Tag Archives: immigration

Addressing the Afghanistan humanitarian crisis

By Justina Wong February 16, 2022

In August 2021, Americans who were already dealing with the upheaval and roller coaster of emotions caused by the ongoing COVID-19 pandemic faced another frustration when the U.S. military suddenly withdrew from Afghanistan. The humanitarian crisis in Afghanistan has caused many mixed emotions for individuals who identify with the military community. And for most Afghan refugees, the struggle is not over.

According to the United Nations High Commissioner for Refugees (UNHCR), nearly 6 million Afghans have been forcibly displaced from their homes, with over 3.5 million people currently displaced within Afghanistan and 2.6 million living in other countries. As of Jan. 2022, more than 76,000 Afghans have been brought to the United States.

What counselors should know

Relocating to another country can be a traumatizing experience. In the United States, Afghan refugees often spend weeks in cramped quarters on military bases not knowing when they will be able to leave and start their lives in America. Once they do leave the base, they face a new set of obstacles in the host country.

Affordable housing is a significant challenge for many refugees, who often flee with only the shirts on their back. They do not have any money or belongings, and this issue can be exacerbated for refugees who resettle in areas with exponentially high costs of living such as Los Angeles and New York City. The refugees who are approved to leave the military base typical stay in a room at a motel, hotel or Airbnb or in the house of a host family. Their housing is paid for by nonprofit organizations or private donors. Finding a sustainable way of providing long-term housing is another concern. They usually do not have a place to call their own.

Other obstacles include language barriers, employment, financial insecurities, transportation, food insecurities and other basic necessities for daily living. Most of them are still trying to process the trauma they experienced fleeing their home country, living on military bases and being relocated somewhere else. A lot of these refugees left their families or extended family members behind in Afghanistan.

It is important for counselors to understand the experiences that Afghan refugees went through to come to the United States. Their courage, bravery and perseverance are closely intertwined with fear, despair and trauma. Counselors should refrain from making the following assumptions:

  • All Afghan refugees want to live in the United States.
  • Mental health services are easily accessible for Afghan refugees.
  • Afghan refugees should be grateful that they are living in the United States.
  • Afghan refugees are taking away jobs from American citizens.
  • All Afghan refugees want to adapt to American culture, including customs, societal norms and foods.

Instead, counselors should be knowledgeable about specific concerns that Afghan refugees face, which include the following:

  • Refugees experience a high level of racism if they live in communities different from their own. One of the reasons they are being placed in California and New York is because these states already have established Afghan communities.
  • Acculturation can be a struggle because of cultural differences in language, customs, social norms and foods.
  • Refugees are less likely to access mental health services because of barriers and mental health stigmas. Some might not understand what mental health means or what mental health services have to offer them because in their home country, these services are not available or mental health is not often discussed.
  • Mental health services and insurance are expensive and viewed as luxuries instead of necessities. With little financial assistance from the U.S. government, most families cannot afford insurance copays or services. Their main focus is providing food and shelter.
  • There are few counselors that are competent in providing mental health services to refugees in their native language.
  • Afghan culture teaches individuals to face the trauma they have experienced, keep their heads down and keep going on with their lives. In doing so, this creates generational trauma.

Being aware of refugees’ struggles and challenges will equip counselors when advocating for Afghan refugees as well as help them build a stronger therapeutic alliance with any potential future refugee clients.

How counselors can help Afghan refugees

Some counselors might think they are not well equipped to support Afghan refugees because of language barriers or lack of knowledge about Afghan culture. However, counselors can support them using basic counseling skills. Instead of focusing on how they are different from refugees, counselors should concentrate on the ways they are similar.

To illustrate this point, consider the following case vignette:

Hamid is a 42-year-old man who left Afghanistan with his wife Zeia and their three sons (ages 5, 3, and 6 months) and relocated to Los Angeles. Hamid and his family are temporarily staying in a building behind the main house of a host family. He expresses frustration regarding being unable to afford food for his family, so the host family refers him to see a Hispanic, female counselor named Theresa, who works at a nonprofit organization that provides wraparound services for refugees.

In their initial session, Theresa has a hard time understanding Hamid because of his limited proficiency in English. After reading his intake paperwork, Theresa believes Hamid could use therapy to discuss his past trauma of escaping Afghanistan and receiving constant death threats for helping the U.S. military as an interpreter, but Hamid is more concerned about having food for his family. They are both frustrated with their inability to understand each other.

Theresa decides to use her love of art to create a visual aid for Hamid, so she can understand his needs better. During their second session, Theresa presents the visual aid — a pyramid of Maslow’s hierarchy of needs she created using pictures — to Hamid, who enthusiastically nods his head and smiles in approval. Hamid immediately points to the picture of food and water and then to the picture of a family. Theresa points to the picture of food and asks if Hamid needs food for his family. Hamid nods.

Theresa then creates a checklist of all of Hamid’s needs using the visual aid. At the end of their session, Theresa concludes that food is Hamid’s main concern. Theresa gestures for Hamid to follow her, and she brings him to one of her coworkers who is a licensed social worker. Theresa asks her coworker to help Hamid fill out an application for CalFresh, a Supplemental Nutrition Assistance Program that provides monthly food benefits to people with low income, so he can receive an electronic benefits transfer (EBT) card to buy food for his family.

While not all counselors are proficient in speaking Pashto or Dari (the two mostly widely spoken languages in Afghanistan), they should be proficient in understanding Maslow’s hierarchy of needs and the use of nonverbal cues and body language in counseling sessions. By asking her coworker to help Hamid fill out an application for CalFresh, Theresa has addressed Hamid’s physiological and safety needs. In doing so, she has built a strong therapeutic alliance with Hamid, and he is more likely to come back to see her and discuss his past trauma in future sessions. She has presented herself as someone Hamid can go to if he needs anything.

How counselors can help military veterans

Afghan refugees are not the only ones struggling with the humanitarian crisis in Afghanistan: Military veterans have been significantly affected too. Veterans might be experiencing feelings of guilt, betrayal, shame, anger, hopelessness, worthlessness or resentment. The U.S. withdrawal from Afghanistan has also caused many veterans to struggle with moral injury, which the U.S. Department of Veterans Affairs defines as the distressing psychological, behavioral, social and sometimes spiritual aftermath of being exposed to events that damages or goes against one’s own moral compass.

Ben (a pseudonym) is a former Marine and personal friend of mine, and for the past 15 years, he has worked as a military contractor in Afghanistan. When I asked him how he felt about the U.S. withdrawal from Afghanistan, he expressed feelings of anger, hopelessness and worthlessness regarding the situation. He was angry and frustrated that he could not go to Afghanistan to help the Afghan interpreters with whom he had previously worked. In his mind, he left his “brothers” behind and that was unacceptable. The thought of abandoning those who risked their lives serving as interpreters haunted him.

Leonid Altman/Shutterstock.com

He felt guilty that many of these interpreters were promised safe passage and a special immigration visa (SIV) to enter the United States for their work as U.S. military interpreters only to discover they were later denied entry. Ben has known some interpreters who have been waiting for as long as 11 years for their SIV paperwork to be approved. The more interpreters reached out to him for help with getting their SIVs approved, the more hopeless and worthless he felt.

He also believes the loss of the war makes it seem like all the sacrifices he and his fellow veterans made were for nothing.

Counselors who work with military veterans should know that moral injury is different than having posttraumatic stress disorder (PTSD). Moral injury can be equally if not more traumatizing because it is focused on feelings of guilt, shame and betrayal. And in my work with military veterans, I’ve found that more of them engage in self-destructive behaviors because of moral injury than from a diagnosis of PTSD.

Here are a few questions counselors can ask clients to better understand a veteran’s wounded sense of morality:

  • What are you feeling? Do you feel guilt, shame, betrayal, anger, resentment, regret, hopeless or worthlessness?
  • What happened to make you feel this way?
  • What did you witness that made you feel this way?
  • Do you feel like you failed to prevent certain events or acts that conflict with your own values, beliefs and principles?
  • Have you found yourself ruminating on things since the event occurred?
  • How would you change the outcome if you had a second chance?
  • Have there been other incidents in your past when you have experienced moral injury?
  • How do you view yourself? Sometimes moral injury comes with a sense of self-loathing and feelings of worthlessness.
  • How do you manage your wounded sense of morality (e.g., substance use, anger outbursts, self-harm or self-destructive behaviors, deep breathing or meditation, volunteering with organizations that help veterans, working with fellow veterans)?
  • What do you need to feel a sense of peace and that you did all you could do with what you had?

How counselors can be advocates

As counselors, we owe it to our clients to advocate for not only their mental health but also their human rights. S. Kent Butler’s vision for his ACA presidential year is to #ShakeItUp and #TapSomeoneIn. These two hashtags represent action. Counselors cannot sit back during this humanitarian crisis and simply sympathize or empathize with military veterans or Afghan refugees. They must advocate and take action.

Licensed counselors could provide pro bono counseling services, process groups specifically focused on trauma or moral injury, or psychoeducational groups on parenting, goal setting or stress management. They could also cofacilitate support groups with Afghan refugees to research the needs of the community. Unlicensed counselors and counselors-in-training can provide similar services with clinical supervision.

Counselors can also volunteer to help Afghans as they rebuild their lives in the United States; this could involve teaching them English or about their basic human rights or helping them figure out where to buy groceries or diapers or how to apply for an identification card. And counselors can facilitate support groups or retreats for veterans struggling with moral injury so they know they are not alone.

There is room for everyone. My challenge to you is to fulfill Butler’s vision to #ShakeItUp and #TapSomeoneIn.

 

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Justina Wong

Justina Wong is a new professional currently earning hours towards licensure at a group private practice in California. She serves on the Military and Government Counseling Association’s board of directors and as a graduate assistant to the president of the Association for Multicultural Counseling and Development. Justina is also a member of the American Counseling Association’s Human Rights Committee.

She wrote this article on behalf of the Human Rights Committee.

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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.

The sensitivity of boundary setting in collectivist cultures

By Shabnam Brady October 11, 2021

In our Westernized culture, we are prone to upholding a dominant approach to managing our relationships that involves boundary setting. Thus, our therapy practices and culture often emphasize setting boundaries as a key element of developing and maintaining “healthy” relationships. The United States mostly engages in an individualistic culture, which can promote and help to sustain boundaries to protect and even nurture a relationship with the self. 

But what about cultures in which the family is at the center and boundaries are often blurred? What is deemed “healthy” in such cultures — and who defines this? These are called collectivist cultures. In collectivist cultures, family members identify closely with one another and often make decisions for the family as a whole rather than for the self. Sacrifice, honor and loyalty are some of the core values of such families and cultures. For example, saying no to the family or setting limits on simple family events or dinners may be perceived as selfish and rude. 

Imagine Maryam, a married mom of two, fatigued from her workweek and yet being asked to host the weekly family dinner. This gathering includes grandparents, uncles, cousins and, of course, mom, dad and siblings. Maryam rushes to the store, then home to cook a very involved rice and stew dish. The family arrives early, adding anxiety to her already-exhausted mental state. 

Later in the week, Maryam attends her therapy session. Her therapist suggests setting limits and saying no to hosting these events in the future or proposing that her sister, Fara, hosts the next time. Maryam agrees, but she struggles because this would mean making a decision for herself and based solely on her own needs. Although this may be considered “healthy” by the dominant culture, it is causing Maryam more stress and, now, added guilt. Maryam may not even feel comfortable sharing these new thoughts with her therapist due to her culture of origin’s boundary for respecting authority (she may potentially view the therapist as the expert and authority). 

Workable boundaries

What do we do, as mental health providers, in the case of Maryam? 

First, we can validate and normalize her emotions. Next, we may pose questions to allow her to further express herself and ponder potential resolutions. In talking with her, we may at some point realize that she is stressed but at the same time happy to see and host her family. There may be no need for behavioral change here; rather, expressing emotions in a safe place and feeling heard by the counselor may be enough for Maryam. Potentially, she may need support identifying her emotions to further express them too. 

If Maryam continues to share concerns about her fatigue level, it may be supportive to suggest what I call a “workable boundary,” with consideration given to her culture and her values. This workable boundary could simply be adjusting the time that everyone comes over so that Maryam has some time to rest first upon arriving home. 

A workable boundary is flexible. It is not rigid like typical boundaries may be perceived or promoted to be. It is similar to a compromise and works to respect the client’s culture of origin and needs. The flexibility may prioritize the client’s culture and empower the client to choose what is workable. 

Straying away from the stringency of a black-and-white approach to boundary setting can be more inclusive. The less we guilt individuals into self-care and self-prioritization, the more we can become aware of their needs, wants, values and cultures. Some individuals in collectivist cultures gain energy, pride, strength and honor when the family is well and happy. 

Prioritizing client boundaries

The connectivity of emotions, identity and well-being in a collectivist family and culture of origin is complex, requiring respect for exceptional and unique boundaries. Roles and authority may serve a special function in the collectivist family experience. 

For example, in my own personal collectivist family experience, as well as in working as a counselor with college and high school students with collectivist cultural backgrounds, I learned that even the majors we chose for our college experiences originated in our family values and expectations. We honored our families by choosing to become accountants, doctors and engineers, among other professions. We struggled and wanted to quit. Yet many of us continued on this path to a field mostly chosen for us by the influence of our collectivist cultures and families. 

Experts on setting boundaries may advise students who are feeling stressed to follow their own career paths, which would encourage straying from the family norm. Here is an opportunity for us to remember our counselor ethics and to prioritize client values over our own and even over those of the dominant culture here in the United States. We can work to be culturally humble and learn to navigate and negotiate values as clients desire to apply them in their own lives. 

The goal of the client seeking counseling at the university counseling center may simply be to feel humbly supported through their time of feeling stuck or yearning to change majors. Their desire may purely be to not feel alone. What seems simple may be forgotten because we are often inundated by the dominant cultural norm of pursuing our own dreams and goals first. While students and clients may report feeling pressure, they may also report feeling pride in their struggles and motivated in their pursuit of this family dream, especially if they are from collectivist, immigrant backgrounds. 

Likewise, choosing whom to marry may be a family-based decision in collectivist cultures. Boundaries may be perceived as vague. Those outside of these families and cultures may view these family roles and relationships as examples of unhealthy enmeshment. Nevertheless, in some cultures, honoring the family will continue to be the foremost concern when making such a major decision. After all, a romantic partner is commonly considered a new member of the family. Thus, the decision requires the approval of the family in these cultures. 

Providing counseling to an individual who is navigating such circumstances and decisions may require offering further values assessment to support the decision-making process. If family is the client’s No. 1 value, this could support the client’s decision to involve the family in choosing a life partner. Setting boundaries prematurely based on individualistic cultural norms may prevent family members from playing their traditional roles in the individual’s life. 

What may be challenging to understand in the dominant culture — including the high value placed on duty, honor and authority — is part of the traditional fabric in some collectivist cultures. Often, we assume that it is harmful for others to choose our life partners. However, in many cultures, this is viewed as the practice of respecting authority and feeling honored to receive this input and potential blessing. Some clients feel excited to enter these life partner journeys with the support and input of their parents and families. Other clients may not, and that is OK too. The purpose of viewing boundary setting from a wider, more culturally inclusive lens is to stop making assumptions about what is “healthy” for all clients and desired by all clients and to stop promoting only the dominant culture’s perspective of boundaries. 

A nonassumptive approach can lead to greater appreciation of the client’s worldview, needs and ability to reach decisions with the support of the therapist. Open-minded, nondominant cultural perspectives can further encourage this process. Taking such steps can also lead to less guilt, potential shame and frustration on the part of clients who experience the world as bicultural (i.e., negotiating and identifying with two cultures). 

It is often more convenient to go along with the dominant culture’s expectations. Likewise, there is frequently less judgment when choosing the dominant culture’s norms. However, this can be harmful for individuals who appreciate and potentially want to choose collectivist cultural values and norms in some life areas. The pressure many may feel in such situations can be overwhelming. For example: wanting to live at home beyond the age of 18, wanting to date someone chosen by one’s parents, wanting to name one’s child with a chosen family name. 

These are just a few examples of the many decisions children and adults who are bicultural may face (and prefer to make) that others can regard as boundary “blurring.” The therapy setting can provide an open, safe space for clients to explore and arrive at decisions that are best for them, taking all cultures involved into consideration rather than focusing only on the expectations of the dominant culture. Counselors can set aside the boundary-setting trend that might seem liberating on the surface but that may in fact be confusing for some individuals from these cultural backgrounds. By diminishing the idea that inflexible boundary setting is the “healthy” option when it comes to managing interpersonal relationships and life decisions, the lifestyles and complexities that many culturally diverse individuals and families experience and prefer can be included and explored.

Sumala Chidchoi/Shutterstock.com

Culturally inclusive practices

I am a bicultural, immigrant American therapist and individual who has experienced and navigated, both personally and in session, the guilt that can arise from the boundary-setting expectations of the dominant culture. In choosing my life partner, I practiced strict boundary setting with family members in my collectivist culture. In choosing to go to graduate school to earn a doctorate, the boundaries were workable, blurred and, at times, enmeshed with my family’s dreams and goals. 

I have supported many diverse clients in navigating different areas of life, including grieving differently than their family, by using workable boundaries that include both their cultural and individual needs. The following steps can support more culturally inclusive practices for navigating boundary setting in collectivist cultures. 

>> Develop and pose questions or prompts that reduce the potential for “dominant culture speak,” such as “your needs” and even the word “boundary.” Instead, consider adding to your language the phrases “cultural considerations” and “family needs tied to your needs and wants.” For example, a possible question to explore with the client is, “I hear that’s hard for you. What are some ways you can meet your family needs that perhaps seem to influence your needs, especially with the weekly family dinners?” 

>> Explore the topic of guilt with clients. How does guilt affect them interpersonally and emotionally? Does it apply in their identity, role and cultures? How, if it all, does guilt come up when considering boundaries with family members, partners or friends? 

>> Investigate what the word “boundary” means to the client. Does it have a meaning? Is it culturally relevant for them or is it a new concept? How would they like to incorporate it into their wellness journey, if at all? 

>> Offer psychoeducation on boundary-setting practices for potential emotional wellness while acknowledging cultural implications. Then ask for feedback and reactions. What does the client think of this concept? Do they agree or disagree? Why? Would they like to explore these practices in their life? 

>> Finally, individualize boundary-setting practices to respect the client’s culture, needs and wants. Assess what these practices are and introduce concepts such as workable boundaries or more innovative ways that may work for the client in an inclusive style. Implement a feedback model in therapy to assess the client’s satisfaction level with such strategies.

 

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Shabnam Brady holds a doctorate in counseling psychology. She is a therapist, professor, author and founder of Therapy for Immigrants (@therapyforimmigrants), an Instagram community whose aim is to raise awareness and expand inclusivity practices in mental health for immigrant communities. Contact her at drbradytherapy@gmail.com.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.

The unique challenges that face immigrant clients from Africa

By Stephen Kiuri Gitonga May 10, 2021

Immigrants to the United States have one goal in common: to attain the American dream. For many, this dream means leading a life with fewer struggles than they experienced in their countries of origin. Africa is the second-largest continent in the world, stretching from Senegal to Somali (west to east) and Tunisia to South Africa (north to south). It has 54 countries and a population of approximately 1.3 billion people. There are about 3,000 African tribes, each of which speaks its own language or dialect.

The most widely spoken languages in Africa include English, Arabic, Swahili, French, Portuguese, Akan, Hausa, Zulu, Amharic and Oromo. It can be easy for counselors in the United States to assume that one Black client is like the other Black client, when in fact one might have been born and brought up in the U.S. and the other might be a first-generation immigrant from Africa. Such an assumption would be disadvantageous to clients from Africa because their varied and diverse experiences would be ignored. If these experiences contribute to the client’s presenting problem and yet are disregarded or overlooked by the counselor, then treatment of the presenting problem would be challenging or even elusive. 

It is important for counselors to take stock of the unique challenges that afflict immigrants from Africa and could complicate their lives in the United States. Mental health counselors are encouraged to pay special attention when working with this population to address the presenting mental health problems and other issues unique to these clients that, if left unaddressed, could have a negative impact on their well-being.

Culture shock

Relocating from Africa to the United States is likely to be a culture shock for the immigrant client. In fact, many immigrants from Africa experience culture shock even before they travel to their new country. 

The process of securing a visa to travel to the U.S. is a daunting experience that takes months — and sometimes years — to complete. Applicants physically go to the U.S. Embassy offices in their countries or regions to attend interviews and complete official paperwork related to their travel. At these offices, they are likely to see armed white police officers in full gear, complete with duty belts, guns, sunglasses and other items dangling from the belts. Applicants may feel intimidated by the sight of these officers, having previously been accustomed to seeing Black police officers carrying gear that is less threatening. 

The interview determining potential receipt of a travel visa can go either way, and applicants are aware that if they are denied, they will not necessarily learn why they were not issued visas. Issuance of a visa is the prerogative of the immigration office. There is no provision for explanations in cases of denial, although candidates can submit new applications for consideration in the future. 

Once African immigrants actually travel to the U.S., they are likely to experience culture shock in multiple ways. Depending on such factors as their previous experience with international travel, their country of origin and the port of entry to the U.S., new immigrants may be shocked by the size of the cities, highways, forests, rivers and lakes, and the sheer amount of food that gets served on a plate. They also observe that cars generally carry fewer occupants than they are used to and that there are more people driving up and down the streets than people walking or using public transportation. Immigrants from Africa also quickly realize that they are a minority race in the United States — a stark contrast to their majority status in their country of origin.

Another cultural experience that may be shocking for the new immigrant from Africa is the sole use of English to communicate. Code-switching, which is common among people who are bilingual, is not possible when English is the only language in use. Other things they learn or observe include the high cost of living, differences in dressing, the prevalence of low-context interpersonal interactions, driving on the right side of the road, a love for sports that are unique to Americans, people who are homeless, panhandlers on the streets, and the menace of opioids, to name but a few. 

The COVID-19 pandemic has introduced another complication to the cultural experiences of immigrants from Africa. In line with their social nature, these individuals support one another whenever a member falls sick by visiting and helping with child care, cooking and other household chores. COVID-19 safety guidelines do not allow people to congregate, especially around someone diagnosed with the disease. While the COVID-19 pandemic was peaking, it was common for people to be buried in communal graves. From an African context, it is uncommon for a person to die and for the bereaved family to be unable to complete all the rituals associated with funerals. It may take time for immigrants from Africa to come to terms with these tragic experiences.

Past and present trauma

Depending on their country of origin, some immigrants from Africa may have preexisting posttraumatic stress disorder or other disorders that have gone untreated from such events as war, physical abuse, sexual abuse, accidents, displacement, political violence, intertribal clashes or terrorism. There is ongoing instability in such countries as Somalia, South Sudan, Chad, Ethiopia, the Democratic Republic of Congo, Libya and the Central African Republic, with many casualties every year. In Nigeria, there is ongoing violence instigated by the terrorist organization Boko Haram. 

Survivors of these instabilities may end up immigrating to the U.S. as refugees or enter the country under another status. Their traumatic experiences in their countries of origin, compounded by new traumatic experiences in the new country to which they have immigrated, can be challenging to treat. Many of these individuals may be unaware that they even have a treatable condition. 

Loneliness

Research points to the seriousness of loneliness to one’s mental health. People immigrating to the U.S. may suffer prolonged periods of loneliness before they form meaningful relationships within their host communities. Loneliness can be compounded by cases of rejection, discrimination, isolation, stereotyping, microaggression and so on in their new communities.

They are often unable to communicate on a regular basis with family members back in their country of origin because communication by mail can take a long time and international phone calls are expensive. Loneliness, coupled with other problems, can lead to depression or degenerate to suicidal ideation for this population. 

Language

Only a small minority of immigrants from Africa report English to be their first language. Most of them have learned other languages before English. Student immigrants from non-English-speaking countries encounter fewer problems because they are usually enrolled in English classes during the first semester of their respective programs. Others who were fluent in English in their country of origin are often surprised at how different American English is from other English dialects and accents. 

Fluency in language is important for self-expression and self-esteem. Immigrants who struggle with the English language might have a harder time adjusting to their new life in the U.S. Another disappointment they typically experience is inability to code-switch — i.e., switch from one language to another — like they were used to doing before their relocation. This is because most of the members of the majority culture with whom they now interact speak only in English. 

New identities

Immigrants from Africa are faced with changing their identities in multiple ways upon arrival in the U.S. For example, in their country of origin, there may have been certain activities and roles such as child care, cooking, driving, mowing the lawn, financial management and so on that were classified by gender. In the U.S., these responsibilities are more commonly shared between men and women. 

If African immigrants were wealthy back in their home country, they likely had employed the services of a live-in houseworker to help with such chores as child care, cleaning, laundry and cooking. These chores must now be shared between the couple irrespective of their gender. Assignment of these responsibilities is often a major source of discord among couples who have emigrated from Africa. That is because in many cultures in Africa, it is the responsibility of the woman to cook, clean, do laundry and take care of the children, irrespective of her other daily roles and responsibilities. Once the couple has immigrated to the U.S., it is often difficult for their families back in their country of origin to understand this new setup of shared responsibility. Families in the country of origin will often comment that the immigrants have lost their cultural identity.

Loss

Immigrants from Africa experience multiple losses as they settle in their new country. Examples of losses include identity, wealth, social status, family bonds, language, cultural traditions, freedom, innocence, traditional food, life goals, favorable climate and familiarity. Depending on the impact of these and other losses, immigrants from Africa may need mental health help to cope. 

It has been particularly challenging for African immigrants during the COVID-19 pandemic to deal with the resultant losses. They are used to living a social life in which they congregate for no apparent reason. During the pandemic, they have largely lost this aspect of their culture because of restrictions on in-person socializing. Likewise, when fellow community members are hospitalized, they cannot be visited. When people die from COVID-19, there is added pain due to restrictions on viewing the deceased or completing traditional funeral rites. Additionally, at the height of the pandemic, people who died from COVID-19 were buried in mass graves, while others were cremated. These are not common practices among many cultures from Africa.

Family relationships

There is a common tradition in Africa alluding to the fact that it takes a village to raise a child. Extended family members, relatives and neighbors are all expected to be involved in the well-being and development of growing children. Immigrant couples do not typically have the luxury of the village caring for their children in the U.S., whose dominant culture is individualistic rather than collectivistic. If these parents are busy at work, college or with other commitments, they take their children to day care for a fee because they are no longer surrounded by close family members or friends who would have cared for their children. This can become a major source of family relationship problems for immigrants from Africa, particularly when these fathers must change their traditional attitudes and beliefs to share responsibility for child care. 

Parenting is another source of strained relationships among African immigrant families. This is in part because the village is now absent, and the couple is left to care for their children with little outside help. In addition, parenting styles in the U.S. are different from parenting styles in Africa. African parents’ cultural practice of disciplining a child may be construed as child physical abuse in the U.S., potentially landing these parents in trouble with the law.

In Africa, the cost of raising a child is low in comparison with the U.S. For this reason, immigrant couples may decide to have fewer children or not have children at all. There are also differences between the first generation and second generation of immigrants from Africa. Second-generation children have greater exposure to the mainstream majority culture and are more likely to be influenced by it. Attempts by the parents to teach the second generation the value of maintaining their culture is often met with resistance, and this can strain family relationships.    

The American dream

The common belief among aspiring immigrants from Africa is that the American dream is easily attainable. Some interpret the dream to be good education, wealth, good health, affordable health insurance and stable income. 

While some immigrants do attain the American dream, others struggle. For the latter, the lack of attainment may become a source of self-pity, shame and guilt, particularly because their family back in their country of origin may not understand that not everyone in the U.S. is wealthy. Some begin to question why they immigrated and may consider immigrating back to their countries of origin. Problems could then arise if communication within the family is not effective.

Racism

The Black Lives Matter movement has unearthed social ills that have plagued the United States for many years. As a marginalized population, immigrants from Africa may be the targets and victims of discrimination, racism, bigotry, hatred, microaggression and other social ills often propagated by institutions that are supposed to protect them. 

Now that these ills have been widely exposed, there is a possibility that they will become added sources of anxiety and associated mental health issues. Questions may arise for these immigrants regarding how safe it is to continue living in a country where they are openly not wanted. Family and friends in their country of origin may begin to have similar questions and feelings and urge them to return home.

Education

When immigrants from Africa enter the U.S. on an F-1 student visa, they are expected to maintain their student status and follow the strict guidelines from the U.S. Citizenship and Immigration Services until they complete their studies. Some of the stipulations include maintaining full-time student status by taking the required number of courses per semester and maintaining passing grades. They are not allowed to seek employment without authorization. Such authorization, when granted, permits them to work for 20 hours per week on campus. 

The cost of higher education for international students is high. Many students are not able to afford tuition to complete their studies and may end up dropping out of school. When that happens, they lose their student visa status and begin the cat-and-mouse game of evading U.S. Immigration and Customs Enforcement for violating their immigration status. 

Students who complete their studies are granted the opportunity to apply for a change of status to become U.S. permanent residents, especially if they have completed graduate studies in high-demand programs such as software engineering, nursing, medicine, computer science and so on. The process takes time, but it is the safer route that most students follow to ensure their continued stay in the country and their eventual attainment of the American dream. Before that happens, they live in constant fear of being deported.

Acculturation

Over time, continued interaction between immigrants from Africa and the majority population in the U.S. results in acculturation. Immigrants pick and choose aspects of the majority culture to adopt and aspects of their respective cultures to retain. In a symbiotic and ideal relationship, the majority culture picks aspects of the immigrant population to adopt as well. It is important that counselors working with immigrant clients from Africa encourage them to maintain aspects of their culture that are meaningful to them, lest they lose their identity completely.

Another source of family conflict may happen when children abandon some of their family’s cultural aspects in favor of aspects of the majority culture. This occurs during the preteen and adolescent years when they are developing their identities, often influenced by the majority culture. It becomes a problem if their parents are not in favor of the adopted tenets of the majority culture. 

Drug and alcohol use

Alcohol in most African contexts is used to serve social and traditional purposes. With the mainly communal lifestyles, people look out for one another to avert misuse in a “brother’s keeper” sort of way. But these close relationships are largely or completely absent in African immigrants’ new country of residence. Here, they do not have close friends or family members to keep an eye out for them or with whom they can share their problems. 

Without education and awareness of mental health counseling, some immigrants from Africa turn to self-medication with alcohol, drugs or both. Addiction is now a serious problem afflicting African immigrants, and it is good practice to assess for drug and alcohol use, even if this is not the presenting issue brought to counseling. Left unchecked, drug and alcohol dependence could easily degenerate into a generational problem that afflicts current and future generations.

Treatment guidance

Professional counselors should consider the following items when working with clients who are
African immigrants.

> Assessment: Effective treatment begins with a thorough assessment. In addition to the issues brought to counseling, it is important for mental health counselors to assess for other issues that are not so obvious. For immigrant clients from Africa, counseling may still be a new concept. They might not be comfortable sharing their problems with strangers. Hence the need for counselors to select assessment instruments and procedures that are less intrusive. 

> Rapport: Research points to the significance of developing therapeutic rapport with clients early in the counseling process. It is also necessary to maintain this relationship throughout the counseling process. It will likely require additional effort to build and maintain a trusting relationship when working with immigrant clients from Africa because counseling may be a new concept for them. In addition, it may be necessary to educate these clients on what mental health counseling is all about and their roles and responsibilities in the counseling process. 

> Cultural sensitivity: Mental health counselors are cultural beings, and they bring their culture to the counseling relationship. It is vital for counselors to be constantly aware of their culture, including the biases, beliefs and stereotypes that they hold about immigrant clients from Africa. It is also imperative that counselors refrain from imposing their culture on these clients. 

It is beneficial for counselors to learn about the unique culture of their immigrant clients from Africa by setting time aside for cultural immersion and attending ethnicity-specific cultural activities from time to time. They will then use ethnicity-specific and evidence-based interventions to work with these clients. 

> Self-care and wellness: Mental health counseling can drain our emotions and energy. Therefore, mental health counselors should engage in a self-care regimen, maintaining regular self-care activities and schedules, to reenergize. Likewise, it may be helpful to educate our clients who are immigrants from Africa on how to engage in self-care and identify wellness strategies for their improved mental health and enhanced overall health.

 

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Stephen Kiuri Gitonga is an assistant professor in the clinical mental health counseling program at Lock Haven University in Pennsylvania. He is a licensed clinical mental health counselor licensed to practice in Idaho, Kentucky, Utah and Pennsylvania. Contact him at skg200@lockhaven.edu.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.

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.