kurdish issues. Reflecting on this now, I realize that my supervisor was only trying to protect me. However, this was also the first time I began questioning the idea that discussing politics in session should be taboo.

As a counselor educator, I am now in a unique position to witness the power of practicing freedom of speech on campus here in the United States. As a professional counselor and educator who comes from Turkey, I am often invited to speak on topics such as diversity and counseling in Turkey, either through panel discussions or in classes.

Not so long ago, a colleague at Pittsburg State University in Kansas requested that I speak to a class about the political climate and turmoil in Turkey, in hopes that it would raise awareness about what has been occurring there. Once again, I was faced with the tension of engaging in a political discussion, but this time with future professionals. This created some inner conflict for me. Many academics in Turkey were dismissed from their jobs for injudicious reasons, such as suspicion of involvement in the coup, suspicion of association with a particular organization, or for being outspoken in criticizing the government. Yet, here I was, about to discuss these very matters in an academic setting.

As Elif Shafak, a Turkish-British novelist, once stated, “You do not have the luxury of being apolitical if you are from wobbly or wounded democracies.” Although I usually discuss such political issues privately, I have come to realize how difficult it is not to share these matters with peers and students in academic settings. In my experiences, many Turkish refugees are very occupied with wanting to discuss previous and current political issues in their home country because of their deep and unmet need for freedom of thought and speech. This suggests to me that our counseling clients who have already experienced many stressful events because of political oppression need to be given a real opportunity to tell their stories in full without being judged.

In recent years, one of the main reasons that Turkish refugees have been coming to the U.S. is because of the political instability in Turkey. As I have been helping some of them personally and professionally, it has become evident to me that political factors are always the center of discussions. Because most of their presenting problems are a result of their stressful experiences with political oppression back home, it made me question once again whether counseling can provide that safe space for them to practice free speech, express their struggles and have their unique stories validated. How can discussing political issues be taboo when most of their problems come from political oppression?

 

Why this topic matters to Donna

As a graduate student in the clinical psychology program at Pittsburg State University, I have been taught on several occasions to avoid discussing political or religious beliefs in session when possible because this can lead to issues of bias and an inability to remain objective. However, in my class on diversity that is required by the program, I experienced another perspective. We were taught that if you are working with a client who is seeking services due to political or religious persecution, you need to be ready and willing to see from the client’s viewpoint. This is especially true in the case of immigrants and refugees.

I was fortunate to be present for the class mentioned by Dr. Karayigit, and I learned a great deal from what he described in his discussion. It opened my eyes further to the possibility that clients I counsel may be experiencing similar distress, and I want to be as prepared as possible for those sessions.

In my current position as a case manager, I work with a diverse population. This often requires me to consider political or religious beliefs in terms of the reason the treatment has been sought and what I work on with a client. I have encountered political and religious beliefs both similar to and opposite from my own. This has not limited my ability to engage in discussions about either with my client, nor has it discouraged me from doing so. Rather, I consider it an opportunity to truly learn about my clients’ stories and how these topics have impacted their lives.

I think the persecution and conflict that clients have experienced due to their political or religious beliefs should be factored in to treatment because these events are a significant part of their stories. It is important to recognize that our clients are human beings, which means that we have to be willing to explore the topics that matter most to them — regardless of our own beliefs.

 

Why this subject is especially relevant

In today’s world, counseling requires an increasingly greater focus on immigrant populations. With refugees constituting an important part of this population, it is important to understand that their distress is often a result of their experiences with political oppression and a lack of freedom of expression.

Working as professional counselors in any capacity, we follow the ACA Code of Ethics, and we are expected to provide the best possible service to our clients. While we have an ethical responsibility to not impose our personal beliefs and values on our clients, we also need to create a safe atmosphere in which our clients can practice free speech and expression of their own beliefs and values. In that case, wouldn’t dismissing the subject of politics in session — especially if it is a significant part of the client’s story — be more harmful? Is it not exacerbating the hardship the client is already experiencing if the client is an immigrant or refugee?

That’s why we believe that allowing clients to express their feelings and thoughts about political factors in a safe, judgment-free space is crucial to remaining authentic and genuine in the service we provide as counselors. To work with this population more effectively, it is important to understand that discussing political issues with these clients can have a positive impact in their lives.

 

Strategies and implications for professional counselors

Although the counseling profession puts a strong emphasis on multicultural awareness and competence, political factors are not typically discussed in counseling sessions. This might be because clients are unsure about the appropriateness of discussing political factors, especially if they are coming from a culture of silence and fear. That’s why, when working with such clients, it is essential to understand their experiences with oppression.

Another barrier to the discussion of political factors is the counselor’s lack of understanding and knowledge regarding the political stance in the client’s home country. When counselors do not have enough information and understanding of different political structures as a whole, it will prevent them from entering the world of the client openly. Having or acquiring this basic understanding is a very important step in communicating with clients whose primary issues stem from a country’s political state. If counselors can provide an atmosphere for clients to openly discuss their experiences, clients will be able to practice freedom of thought and expression. Having such an open dialogue will reinforce these clients’ abilities to engage in freedom of expression.

Following is a composite of suggestions to work more effectively with refugees who have experienced political oppression:

  • Learn as much as you can about the basic political structure (e.g., totalitarian, authoritarian, democratic) of clients’ home countries.
  • Become knowledgeable about the history of oppression in both your own country and your client’s country. Where does your client fit within the political power structure? How is the client affected by his or her country’s history of oppression?
  • Recognize and acknowledge the negative impact of political oppression on individuals (e.g., lost socioeconomic status).
  • Recognize your own political biases to manage any countertransference (e.g., What is your political hot button? How do you feel about refugees coming to your country?).
  • Be a role model by encouraging your clients to practice freedom of thought and expression (e.g., clinically relevant self-disclosure).
  • Challenge your clients’ speech codes, especially if they hold faulty beliefs about political oppression. For instance, a client might say that if academics were dismissed from their jobs, then the government must have had a valid reason. It is important to challenge clients’ faulty beliefs by asking such questions as, “By what criteria have they dismissed people from their jobs? What is the measure here?”

 

 

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Cebrail Karayigit is an assistant professor in the Department of Psychology and Counseling at Pittsburg State University. He is currently teaching graduate and undergraduate psychology and counseling courses, and supervising practicum/internship students in the school counseling program. Contact him at ckarayigit@pittstate.edu.

 

Donna M. Nesbitt is a graduate student in the clinical psychology program at Pittsburg State University. She is currently working as a clinical case manager.

 

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