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Breaking the silence around the childhood sexual abuse of Black men

By Lisa R. Rhodes August 30, 2022

In October 2019, Tyler Perry, the multimillionaire writer, actor, and movie and television producer, shared painful details from his childhood in an interview with People magazine. “I don’t think I ever felt safe or protected as a child,” Perry recounted, as he explained how his father, who he later learned was not his biological father, routinely beat him with a vacuum cord.

In addition to the physical abuse, Perry disclosed that by the time he was 10 years old, he had been sexually abused by three different men and a woman — all of whom were known by his family. 

“It was rape,” Perry said in the interview. “I didn’t know what was going on or the far-reaching effects of it.”

Perry is not the only Black male public figure to reveal that he was sexually abused as a child. Other Black male public figures, such as gospel singer Donnie McClurkin, have come forward to reveal the harmful impact of this early trauma. Despite these public disclosures, the silence that surrounds the childhood sexual abuse of Black men is deafening. 

“In many homes and social circles, the topic is still avoided — it’s taboo,” says Robin D. Stone, a licensed mental health counselor in New York City and a survivor of childhood sexual abuse. “In some cases, men haven’t shared with anyone that they’ve had this experience, that they have this history.” 

The fact that it is taboo means that Black boys who have been sexually abused rarely, if ever, tell anyone that they have been violated and the silence continues into adulthood. Stone, a member of the American Counseling Association, says the impact of childhood sexual abuse on Black men leaves them with psychological wounds that they learn to “pack away” for years.

The silence surrounding this issue makes it difficult to know how pervasive it is. According to a 2006 study by the Centers for Disease Control and Prevention, about 1 in 6 boys in the United States were sexually abused before age 18. And the Children’s Assessment Center acknowledges that race and ethnicity are key factors, with Black children being almost twice more likely to experience child sexual abuse than white children. 

Rebekah Montgomery, a licensed professional counselor and owner of Dove’s Heart Counseling LLC, a practice with offices in Ann Arbor, Michigan, and Detroit, agrees that sexual assault and any form of sexual abuse are rarely discussed in the Black community.

“You can learn proper coping skills, you can reframe your brain, but it is still going to be something that can trigger later in life,” says Montgomery, an ACA member who counsels Black male survivors of childhood sexual abuse. “When you awaken those sexual feelings as a child, especially before puberty, you develop unhealthy ideas about what sex is and what’s appropriate and not appropriate.”

Building trust and safety

The counselors interviewed for this article all agree that to build rapport with Black male clients, counselors must be willing to engage in direct, honest and open communication, which creates an environment where the men feel safe enough to trust the therapeutic process. 

“I feel when they come [to counseling], they want to say something [about the sexual abuse], but you have to build their trust because they live in a country where — because of the color of their skin — they don’t trust because things have worked against them in very purposeful ways,” says Damion Davis, a licensed professional counselor in Addison, Texas. 

“In some cases, African American men don’t trust counselors who are of a different race than they are because they assume that there won’t be a cultural understanding,” he adds. “If there’s not a cultural understanding, then they don’t feel comfortable disclosing things.” 

Davis focuses on creating a strong relationship with his clients. During the first session, he works to establish trust with his clients by asking them about their family connections, where they went to school or college, and where they grew up. He also allows clients to ask him questions, such as about his credentials and educational background. And he keeps a photo of his wife and daughter in his office to remind clients that he is human.

“It’s about mutual transparency,” says Davis, an ACA member and founder of the Davis Counseling Center PLLC. 

Montgomery says a personal connection is also important in her efforts to build rapport with clients. She discusses the ethics of counseling, confidentiality and her responsibility to ensure a client’s physical and emotional safety with every client who comes into her office. She also lets clients know that during therapy they can express whatever thoughts or feelings they may have.

“My office is a judgment-free zone. All thoughts and emotions are welcome,” Montgomery says. “I like the office to feel comfortable enough for you [the client] to feel the way you need to feel, at least for that hour.”

Montgomery says she is also open to clients asking questions about her credentials and counseling experience. “They want to know they’re in good hands,” she says. “They need to get to know me just as well as I need to get to know them.”

Counselors should also acknowledge if there’s a gender or racial/ethnic difference between the counselor and client, advises Stone, owner and founder of Muse and Grace Mental Health Counseling Services in New York City. Acknowledging any differences upfront can help create a safe space for male clients to share their experience or to ask the counselor questions, she explains.

“If there’s an elephant in the room, talk about it,” she says. “It’s there whether you name it or not.” 

Montgomery recommends counselors “take on the role of an expert learner” when providing treatment for clients of diverse backgrounds. “You have to be aware enough to listen and learn and apply your therapeutic techniques on a case-by-case basis,” she says. “It has to be an equal exchange of awareness, growth and learning to make it comfortable and [to] help them feel comfortable in the therapeutic environment.”

Disclosing the abuse

The results of this early trauma can lead Black men to seek counseling — but for reasons other than sexual abuse. Montgomery says some of the reasons why Black men come to her practice include anger management, depression, anxiety and sexual dysfunctions. Clients may come to counseling because they were caught looking at pornography while they were at work and are in danger of losing their jobs or because they’re having intimacy problems with their wives, she adds. 

Although these symptoms can often be traced to childhood sexual abuse, many men are often unaware of the origins of their problems, Montgomery notes. “During the therapeutic process, experiences with sexual assault emerge and often get identified as a feasible cause of their mental and emotional concerns,” she says.

The counselors interviewed for this article say a client’s reaction to the realization of childhood sexual abuse can result in a tacit attempt to accept the trauma, conflicted feelings about the experience, doubts about their intrinsic worth or concerns about their sexual orientation.

“Sometimes it’s a confirmation,” Montgomery says. “They’ve already been kicking around the idea. They never thought of it [the trauma] as being [sexual] abuse, but after we confirm that they were sexually abused, they say, ‘Yeah, I kind of figured it.’”

Montgomery says confirming childhood sexual abuse often starts with asking clients how the experience made them feel. “Most Black men recognize that the sexual abuse can cause conflicting feelings,” she says. “At the time of the abuse, they may have been conflicted by their physical enjoyment and the emotional toll the abuse left.” 

“Most men never disclose their sexual experiences, so we explore the unspoken rule of keeping the abuse a secret,” she continues. “We explore [state] laws that define sexual abuse/assault, including the age of consent, the difference between molestation and rape, and [the] potential consequences for someone who sexually abuses children.” 

Davis, a clinical assistant professor of counseling at Southern Methodist University, says he is often the first person his clients have told about their abuse. “It’s really hard [for them] to accept the fact that the abuse happened because it leads to feelings of low self-esteem, inadequacies and, of course, anger,” he notes. “They feel this way because being sexually abused for them is very emasculating. It makes them question their manhood. A lot of people, but definitely Black men, like to feel a sense of control.” But when the abuse happened, they felt they had no control over their circumstances, Davis says. 

It’s OK to express emotion 

Counselors may first have to help Black men understand that they are allowed to have feelings and emotions about the experience. Stone, author of No Secrets, No Lies: How Black Families Can Heal from Sexual Abuse, notes that boys, particularly Black boys, are raised to believe that expressing emotions and anything other than the binary feelings of anger/happiness or weakness/strength is not allowed. 

The taboo about childhood sexual abuse is so persistent because “many boys continue to be socialized in ways that leave them little room to be vulnerable and to express vulnerability,” Stone says. “If they aren’t able to access their feelings, they struggle socially and grow up to be men who struggle socially.”

Montgomery notes that hiding or suppressing emotions has been a survival strategy for African Americans, especially boys and men. Historically, expressing feelings or emotions carries a serious threat of violence and death — from lynching to being shot or killed by the police, she says. 

Montgomery learned that Black men can put up a wall of defense against feelings and emotions when conducting research for her doctoral dissertation, which explored connections between the low use of professional mental health services by Black men in the inner city and their exposure to chronic trauma.

“I was pretty shocked by the results,” she says. All 10 of the men she interviewed for the study recognized that they had experienced some form of trauma, such as police brutality, violence and the implications of racism. But they did not consider how being guarded toward others, expressing pent-up anger, being defensive or declining to address mental health issues such as depression or anxiety can be a problem, she says. 

Montgomery says the men responded to the trauma by developing a “coat of protection” that served as a valuable tool for survival. And she says she sees this same “coat of protection” in Black men who have survived childhood sexual abuse. Her study reinforces the importance of helping this clientele to express and process their feelings and emotions. 

When clients have a hard time expressing how they feel about the abuse or don’t know what word or words may fit what they are thinking or feeling, Montgomery asks them to do a Google search for “feeling words” on their smartphone, and then together they explore educational websites (such as psychpage.com/learning/library/assess/feelings.html) that list different feeling words, along with charts and pictures, to help them define the word or words that best describe their emotions or feelings. 

Some clients have a limited vocabulary to describe their feelings, Montgomery says, and this exercise helps them overcome that by increasing their vocabulary and awareness about the complexity of emotions. For example, they learn that sadness can also be described as disappointment, and someone who is mad may be resentful. And it reminds clients that “they have emotions and feelings and its OK,” Montgomery adds.

“We spend time identifying emotions and giving them a name,” she continues, “and we try to find the word that best fills in the blank” of how they feel about a situation or experience.

After selecting a word from the list, discussing its meaning and talking about whether it matches their emotions or feelings, clients can say, “I’m feeling disrespected right now” or “I’m feeling jealous right now.” And once clients can correctly name what they are feeling and understand its meaning, they will “always know what that feeling is in every situation,” including experiences from their past, Montgomery says. 

Monkey Business Images/Shutterstock.com

She also recommends using trauma-focused cognitive behavior therapy (TF-CBT) with this population. Although TF-CBT is typically used with clients who are under the age of 18, she says these techniques can also be beneficial for Black men who have experienced childhood sexual trauma because it will help them learn healthier ways to cope with the trauma. This approach allows them to process their feelings and emotions rather than avoid them, reframe thoughts and behaviors resulting from the trauma, develop new behaviors and skills that bring a more desired or healthier outcome, and create healthy relationships, she explains. 

Stone says that incorporating poetry and bibliotherapy into treatment can also help survivors process emotions. She often uses James Pennebaker’s expressive writing framework with clients who have experienced trauma. “His research shows that expressive writing helps to ease psychological and physical symptoms related to trauma and other disturbing experiences,” she notes.

This framework asks “the client to write their deepest emotions and thoughts about a disturbing experience for 15 to 20 minutes a day over four days,” Stone says. “I then invite them to reflect on what they wrote (not necessarily to share it with me) and to consider how what they wrote makes them feel, where they feel it in their body and what, if any, changes they may want to make in the way they think or in the way they are living.”

To help clients connect to a fuller spectrum of feelings, Stone also has clients practice connecting their experiences to feelings and then their feelings to bodily sensations. She uses a feeling wheel, similar to the one developed by Gloria Willcox, to help clients explore what their body feels like when they experience certain emotions such as insecure, embarrassed, bored or proud. This helps the client identify feelings and “become more fluent” in expressing how they feel, Stone explains.

Davis recommends counselors normalize clients’ feelings of anger, shame, guilt or embarrassment about the abuse. Normalization, he explains, helps to break down the stigma  associated with being a survivor of child sexual abuse. “It helps them to know that they were victimized, but they are not victims,” he says.

Counselors need to affirm these clients, Davis says, and let them know they can work through the trauma of the experience and deconstruct some of the negative stigma that is tied to being a Black man who was molested. 

“I tell them [clients] how they feel is appropriate because someone has taken advantage of them and together, we’re going to build them up from there,” he says. “I let them know they’re not the only man who has gone through this. … I remind them that the worse part of what they’ve gone through is over. They are in recovery mode.”

Reframing the narrative 

Davis uses narrative therapy to encourage clients to tell their own story about the abuse. This approach, he says, can help clients “define the trauma in their own words and control the details of it.” He says it’s not necessary for him to know the exact details of the sexual act, but it is important to hear the client’s story because survivors attach meanings to the experience and to the abuser.

“Many times, they don’t realize that the meanings they have attached are very negative and they assign it to themselves. They don’t assign it to the abuser,” he notes. So he works with clients to help them explore the meanings they have attached to the experience, and together they begin to pull away the layers so clients can see what happened to them without assigning negative thoughts and feelings to themselves.

Davis also encourages clients to “think about their thinking” and “put negative thoughts on trial.”

He once worked with a client in his 30s who was molested by another man when he was a teenager. When disclosing the abuse, the client said, “I should have known better.” 

Davis helped the client put that thought on trial. They discussed how the client felt sad, embarrassed and angry at himself because he thought he should have known how to prevent the abuse. Davis then asked him, “What evidence do you have that this thought is true?” 

Davis also asked the client to image a child who is the same age he was when the abuse occurred and if he would blame that child for being sexually abused by someone they trusted. The client said he wouldn’t blame that child. So Davis asked, “But you blame yourself?”

Reframing the issue in this way, Davis recalls, helped the client consider alternative truths about his own abuse and realize he was being unfair to himself in his thoughts and feelings about the abuse. 

Montgomery says she tries to reframe unhealthy behaviors in her work with clients who have been sexually abused. One client, in his late 40s, came to see Montgomery because he was angry and didn’t know why he felt this way or how to process those feelings. The client did not recognize that he had been sexually abused as a child or that his feelings of anger were due to the death of his abuser, she says. 

This particular case was complex, Montgomery continues, because the client grew up in an environment wherehe was exposed to women in the adult sex industry, and from the time he was a teenager, some of these women routinely had sex with him. Crime and violence were also a part of his environment, which compounded the trauma, she adds.

Montgomery learned that he had also been abused by a female family member, but he viewed all of these sexual experiences as a “rite of passage” into manhood. Montgomery says the client told her that he’d had sex with “hundreds of women,” but he did not recognize that legally he had been violated by his female sex partners. 

Black men often have a hard time seeing being abused by a woman as sexual assault or rape, Montgomery explains. “If you’re sexually abused by a woman, it’s like, ‘Congratulations! Good for you,’” she says. 

Hypersexual behavior can be a response to the trauma of being abused as a child and it can lead to unhealthy behaviors if not addressed, Montgomery notes. This particular client did not understand how years of indiscriminate sex with multiple partners as a youth was an unhealthy behavior that posed a danger to his well-being, she says.

Montgomery used psychoeducation with him to discuss the risks of hypersexual behavior, such as sexually transmitted infections, pregnancy, emotional baggage from multiple partners and problems with true intimacy in relationships.

Montgomery and the client also focused on harm reduction in session. She says they discussed what needs the client felt were being met when he had the desire to have sex with multiple partners and how he could meet those needs in another way. The client decided that when he felt the need for attention or to be loved, he would choose to have sex with only one or two partners rather than multiple women, go the gym or shooting range, or spend time with his children. 

The goal, she says, was to redirect the client’s energy from unhealthy behaviors to more positive choices. “We tried to help him tie his emotions to his behavior,” she explains, and to change that behavior so he wouldn’t cause harm to himself or others. 

Counselors may also have to help Black men who were sexually abused by a man process their feelings and emotions around their own sexual orientation. Because of negative stereotypes associated with homosexuality within the Black community, some Black men “may feel like their manhood was tainted because of what happened to them,” Davis says. Cognitive restructuring and psychoeducation about sexual orientation, he notes, can help clients articulate what their sexual desires are and learn that they, not the sexual abuse, define their sexuality. 

He also tells clients, “An experience that happened to you, that was not your choice or free will, doesn’t define your sexual orientation.” 

Reclaiming power 

Disclosing childhood sexual abuse can also result in victim blaming or self-blame, Stone notes, and blame can even come from peers or family members. There’s often the belief that the survivor “should have done something” to prevent the sexual act or in response to the abuse, she says. 

Stone advises counselors to help clients think about what it meant to be small and/or vulnerable and how much “social capital” they or the people who perpetrated the abuse had in their family or community. “I use ‘social capital’ to speak to the extent that one is known and trusted and has influence in a social dynamic, such as a family,” she explains. 

Boys are most often abused by someone who has social capital in the community, such as a coach, minister or family friend, Stone says. She suggests counselors discuss how much power or social capital the client thought they had in the situation by asking them, “Who do you think would have listened to you? Who might have taken you seriously? Who do you think would have been on your side if you had told them what had happened to you?”

Counselors can also acknowledge the strength it took for the client to survive the sexual abuse and to seek counseling, she adds. “It’s a radical act of self-care” to seek professional help, Stone notes, and counselors need to say so.

Davis says the low self-esteem that clients experience can also lead to feelings of fear and anxiety. “You feel you’re always on pins and needles because you’re waiting for the next thing to happen to you,” he explains. 

Davis uses imagery exercises and reframing thoughts to help men break from a victim mentality and reclaim their power. Approaching it this way allows clients to learn to “separate themselves from what happened to them,” he says. “I have them imagine who they were when the abuse happened, and I have them imagine who they are now, standing by that person.”

He also helps clients understand that because they were children when the abuse occurred, they couldn’t protect themselves. He then asks clients, “What are you and I going to do now to protect that 12-year-old you?” This question, Davis says, can lead to a discussion on ways the client can create healthy boundaries and a sense of safety so they aren’t afraid they will fall victim to sexual abuse again or be taken advantage of by others. 

“Many times, when a person experiences trauma, they get stuck there,” Davis says. “But I help them by reframing their thoughts and [bringing them] to the present day.”

Reaching out to black men

The counselors interviewed for this article all agree that the profession can do more to encourage Black men to come forward and seek mental health treatment. Montgomery suggests that counselors of diverse backgrounds and specialties advertise the fact that they treat people from marginalized groups and that they specifically treat men who have survived childhood sexual abuse. 

The Black men she interviewed for her doctoral study suggested some possible ways to improve the Black community’s access to mental health support services that she says can also apply to outreach efforts concerning sexual abuse for all Black men, particularly boys. These solutions include promoting the idea of positive mental health services in elementary schools; normalizing discussions about mental health, sexual abuse and other traumas; providing interventions for coping with and calming emotions early in life; and encouraging and normalizing help-seeking behaviors.

Counselors need to be “in places where Black men are,” Davis stresses. He plays in a basketball league with other Black men, and because many of them know that he is a counselor, they sometimes ask questions about mental health issues. When they do, he connects them with other mental health professionals who can help them. Davis also suggests clinicians reach out to universities and colleges, Black Greek fraternities and Black churches to find and connect with people who may be in need of counseling services. 

The counseling profession should reach out to Black men, he says, instead of waiting for this clientele to “reach out to us.”

 

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Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

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

Building trust with reluctant clients

By Bethany Bray June 22, 2022

The Washington Post’s “Dear Carolyn” advice column recently fielded a question from a person who was unsure if they were ready to seek counseling to cope with a strained relationship with a parent. Although the person was aware that counseling could be helpful in this particular situation, they were still reluctant to seek services. “I can’t bear the thought of sharing any sort of emotions or history with a complete stranger, especially when I hear people have to reshare as they try two or several counselors to find the right one,” they wrote.

In her response to this letter, advice columnist Carolyn Hax advocated for the person to try counseling and addressed their hesitancy by saying, “The ‘total stranger’ is actually the point. … That extra, disinterested, trained, and informed set of eyes can help any of us see things we’re too close to see.”

The author of this letter is hardly alone in their hesitance. Data from the National Alliance on Mental Illness indicates that roughly one in five American adults experienced mental illness in 2020, yet less than half received treatment.

And part of this reluctance may stem from the fact that counseling does involves being vulnerable to a stranger — albeit a professional stranger — and working through emotions, trauma and issues that can be painful, sad or fear-provoking. When combined with feelings of shame, stigma or bad memories of a past therapy experience, it’s no wonder that clients are often nervous, fearful or hesitant to start counseling.

Counselors understand the importance of the therapeutic relationship. But when a client is hesitant or reluctant, practitioners need to make trust and relationship building the central focus of counseling work, along with a little extra patience and unconditional positive regard.

An extra dose of validation

Bri-Ann Richter-Abitol, a licensed mental health counselor (LMHC) in New York and a licensed clinical mental health counselor and supervisor in North Carolina, has worked with clients who were so apprehensive about trying counseling that they were visibly shaking in their first few sessions.

Richter-Abitol owns a private practice in Wake Forest, North Carolina, that specializes in counseling for anxiety disorders. She and her staff offer individual and group counseling with a focus on creating a welcoming, nonintimidating environment.

When a client’s body language indicates that they’re nervous or hesitant as they begin counseling, Richter-Abitol uses it as an opportunity to acknowledge their concern and validate that what they’re doing is hard. Her focus becomes normalizing the therapy process, rather than jumping into any kind of assessment or intake regimen.

“This [hesitancy] is extremely common, even for clients who have been in counseling before. … If I notice that a client is really anxious, I use immediacy and point out that it is scary to be here, and I applaud them for coming in,” says Richter-Abitol, an American Counseling Association member.

Clients who are hesitant to try counseling need transparency, patience and an extra dose of validation from their counselor, agrees Megan Craig, an LMHC who counsels clients at a community mental health agency in the Boston area. She often emphasizes to clients that they’re not doing something “wrong” if they are having trouble opening up or aren’t immediately comfortable in therapy. Applauding a client’s bravery to walk through the door also creates an opportunity to ask them what motivated them to make that first appointment — and, in turn, helps the counselor learn more about the client, Craig adds.

Validation played a key part in fostering connection with a female client Craig once worked with who kept being referred to different clinicians within Craig’s agency because of staff turnover.

By the time she was put on Craig’s caseload, the client was “exhausted” and fearful of losing yet another practitioner. So, she had spotty attendance and would often cancel appointments.

“She felt like she hardly wanted to be there [in counseling sessions]. She had told her story so many times, only for her clinician to leave. She kept having to start over from scratch and be vulnerable with a new person,” Craig recalls.

Craig was honest with the client and broached the subject directly, validating that her exhaustion was understandable and warranted.

Craig also realized she needed to slow the pace of therapy with this client. Their early counseling sessions focused on lighter topics, such as work stress. It was one year into counseling before the client was comfortable enough to begin talking about heavier topics, including her trauma history.

The client’s attendance eventually improved but not until Craig spent months building a relationship with her.

“At first, I second-guessed myself and wondered if this [early work] was ‘therapeutic enough.’ But that’s what she needed. That was what was therapeutic for her,” Craig says. “She needed to establish the trust that I wasn’t going to leave and would stay with her. Just me showing up [to counseling sessions] is exactly what this client needed.” 

Fear of judgment

Counselors are no strangers to the importance of the therapeutic relationship, and decades of research show how central and essential it is to client engagement and growth, says Michael Tursi, an LMHC in New York. Counselors, however, must make relationship building an utmost priority for clients who are hesitant. They have an opportunity to display nonjudgment every time they respond and interact with a client, he notes.

“It’s one thing to say, ‘the therapeutic relationship is essential,’ but there are some clients who really might not be willing to engage at all until they see certain things, especially nonjudgment, in their counselor,” he says. “When counselors meet with clients, right from the beginning, they have an opportunity to display nonjudgment.” 

Tursi, an assistant professor in the mental health counseling program at Pace University’s Pleasantville, New York campus, has done research on client experiential avoidance (i.e., when a person is resistant to experiencing strong or adverse sensations, emotions or thoughts) and engagement in counseling. For his doctoral dissertation, Tursi interviewed a cohort of clients in counseling who self-identified as experiencing this phenomenon, and he, along with two other colleagues, published the findings in a 2021 Journal of Counseling & Development article.

Tursi measured his study participants’ level of avoidance by having them complete the Multidimensional Experiential Avoidance Questionnaire developed by psychologist Wakiza Gámez and colleagues.

According to Tursi, one data point in his research quickly became very clear: Each and every one of the participants talked about fear of judgment from their counselor. The study participants acknowledged that they became more engaged in counseling once they established that their counselor was trustworthy and nonjudgmental.

In fact, the participants viewed counseling as a potentially harmful or threatening relationship until their counselor had fostered a trusting relationship with them and eased their hesitancy, Tursi adds.

Some participants talked about “testing” their counselor by intentionally saying something to elicit a response to gauge how trustworthy the counselor was. Even if a client does not do something like this intentionally, Tursi notes, they are very aware of how a counselor is responding to them.

“Nonjudgment is central to working with any client. But these clients might need a counselor who is quite in tune with [the fact that the] client is concerned about judgment and be patient with that,” says Tursi, an ACA member.

A key aspect of creating an atmosphere of nonjudgment is for counselors to be aware of a client’s comfort level, he says. This includes keeping an eye out for indicators that a client is anxious, such as body language, and checking in regularly with the client to talk about how they feel things are going.

A client should never feel pestered or pushed into talking about issues; they should come to the decision to disclose on their own, Tursi emphasizes. Counselors need to temper the expectations of what they think or expect a client will need or be willing to do. 

“Attending to where your clients are is important. We shouldn’t go into therapy and assume clients are going to disclose right away rather than do the therapeutic work that we think they need to do,” he explains. “Counselors should make sure they’re focusing on providing conditions for these clients to engage. … The client is never going to get there [make progress], in any kind of meaningful way, unless they’re engaging in sessions.”

Tursi hopes his research spreads awareness among counselors that experiential avoidance is very common and that some clients may come into counseling believing — for a variety of reasons — that it could be a relationship that is potentially harmful. Tursi draws on the work of Barry Farber, a professor of psychology and education at Teachers College, Columbia University, when he emphasizes that it’s easy to have unconditional positive regard for clients who come in ready to trust and work with their counselor. But it’s equally important to provide that regard for clients who are hesitant, although it may be more difficult. Patience should be a counselor’s watchword, Tursi adds.

“As counselors, we have to be aware of situations in which we have difficulty providing positive regard and continue professional development to improve our abilities to provide nonjudgmental acceptance at times that it is difficult,” Tursi says.

Check yourself 

As a practitioner who specializes in counseling clients with anxiety, Richter-Abitol finds that rapport building with clients who are hesitant must involve self-awareness on the part of the clinician. This includes keeping her own wants, expectations and assumptions about work with clients in check, she says, and asking for client input on the pace and direction of their treatment.

Richter-Abitol is transparent with her clients: She lets them know that they are “in control” of what they want to talk about in sessions and emphasizes that she won’t “make” them talk about anything they’re not ready to.

“You have to meet the client where they’re at and let them set the agenda. I have had clients who have taken months to build rapport, and if you [the counselor] are not patient, you may never get to that point,” Richter-Abitol says. “You have to constantly check yourself outside of sessions and tell yourself that even small successes contribute toward long-term goals. Small things add up.”

polkadot_photo/Shutterstock.com

Richter-Abitol, like Tursi, argues that the therapeutic relationship must take priority with these clients, rather than diving into a treatment plan based on their diagnosis or what the practitioner thinks they need. Counselors should get creative to find ways to bond with the client prior to moving into heavier work, she suggests. For young clients, this might be therapeutic games or activities; for adults, it might be a discussion of lighter topics that help paint a picture of who they are, including things that they like, dislike and what motivates them.

“Those conversations can lead to deeper ones,” she says. “It’s not helpful to be too rigid. You can have things that you’d like the client to work on, but ultimately it has to be up to them. Flexibility is important.”

Richter-Abitol has found that clients feel more empowered when she lets them take the reins in this way. And many begin to open up naturally when they don’t feel pressured to do so.

This approach requires counselors not only to be in touch with and sensitive to their client’s needs and level of readiness in counseling but also to check their own inclination to take charge when a client is slow to make progress. It’s all too easy to assume that a client who isn’t making progress — or not progressing in a way the counselor might want or expect — isn’t benefiting from counseling, Richter-Abitol notes.

Instead, she advises practitioners to take a step back and consider the client’s full context, including the barriers and challenges that are making it difficult for them to engage with a counselor.

“Their fear or discomfort can come off as resistance or presenting a vibe that ‘I don’t want to be here.’ … They just don’t know how to feel about this space yet, and you need to give them time to figure that out,” Richter-Abitol says. “Don’t make the assumption that someone who is uncomfortable isn’t gaining anything from the experience. It might not be that they don’t want to be there but they just don’t know how to be there yet.”

Have honest conversations 

If patience is the first thing that clients who are hesitant or slow to engage in counseling need from a practitioner, transparency is the second. For Craig, this comes in the form of direct questions to the client to gauge their comfort level and an honest invitation to let her know when things aren’t working.

If a client appears uncomfortable or is hesitant to engage in counseling, Craig will address it directly, saying, “Here is what I’m picking up on. Tell me if I’m right or wrong.” She emphasizes to clients that she cares for their well-being and genuinely wants to hear how they’re feeling — and that they have a choice and a say in the counseling process.

Sometimes what counselors view as resistant behavior in clients can be caused by the use of methods or techniques that aren’t a good fit for that individual, Craig says, or it can be that the practitioner themselves is not the right fit. Because clients may not bring up problems to a counselor on their own, she makes a point to broach the topic with honesty, explaining that no therapist is going to be the best match for everyone who walks through their door.

“If someone is taking the huge step to start counseling, I want them to benefit from it as much as possible. I’m honest and tell them that they’ll never make progress if we are not a good fit,” says Craig. “People are not ready for different reasons, and that’s why I like to have such open conversations. … I might not be able to give them everything they need, but I certainly want to talk about it and I want to try.”

She not only checks in regularly with clients throughout therapy but also makes time for a deeper conversation about what is and isn’t going well once a year (on their anniversary as her client). 

During these check-ins, she prompts clients with questions such as:

  • How do you feel about our work together?
  • Do you respond well to me taking the lead in counseling, or do you prefer to take the lead?
  • What has been helpful during our work together?
  • What do you need more of? And less of?
  • What did you expect from therapy and how has this not met your expectations?
  • What’s working and what’s not?

Not only do these conversations provide Craig with valuable feedback, but they also help set an example for the client to advocate for their own needs outside of counseling, she notes. Learning to be able to communicate their needs and expectations is a big — and important — milestone for many clients.

Craig recommends clinicians ask clients directly about how things are going in counseling rather than fall into an easy pattern of making assumptions about individuals who are avoidant or hesitant to engage. Honest feedback from a client is a good thing, Craig stresses, and not something that a counselor should take personally.

Overcoming cultural barriers

Counselors also need to take a proactive approach when clients are hesitant because of challenges and barriers related to their cultural background, says Camila Pulgar, a licensed clinical mental health counselor associate who is a research faculty member at Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

Building trust and forging connection with clients who are from marginalized cultures require a counselor not only to be comfortable broaching the subject of culture (and cultural differences) in client sessions in an ethical and compassionate way, Pulgar says, but also to be fully aware of and sensitive to the many barriers that keep them from accessing counseling or being fully comfortable in the setting. 

A native of Chile, Pulgar specializes in the mental health needs of Latinx clients, including suicide prevention. She does clinical work once a week in her faculty position at the medical center, and she is the only bilingual (Spanish/English) provider on her team. Being the only bilingual counselor is not unusual for Pulgar; in fact, this has been the case for most of her professional career, she says. The mental health care system in this country is simply not built to support the needs of clients whose first language is not English.

Language is only one of many barriers that can deter clients from minority cultures from seeking or becoming fully engaged in counseling, Pulgar points out. Individuals may face logistical challenges such as trouble accessing transportation to appointments, finding child care or affording the cost of sessions. They may also be fearful or have adverse feelings about counseling because of stigma, past harm or skepticism about therapy within their culture or family group.

“If people make it to my office, they’re usually hesitant to share their mental health journey with their family members because of stigma. I often hear ‘I don’t want anyone else to know I’m here’,” says Pulgar, who also sees a small caseload of clients at her private practice in Winston-Salem, North Carolina. “When we talk about their supports and who they can reach out to in times of crisis, they often don’t list anyone [in their family] because they don’t want their family to know they’re struggling.”

Shivonne Odom, a certified perinatal mental health provider whose private practice is the only practice in the Washington, D.C., area that specializes in perinatal mental health care and is owned by an African American therapist, says this is also common among her clients, the majority of whom are African American.

She’s had clients whose families reacted very negatively when they found out the client was attending therapy, and other clients have chosen not to disclose the fact that they were seeking counseling to their families and, in some cases, even their spouse.

Hesitancy is very common among Odom’s clients; she recently had a client tell her that she needed to take an hour-long walk to calm her nerves before logging in for her first counseling session.

There is an extra layer of stigma for minority clients who are seeking perinatal mental health care because pregnancy and childbirth are often assumed to be a joyful and happy time — not one of despair. All of these challenges add up and severely affect clients’ help-seeking behaviors, says Odom, a licensed professional counselor in Washington, D.C., and a licensed clinical professional counselor in Maryland.

Pulgar notes that conversations around challenges in minority mental health care often place the blame on the stigma that many cultures have regarding counseling. In reality, minority populations face many barriers when seeking treatment, and that should be an equally, if not more, important part of the discussion.

This issue is compounded by the fact that most of the evidence-based treatment methods that students are taught in graduate counseling programs were created by and tested within members of the majority population. So, it makes sense that many of counselor’s go-to methods may not be a good fit for some minority clients, says Pulgar, an ACA member.

Clients can also become discouraged if they are referred to counseling by a medical provider and none of the counselors on the referral list look like the client, Odom adds. Because of this, she goes out of her way to accept many different types of insurances and often consults and works with multidisciplinary professionals in related fields, such as lactation consultants, to advocate for her clients and ensure that other providers know of her services.

Counselors should also be aware that these clients are often unfamiliar with the process of counseling. A first step toward forging a therapeutic connection can be to explain what therapy is (and isn’t) and why it’s helpful, along with the concepts of privileged information and confidentiality, Odom says.

Pulgar and Odom emphasize that one way to reduce these clients’ stress and barriers to treatment is for counselors to become knowledgeable of culturally connected resources in their area, such as nonprofit organizations and support groups and services.

Free support groups can be very helpful to validate a client’s feelings and experience in a way that individual counseling can’t, Odom says. And if there isn’t a group that matches your clients’ culture and identity (e.g., single mothers by choice), she suggests that counselors consider seeking training to start and lead one.

It’s equally as important for counselors to forge a connection with the marginalized community in their area as it is to build a strong therapeutic relationship with individual clients, Pulgar says. She suggests that practitioners start by becoming involved with organizations that serve the local marginalized community and participate in events such as health fairs.

“Get out of the four walls of the office,” Pulgar stresses. “Marginalized communities are so collective, and community is an important part of life.”

Small changes, big impact 

Counselors have an opportunity to build trust with a client with every interaction. And sometimes, seemingly “small” things that are outside of the core work of counseling can make a big difference to a client. Here are just a few small steps clinicians can take that will make a big impact on clients. 

Explain the process of counseling and why it’s helpful. Don’t assume that clients know what therapy is or what it entails, Tursi advises. “If they’ve never been to counseling previously, the idea of connecting with feelings might be very foreign to them,” he says. “They might start counseling thinking that the counselor can just make these [difficult] feelings go away. When instead, counseling [works to] change their relationship with their feelings — and a practitioner may need to explain that.”

Remember that a breakthrough does not mean clients are completely comfortable in counseling. A counselor whose client makes a significant gain toward trusting their practitioner in one session may feel that they’ve built their relationship enough to move on and address other issues. However, the only way to truly build trust is to have patience and show a client, over time, that you are trustworthy, Craig says. This is especially true for clients whose trust has been broken by others in their life, including health care providers. “Remember that even if they open up about their fears, it doesn’t mean they’ll be less fearful at the next session,” she adds. “It’s about patience and giving them that chance to warm up.”

Welcome clients before they even sit down. Forging trust with hesitant clients takes “more than what you are doing in the [counseling] room, it’s the whole experience,” Richter-Abitol says. “And we want to make people feel as welcomed as possible. … I know what it takes to walk through that door, and how hard it can be.”

She has taken client comfort into consideration in every aspect of her practice, from choosing cozy décor for the waiting room to a casual staff dress code. She built her website to be particularly user-friendly and extend a welcoming vibe before clients even set foot in the door. For example, she provides a detailed biography of all members of the clinical team, including photos of the practitioners, adjectives that describe them (e.g., bubbly, enthusiastic, loyal, creative, motivated) and a description of what a client can expect when working with them. 

“We try and dial down the clinical and dial up the parts of our personality” on the website to make potential clients feel comfortable, Richter-Abitol explains. “With the anxiety population, fear of the unknown is a big issue, so seeing the office and the pictures [online] helps fills in that space [and] helps people form connections before even coming in.”

Pronounce their name correctly. And if counselors are not sure how to pronounce the client’s name, they should ask and remember it, Pulgar says. This is a seemingly small thing that can be overlooked by practitioners, she notes, but it lets the client know that a counselor values their identity.

Don’t assume they’re resistant. Clients who are opposed to treatment and those who are hesitant or slow to engage in counseling can exhibit some of the same behaviors, such as canceling appointments frequently, answering a counselor’s questions with one-word answers or avoiding talking about heavier topics. However, counselors have an opportunity to build trust and explore the reasons why a client appears reluctant, rather than labeling them as resistant.

“We have been taught [in counselor trainings and graduate programs] that it’s a normal way to view clients. It’s really discouraging to know that [the word ‘resistant’] is even part of the dialogue,” Craig says. “Just because your perception as a clinician is that a person is not trying doesn’t mean that they’re not trying. They might not be doing the homework you assign, but they’re showing up every week. And that may be all that they can do right now. That is trying for them. Be sensitive to what they need to make progress.”

Do no harm and seek training. An important aspect of building trust with hesitant clients is ensuring that a practitioner is providing ethical, appropriate and competent care to keep from exacerbating their hesitancy or repeating any bad experiences they might have had previously in therapy. This includes seeking training, consultation or supervision when a counselor has a client who comes from a culture or is dealing with a challenge that the counselor is not familiar with.

In the case of perinatal clients, clinicians who are not trained in the needs and nuances of work with this population risk providing inaccurate — or even harmful — care, Odom says. Some of the symptoms that can be common in perinatal clients, such as intrusive thoughts about harming their baby, can easily be misinterpreted, she explains.

“We [counselors] have an ethical duty to only practice in areas in which we are trained, and if we’re not, we have an ethical obligation to reach out to providers who are and consult with them,” Odom says. “Don’t be afraid to take a training on perinatal [mental health]. I have seen way too many clinicians treating these clients [inappropriately] and it leads to clients having to unjustly interface with systems that will do harm.”

Leave the door open for them to return. Clients who are hesitant about counseling are more likely to drop off a practitioner’s caseload. Counselors should take measures to focus on retention with this client population, but they should also understand that when the client stops counseling, it doesn’t mean that it wasn’t beneficial. Sometimes people simply have so much going on that life “gets in the way” and they can’t come to regular sessions, Pulgar points out.

Practitioners should emphasize to these clients that they’re always welcome to return to counseling whenever they’re ready. Instead of placing blame and asking the client not to return after missing multiple sessions, a counselor can instead say, “I understand this may not be the best time to start counseling in your life, but please do reach out when it is. I am here for you, please keep my number,” Pulgar says.

“The truth is, not everyone is ready for counseling when it comes time for the appointment, even if they made the phone call [to schedule]. They may not be ready to engage yet in the process of what counseling demands,” Pulgar says. “Stay calm and don’t overthink ‘What am I doing wrong?’ or ‘What more can I do?’ Take a couple of deep breaths and think about ways that the door stays open. … If clients get a good sense of counseling just with that interaction with you, maybe in a year or five years, they will come back. That interaction, although brief, can give them a positive feeling about counseling.”

 

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Reasons why 

Many different factors and barriers deter people from seeking counseling or feeling comfortable in sessions. This is by no means an exhaustive list, but some common client fears and concerns include:

  • The client (or someone they know) has had a bad, hurtful or unhelpful experience previously with a mental health or medical practitioner.
  • They come from a culture where counseling is not widely accepted or a culture that has been historically maligned or harmed by mental health professions.
  • They are struggling with an issue that involves feelings of shame. 
  • They are afraid to confront the issue they are struggling with; this can include hesitancy to relive trauma as they process it or fear of showing vulnerability or imperfection.
  • They fear being given a diagnosis and/or being misdiagnosed.
  • They worry the counselors will judge them.
  • They fear meeting and opening up to a person they don’t know. 
  • They experience overwhelming negative or catastrophizing thoughts (e.g., “Counseling is not going to work”).
  • They face logistical challenges (lack of insurance or inability to pay, trouble finding child care or transportation, etc.).
  • They worry that others (family, peers, etc.) will find out they are attending counseling.
  • They do not have a choice in attending counseling (e.g., a person who is mandated to complete therapy, often as the outcome of a court case).
  • They are hesitant or unable to connect with a practitioner who doesn’t come from the same background or experience as them (e.g., a Latinx or LGBTQ counselor, one who has served in the military, one who understands miscarriage and infertility).

This information came from interviews with the following counselors: Megan Craig, Shivonne Odom, Camila Pulgar, Bri-Ann Richter-Abitol and Michael Tursi.

 

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

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

Voice of Experience: How do you know?

By Gregory K. Moffatt April 27, 2022

My supervisee (we’ll call her Tasha) sat back in her chair and, with a look of confidence that I love to see in a first-year supervisee, told me that she had a successful session with one of her clients.

“I feel really good about it,” Tasha said.

I love watching the tentative and fearful looks that I see during the first few months of supervision gradually transition over to those first glimmers of “I’ve got this.” But that evolution also makes me nervous.

“Tell me about your feelings of confidence, Tasha. What happened that makes you confident you did a good job?”

Tasha reported that the client had made progress the week before after several weeks of stagnation in their work together. That is a good sign of course. But then Tasha said something that always raises a red flag in my supervisor’s brain.

“I don’t know, but I was explaining … and it just felt right. I think I got through to my client.”

I don’t know whether Tasha got through to her client or not, but the fact that she couldn’t operationalize it, along with the fact that she was “explaining” something to the client, made me nervous.

We’ve all been there as counselors. Everything just seems to click, and we close a session feeling good. But we also know that, in general, our feelings are not always trustworthy.

I suspect Tasha’s good feelings were reflective of her “explaining” things rather than anything the client did or said. Nothing is wrong with a little psychoeducation, but explaining well doesn’t mean that Tasha’s client “got it.” In fact, confidence based on her own feelings could even increase the probability that Tasha would miss it if her client didn’t get it.

Most veteran therapists at one time or another have felt good about a session only to find out later that their client didn’t share that feeling. The opposite is also true. Sometimes when we aren’t certain that we have connected well, we find out later that the session was a breakthrough moment.

I’ve made this error myself. I once worked with a young man who was strong, energetic, mature for his age and very verbal. He was one of those easy clients we all enjoy seeing on our calendars.

I thought we had hit it off pretty well in our first session and looked forward to each week with him. But after four or five sessions, he stopped coming. After he missed two sessions, the receptionist in the agency where I was working reached out to see if he wanted to reschedule.

Clint Adair/Unsplash.com

As you can easily predict, he didn’t reschedule. What was more disheartening to me was his reason. He told the receptionist that he just didn’t feel like I was the right fit and that he had decided to go elsewhere. He shared no details beyond that, but I’ve never forgotten about what happened.

My mistake was errantly assigning the cause of my feelings. I supposed that I felt good because he was connecting with me when, in fact, I most likely was feeling good because of things about me. Yikes. It is never about us.

I’m always happy when new clinicians experience successes. It would be a miserable career if we never had those positive experiences and interactions, so I celebrate their successes. But I don’t stop there. I always ask why they think it went so well.

If the answers have to do with “gut feelings” or something about the clinician, I suggest caution. The session might have been amazing, but I don’t trust feelings that I can’t operationalize.

Feelings are unstable things on which to base decisions. Most of us have had an experience where we were positive that a relationship in our personal lives was right, only to be equally convinced sometime later that it wasn’t. Our initial feelings about relationships are often based on newness, first impressions, expectations, appearances, sex or other shallow pieces of data. As the relationship progresses, the more important data points eventually become evident and are much more reliable than our initial feelings.

It is the latter data set that tells us if we should continue the relationship, adjust it or terminate it. And that same type of data analysis should be part of assessing our feelings about our sessions.

Feeling good about a session is fine; just ask yourself why you feel good. If it is because of something that your client did, said or presented, great! But if you can’t nail that answer down, be cautious.

 

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

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

Four lessons in building therapeutic relationships

By Anne-Marie Burke November 9, 2021

Tell me if this resonates: You enter graduate school bright-eyed and bushy-tailed, fresh with hope and galvanized by various novel theories that promise to offer you some sliver of competence when you enter the counseling room in barely a year’s time. Like any counselor-in-training who takes seriously the ethical imperative to “do no harm,” you are practicing basic skills, reflecting on how developmental models and family systems reveal your own skeletons, and thinking to yourself, “Surely these heady ethics issues won’t come up in internship.” (They do — immediately.) 

But you are still stuck. There are nagging questions jangling in the back of your skull: “How in the world do I counsel someone? Where do I even begin? What do I do when I am totally lost in a session?” 

Seeking to know the future and set my expectations, I consulted with a diverse milieu of practitioners, doctoral students and professors. Nonetheless, satisfying answers eluded me. As my anxiety grew, I was forced to seek comfort in the cozy lap of our profession’s favorite platitude: Trust the process.

Having since finished practicum/internship, I can now appreciate the futility of trying to anticipate all that this defining year has in store for counselors-in-training. Although I cannot tell you what to expect, I can shed light on the complexity of your experience and encourage you to lean into the promise of the therapeutic alliance.

Counseling’s heartbeat

The importance of the therapeutic alliance for client change cannot be overstated. It is the heartbeat of each intervention, technique and theoretical approach in the counseling profession. Furthermore, scholarship abounds with evidence of its effectiveness in the field.  

But what is the therapeutic alliance? An agreed-upon definition is difficult to find, but two common threads are routinely mentioned:

  1. A mutual respect is present between the client and the counselor as they embark on the shared purpose of resolving the client’s issues.
  2. Once safety and trust have been established, honest disclosure from the client is required, alongside support and nonjudgmental feedback from the counselor. 

These key aspects of the therapeutic alliance have their own implications: How do we establish mutual respect? How can we ensure safety and trust? Instead, I have simplified the therapeutic alliance down to one thing: figuring out what the client needs from me in every moment. 

Branislav Nenin/Shutterstock.com

Despite initially feeling underqualified to counsel clients — some of whom were at their most vulnerable — I was not ill-equipped. Theories and hypotheses lit my path, while companions such as horizontal and vertical processing, reflecting and silence never failed to fuel my clients’ process of discovery. These tools, along with many others, emboldened me to take risks with clients that, in turn, spurred them to “try on” emotional intimacy with me.

But in the beginning, it was not pretty. Impatient with the skills I was learning, I lurched from one to the next, hoping something would stick. For example, when an open-ended question and simple reflection did not produce the kind of insight I intended, I would jump to psychoeducation or a more complex reflection rather than giving space to my client to process what I had said. Thanks to good feedback from my supervisor and group members, I gradually slowed the pace of sessions down considerably and challenged myself to “be” with my clients intentionally. As I became purposeful in my skills, particularly with reflections, rather than panicking from one to the next, my clients relaxed with me and also became purposeful in their responses. This had an opening effect that laid the groundwork for safety and trust. 

Still, I made mistakes. I went headlong into directions that clients did not buy, catapulted to interpretations that pushed them away and introduced concepts that they simply could not wrap their heads around (e.g., they have value as a person because they exist, not because of how they perform). In such moments, the therapeutic alliance can crack; it can even rupture if these moments are frequent. Even the smallest misstep can create a distance that did not exist before. Recognizing those mistakes and renewing my commitment to figuring out what the client needed from me in that moment put me back on course. 

Doing this often allowed many of my therapeutic relationships to flourish. Because of this, I found that I could also offer difficult feedback to my clients. I believe that clients show up in the therapy room similar to how they show up in everyday life. Knowing this, if they engage in a pattern of behavior with me that is detrimental to building relationships, I judiciously offer feedback regarding their impact on me. 

For example, one of my clients struggled with impulsivity during conflict. She needed to resolve issues on her terms, leaving little room for how her partner processed conflict. During a session, I noted her compulsion to speak over and over again about the conflict as if I were not even there. Because I trusted our relationship, I was able to say, “I know you care deeply about the people you love, and this conflict is wearing you thin, but as you talk about it, I feel an overwhelming need from you to repeatedly say everything you need to say rather than engage in a conversation, and this makes me feel distant from you. I wonder if others in your life feel this same disconnection when you are attempting to resolve a conflict?” 

Her normally tough exterior immediately crumbled, and she burst into tears. She responded, “I thought I was doing everything in my power to overcommunicate and show how much I care about this person, but I am definitely not doing that.” It was the therapeutic alliance that helped the client believe me because she knew I cared about her. This exchange and realization led the client to engage in productive interpersonal work from there on out.  

Navigating the frontier of uncertainty

Perhaps all this talk about therapeutic alliance comforts you. You are skilled at constantly navigating your clients’ specific sensitivities and acknowledging your own mistakes. I hope this brings you substantial peace of mind. But do not be deceived. There is something else bubbling underneath all of this, and it is magical.  

The great pleasure of the therapeutic alliance is not that you can control it. In fact, the opposite is true. You have no clue where it will take you. For instance, I recall a time when one of my clients was laughing about their dog’s odd name one moment, and the next they were divulging their mother’s rape and their subsequent childhood in victim protection. 

In every session, no matter how I prepared, I landed in uncharted territory. This uncharted territory is the fertile but painful frontier of uncertainty. In this frontier of uncertainty, I made it my singular responsibility to shepherd properly by modeling presence, authenticity, cognitive flexibility and emotional agility. As a practicum/internship student, I noticed four counterintuitive ways to navigate this frontier and build powerful therapeutic relationships. 

Lesson No. 1: Do not infantilize clients. I treat clients as the adults they are by going over my center’s attendance policy with them and charging them for no-shows and late cancellations. This can lead to some awkward conversations, and, candidly, it is tempting to not charge them. Yet when I do have these conversations, clients show up, work with me in advance to reschedule their appointments or tell me to charge them because they know the policy. 

In other words, they treat me as a human whom they can affect with their actions. It is an invitation for the client to meet me at a boundary, which, by nature, brings connection rather than pushing us away from each other. Resistance to paying indicates other boundary issues that are worth exploring together. 

Lesson No. 2: Allow clients to be the experts of their own lives. Remember the abrupt drop into uncharted territory that I mentioned earlier? Generally, a big dose of anxiety accompanies it. Here, instead of asking myself what is going on with the client right now, I quickly ask myself what is emerging inside of me at this very moment. A quick scan of my internal environment usually tells me that I am too preoccupied with looking incompetent or fearful of disappointing my clients. This makes me overly involved in my own need to find answers and not involved in my clients’ search for their answers. 

My goal is to help clients make meaning of their life, not ascribe my meaning to their life. Recognizing whose search I am in — mine or theirs — and then permitting myself to not know their answers generally allows me to enter back into the session and sync into their process. This takes us to places that my limited understanding never would have given us access to. 

Lesson No. 3: Allow clients to feel that they matter to us. One of the most effective ways I have done this is simply to ask my clients, “Are you getting what you need?” Better yet, I ask them to tell me what they got out of the session. This helps both of us know where we stand. 

We are taught in counseling skills classes to summarize a session. Doing so demonstrates that we have listened thoroughly and, more important, ensures that the client feels safe and seen. If I have not done this throughout the session, then asking the client to tell me what they got out of it at the end is not going to bring us closer. But if I have gone to great lengths to show that I have seen and heard the client throughout the session, then asking them to summarize is a good way to see where we are on the same page and where we are not. 

What stuck? What did not? We see what we are creating together, which further bonds two people. (Note: I am careful here to ensure that clients are not giving me answers for my own ego. When we have a strong bond with our clients, they might want to please us. Teaching them to discern their progress through what Carl Rogers called their own “intrinsic valuing system” rather than our “conditions of worth” is critical for their long-term success.).  

Lesson No. 4: Seek out exceptional supervision. My supervisor sharpened my attunement to the therapeutic alliance by leading me to the root of my countertransference. 

In a couple’s session, I was determined to amplify a boyfriend’s voice by redirecting to him each time that his girlfriend would cut in. It had begun sinking in that their relationship was in jeopardy, and, naturally, she was in a lot of pain. But instead of validating her pain, I stayed the course to see what was happening inside of the boyfriend. In a sense, I cut her off emotionally. 

This backfired in two ways. One, there was an insurmountable distance between the girlfriend and me for the rest of the session. And two, rather than continuing to express his own emotions and thoughts, including his desire to end the relationship, the boyfriend turned his attention to comforting and validating his girlfriend. She could not see his pain without her pain first being acknowledged, and he was in pain because he was causing her pain. And I missed it because I had my own agenda. How did this happen? 

Upon listening to the recording of the session, my supervisor nonjudgmentally asked me what my feelings were toward the girlfriend to have skipped such an important reflection. I answered that I had not wanted to allow her to monopolize the conversation in yet another session. But there was more to it below the surface. 

At the beginning of the session, the girlfriend had accused me of turning her boyfriend against her. This had caused a high amount of tension in me and a desire to defend myself, even though I knew her accusation was only a distraction from what was going on between her and her boyfriend. I knew it was much easier to blame me than for her to see the signs that had been present in their relationship for months. 

I processed the accusation as therapeutically as possible, trying to redirect her to the boyfriend’s wishes to end the relationship. But in truth, I was angry and caught off guard. I unconsciously cut myself off emotionally to her in order to align with him. This resulted in all of us being isolated from each other.

Surprise! They never came back. I failed. But in this failure, my supervisor helped me uncover an invaluable piece of guidance: I should not be afraid to ask myself what I am feeling toward a client. I find that my answers are often surprising and worthwhile. I must then assess honestly whether my feelings are affecting my desire to build a relationship with the client. Are these feelings hindering my ability to prioritize my client’s growth? This does not mean that I should just tell clients what they want to hear, but it does mean that I should guard against withholding empathy from them because of my own negative feelings.

The catalyst for change

Despite implementing good tools to enhance the therapeutic alliance, I have had several clients who simply did not want me to continue as their counselor. In some cases, it may have had absolutely nothing to do with me personally. It may have been that I reminded them of someone, that my age made them uncomfortable or any number of other reasons. One former client came to her second session only to tell me that she did not want to continue working with me and not to even bother giving her referrals. 

On the other hand, I witness so much change in other clients’ lives that I overflow with joy. I celebrate those moments and allow fulfillment to cascade through my body. Then, I stop and reflect. Coupled with those moments are the tentacles of hubris tempting me to believe that I am bigger than the therapeutic process. I am not. The therapeutic process — and my clients’ engagement in it — is the catalyst for change. It’s not about me. 

I stay bound to the therapeutic process with my clients and bound to my role in their process. I am not bigger than this process. This truth buffers me on the days (I think) I am totally ineffective and, conversely, humbles me on the days I want to take more credit than I deserve. Good news: This reality testing is also a good way to prevent burnout. 

As I write this, I find myself wishing desperately that I could tell all counselors-in-training what to expect, but I cannot. You will engage in dozens of new therapeutic relationships, all of which must be watered, pruned and loved differently. Those of us who have come before you are cheering you on. Keep doing your work, and trust that if you do, you will get more comfortable in not needing to know what to expect.

 

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Anne-Marie Burke graduated with a master’s degree from Georgia State University’s mental health counseling program. She is a clinical mental health counselor and national certified counselor practicing at Samaritan Counseling Center in Atlanta. Contact her at amburke@samaritanatlanta.org.

 

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.

Restoring relationships with survivors of human trafficking

By Lindsey Phillips August 4, 2021

Jenna Hershberger, a licensed associate professional counselor, was working on a crisis response team for a regional human service center in North Dakota when she received a call from a young woman reporting physical abuse. The woman was forthcoming about her medical complaints but not the state of her mental and emotional health. Hershberger could tell there was more to the woman’s story, so she asked to meet her in real life to discuss things further. The woman agreed.

During their in-person meeting, Hershberger, a therapist at the Village Family Service Center in Fargo, North Dakota, noted signs of potential sex trafficking. “Her presentation was really concerning. She was very tearful,” Hershberger recalls. The woman also kept mentioning how her “friends” had forced her to do things while she was under the influence of substances. The more the woman shared, the more convinced Hershberger grew that the people being referenced were human traffickers, not friends. When Hershberger asked where the woman was staying, she revealed that she was currently homeless.

After talking for a while, the woman finally acknowledged that she had been forced into sex trafficking and wanted to get out. She was scared and didn’t know what to do. Fortunately, Hershberger did. She found the woman a safe shelter for the night and helped her locate mental and physical health services.

“I’m in North Dakota … [where] prevalence rates [of human trafficking] are lower, yet it’s still happening,” says Hershberger, a member of the American Counseling Association. “The tragedy where I am and in Midwestern, rural areas is that people just seem to say, ‘Well, this doesn’t happen here.’”

Jared Rose, a licensed professional clinical counselor and supervisor with a private practice, Moose Counseling and Consulting LLC, in Toledo, Ohio, has also encountered a “that doesn’t happen in my community” mentality when it comes to human trafficking. He began working in anti-trafficking about 15 years ago when someone involved in an anti-trafficking organization in Toledo approached him because of his work with the LGBTQ+ community and with people infected with, affected by or at risk for contracting HIV, both of which often intersect with trafficking. When conducting trainings in rural Ohio counties, Rose has heard law enforcement say, “That’s not happening here.” This statement makes Rose cringe because he knows firsthand from his work with individuals who have been trafficked that it is happening.

Human trafficking, in fact, is more common than we think. The International Labour Organization reported that approximately 40.3 million people were in modern slavery globally in 2016. Sometimes people incorrectly assume that human trafficking is a problem only in developing countries, but the National Human Trafficking Hotline identified 63,380 survivors of human trafficking in the United States from 2007 to 2019.

Rose, an ACA member who wrote an ACA fact sheet on human trafficking awareness for school counselors in 2019, finds that too many counselor clinicians also remain unaware of the definition and signs of trafficking. “You could have the epitome case sitting in front of you,” Rose says. “And if you don’t even know what trafficking is, you’re going to miss it.”

Recognizing the Signs

The U.S. Department of Homeland Security defines human trafficking as the use of force, fraud or coercion to obtain some type of labor or commercial sex act. Rose, an assistant professor of counseling at Bowling Green State University, advises counselors to stay alert to signs of force, fraud or coercion with clients. “Take note of who they are with and where the power and control lie,” he says. For example, is someone else benefiting — often financially — from the client’s actions? Does someone else seem to be in charge or making all the client’s decisions for them?

Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, also looks for visual signs such as bruising, scarring or branding. Individuals who are being or have been trafficked are often branded with “ownership” tattoos with the name of their trafficker or with symbols such as a star or cowboy hat. Because sex acts place a lot of strain on the body, survivors often discuss medical complaints such as dental issues, migraines or urinary tract infections, she adds.

Clients who have been trafficked “may appear overly compliant and submissive, or they might appear really abrasive and abrupt,” Hershberger points out. Counselors must recognize “that those strategies were adaptive at one time but they’re not right now.”

As it relates to falling victim to trafficking, Rose notes that the No. 1 risk factor for children is being unhoused. He prefers the term unhoused to runaway, he explains, because children are often abandoned or “thrown out” by their families. “Within a matter of two to three days of being out of the home, kids are approached [by traffickers], and one-third of those [unhoused] kids are going to get trafficked,” he says. “So, that piece of being unhoused — couch surfing, staying at a shelter, living on the street or whatever the case may be — puts them at significantly higher risk.” Children who are already vulnerable may easily fall prey to an adult who shows them attention or what they initially perceive as support, he adds.

Other risk factors include lower socioeconomic status, past trauma (sexual, physical, emotional, verbal or spiritual), being differently abled, substance use, and belonging to a racial or sexual minority group, Hershberger says. Given the complex trauma that these individuals experience, they often present with comorbid disorders such as substance use, bipolar and severe depression, she notes.

Counselors may overlook or miss signs of trafficking when they take the client’s circumstances or presenting issues at face value, notes Paige Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University. For example, if a client is homeless or doesn’t have any identification, counselors may start to talk about the emotions, behaviors and social systems surrounding the client’s chronic homelessness and help them come up with a plan to find a more stable environment. But in doing this, clinicians may miss the larger picture, stresses Dunlap, a licensed clinical mental health counselor with a private practice in Greensboro, North Carolina. Perhaps the client was forced into sex trafficking after being taken from their home or fleeing an unsafe environment.

“There’s a lot of different risk factors. There’s a lot of different things to look for. There’s a number of populations that we are particularly concerned about, but at end of day, it all boils down to vulnerability,” Rose says. For that reason, he stresses that counselors need to be cognizant of that vulnerability piece in connection with their clients.

Sometimes counselor practitioners worry that they won’t be able to recognize the signs that someone has been trafficked, Rose says, but he reassures them they know how to read interpersonal reactions. They know when someone is looking to another person for answers. They notice when people’s stories do not match up.

Counselors also need to consider what a trafficking survivor might look like in their particular clinical setting, Hershberger says. For example, if a counselor is doing crisis work, they might have someone who is in denial about being trafficked or confront a situation that appears to be domestic violence.

The office setting may determine the likelihood of a practitioner encountering an individual who is currently being trafficked or who has gotten out. Counselors who work in public health settings or hospitals are more likely to see individuals who are currently being victimized when these individuals come in for a medical issue such as testing for a sexually transmitted disease or injury from abuse, Rose notes. Counselors working in private practice or at a community agency will typically see these clients after they have been extricated, he says.

Establishing trust and safety

People who have been trafficked may find it difficult to trust others. Before thinking about clinical treatment plans, counselors need to establish a sense of safety and a healthy therapeutic rapport with these clients, Hershberger stresses. These individuals have experienced “complex trauma in the sense that it’s repeated for long duration and often comes from people who should be caregivers,” she explains, “so it makes it really hard for survivors of trafficking to trust us. We need to be really authentic because survivors will pick up on it if [we’re] not.”

Hershberger, president of the North Dakota Association for Counselor Education and Supervision, advises clinicians to maintain an open-door policy with survivors of human trafficking, especially when they are working on engagement with the client. People who are dealing with significant trauma may be more prone to canceling sessions, so adhering to a policy of termination after two missed sessions will not help build engagement and rapport with these clients, she cautions.

Counselors’ innate desire to help clients heal can sometimes be an impediment to build-ing this relationship. Rose sees counselors who want to dive right into the trauma work before first building strong therapeutic and strategic foundations, which can take a long time. “The minute we try to push too much — even if our best intentions are there — is when someone can have [a negative] reaction” and feel that the counselor is forcing them to do something they don’t want or are not yet ready to do, he says.

Rose has also witnessed the inverse: clients who get frustrated when counselors don’t jump straight into the trauma work. When this happens, he explains to clients that although they may feel ready, their whole system may not be. To further illustrate the point, he compares trauma work to a physical wound: “If I start poking around at a wound and you don’t trust me yet or your entire system isn’t ready to allow that yet, you’ll immediately pull back and you’re not going to want me to go near it,” he tells clients. “And the same [thing] is happening cognitively and emotionally with trauma. If we start poking around and you’re not ready, then it’s going to fall apart on us.”

The need for clinical trauma care

Rose asserts that counselors are in a prime position to provide clinical psychotherapy and trauma-focused work. Rose is an executive member of the Lucas County Human Trafficking Coalition, and he was awarded the Social Justice Leader Award from the Human Trafficking and Social Justice Institute in 2017.

Mental health services geared toward survivors of trafficking are great at managing clients’ symptoms through art or expressive therapy or group work, but Rose finds this is often where their treatment ends. “It has to be more. It has to be evidence-based trauma work,” he stresses. “We can’t just treat symptoms. We have to treat the whole person, and we have to treat the trauma.”

“Folx that have been labor trafficked have all sorts of layers of trauma damage. … Sex traffic victims have all of the symptoms of domestic violence, emotional abuse, physical abuse, sexual abuse — all rolled into one very unpleasant package,” he continues. “And expressive therapy is not going to treat that trauma; it’s going to treat the symptoms. If we really want to help folx, we have to go deeper, and that’s where counselors really need to come into play.”

Rose, a certified therapist in eye movement desensitization and reprocessing (EMDR), recommends that counselors use an evidence-based trauma treatment that follows a triphasic approach that a) establishes a foundation, b) reprocesses and works through the trauma and c) plans for the future. Rose often uses EMDR when he’s working with this population because he finds it helpful to treat the root cause of the trauma. He also recommends trauma-focused cognitive behavior therapy, especially when working with children and adolescents.

Take the relational approach

Hershberger points out that traffickers differ from other sexual offenders (who are often described as socially awkward and desire a sense of belonging) in that they are often socially intelligent, charismatic and good at forming relationships. They gain the trust of vulnerable individuals by initially fulfilling their need for love, connection and belonging, she explains. For example, the trafficker could be the first person in the individual’s life to recognize and celebrate their birthday or give them special attention, such as taking them to get a manicure.

These acts can cause some survivors to form bonds with and defend their traffickers — a condition often referred to as Stockholm syndrome. Hershberger and Dunlap point out that something similar sometimes happens with individuals who experience domestic violence. “Survivors will often defend their trafficker because they didn’t have that sense of belonging or that family growing up. So, this is the first time they’re experiencing that — along with horrible kinds of trauma — but it’s hard for them to differentiate that,” Hershberger explains.

According to Hershberger, these trauma bonds illustrate survivors’ desire for human connection. Traffickers thwart this connection by exploiting this desire for their own gain.

“Human sex trafficking is the ultimate anti-relationship,” argues Hershberger, who recently presented on this topic at ACA’s Virtual Conference Experience. Survivors of sex trafficking have been forced “to exist in a world absent of authentic, growth-fostering relationships,” she explains. Thus, she recommends that counselors use a relational-cultural approach with this client population to foster an authentic growth-fostering connection.

To explain this approach, Hershberger presents Marie, a fictional client: When she was 14 years old, Marie lived in an abusive home where her mother’s boyfriend molested her. So, Marie was excited when Jake, a 24-year-old man, approached her and promised a better life as his “girlfriend.” He bought her nice things and told her she was “amazing in bed.” One day, he told Marie some money hadn’t come through at work and asked if she would help him by having sex with a few guys. When she resisted, he beat her until she complied. He forced her into sex trafficking, and she was having sex with as many as 10-15 men a night. (See Hershberger’s 2020 article, “A relational-cultural theory approach to work with survivors of sex trafficking,” published in the Journal of Creativity in Mental Health, for a more detailed discussion of this case study.)

Following a relational-cultural framework, Marie’s counselor first establishes a sense of safety and trust, and they are authentic, empathetic and consistent in their interpersonal interactions, Hershberger says. So, if the counselor makes a mistake by showing up late for session, they own that mistake, apologize and ask Marie how they can make up for it.

Marie may have internalized negative beliefs or self-blame such as “I’m only good for my body and others’ use” or “I’m not worthy of being loved.” The counselor can help Marie first identify and name these beliefs, and then they can work together to challenge these negative beliefs. The therapeutic relationship further challenges Marie’s distorted thinking about herself and relationships, Hershberger notes, and models what a healthy relationship entails.

To challenge Marie’s belief, the counselor could use self-disclosure and tell Marie, “I experience you as a creative, confident individual who is worthy of being loved.” Hershberger recommends that counselors use the client’s own words when reflecting positive attributes to help the client identify and own their strengths.

As Hershberger points out, traffickers try to keep victims in a constant state of uncertainty about their environment, safety or identity. So, the counselor’s role is to identify moments or thoughts that are unclear, such as Marie’s negative perception of her self-worth, and help her add clarity to them.

Hershberger names bibliotherapy and narrative therapy as useful approaches for empowering survivors of trafficking and helping them find their own voice. For example, the counselor could ask Marie what name her trafficker gave her and the name she wants to use moving forward. Then, Marie could journal about this new identity and the qualities associated with it.

The counselor could also add in creative techniques such as collage or relational imagery. For example, Hershberger once had a client who identified with the image of a wounded deer because they too had been hurt and abandoned. The wounding paralleled their own trauma around the physical abuse they had experienced while being trafficked. Later, Hershberger used this image to help the client think about what they wanted their future identity to be and to create a collage of their strengths.

The therapeutic relationship becomes a healthy relationship — one that is safe, dependable and empowering and that counters the disconnection and uncertainty survivors experienced when they were trafficked, Hershberger says.

Preparing to work with this population

The best way to understand what is going on with human trafficking in a specific area is to get involved and volunteer in the community, Rose says. One place to start is joining or attending meetings of local, regional or state trafficking coalitions and task forces. “You can learn more about what agencies are providing services for this population,” he says. “They need to know where mental health providers are, and you need to know where additional services are for survivors.”

Rose advises counselors to approach these partnerships with an attitude of wanting to learn and help. Communities don’t respond well to people who think they know what is best or have all the right answers, he says. Instead, inform these organizations of the crucial skills they may be missing. Counselors have “the clinical piece that a lot of these places need and strive for,” Rose notes. “There’s a lot of social workers, nurses and different helping professionals, but clinical mental health treatment may not be what they have.”

In addition to attending monthly meetings of North Dakota’s trafficking task force, Hershberger prepared to work with this population by reading case examples and familiarizing herself with these tough stories. She also reached out to other clinicians in the field to hear about their experiences. As she points out, “It’s one thing to hear terminology, but it’s another thing to hear somebody’s story.”

Rose and Dunlap recommend that counselors limit their caseloads (if they have that option) when working with this population. “You can’t hear the thing of nightmares for three, four or eight hours a day and expect to be OK by 6 or 7 o’clock at night,” Rose says. Both he and Dunlap, an ACA member who researches and works with youth with disabilities, survivors of human trafficking and criminal populations, have had to learn how to balance their clinical schedules better. They intentionally leave time between these difficult sessions so they can reflect, reenergize and regroup before seeing their next client.

Counselors must also remember that not every client-counselor relationship is the right fit, Rose says. For example, someone may refer a female survivor of sex trafficking to him because of his expertise in EMDR, but if she has been abused by men her entire life, she may not want to work with Rose regardless of his qualifications and reputation as a counselor.

“These clients have had people treat them really poorly their entire lives,” he points out. “Part of that therapeutic relationship is recognizing maybe I’m not the best counselor for every person I want to help, and that’s OK. Just giving [clients] that freedom and autonomy will help them along in their journey. They don’t have to work with me to fix the problem.”

Rose reminds counselors there are other ways to help serve this population without working directly with clients. Counselors can get involved in local agencies that work on human trafficking, provide education and trainings, or work on prevention, he says.

Hershberger understands how difficult it can be when counselors must refer a client. Because she was part of a crisis response team when she met the woman who was a survivor of human trafficking, she wasn’t able to continue working with her. The woman was referred to another clinician who worked for the human service center. “That was hard,” she recalls. “I couldn’t stay with her, and having that continuity of care would have been nice.”

Hershberger did have a chance to meet with the woman a few months later. With the help of her new counselors, she was making progress toward creating healthier relationships.

fizkes/Shutterstock.com

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Working with perpetrators of human trafficking

Paige Dunlap, a licensed clinical mental health counselor in Greensboro, North Carolina, once worked with an agency in Detroit that assisted individuals who no longer wanted to be engaged in gang activity. In sharing their stories, some of the group members disclosed that they had been directly or indirectly involved in trafficking other individuals. After recovering from the initial shock of hearing that, Dunlap started to think and educate herself about ways counselors could help perpetrators of trafficking.

“We as counselors don’t really talk about this hidden population” of perpetrators, she says. “We don’t know too much about them.”

Often people’s biases can cloud their judgment about these individuals. The more Jenna Hershberger, a licensed associate professional counselor in Fargo, North Dakota, researched and worked with cases of sex trafficking, the more she discovered the dichotomous thinking attached to it: People consider traffickers to be “bad” and survivors to be “good.” But it’s more complicated than that, she says.

“In the literature, we see that traffickers and survivors experience the same kinds of childhood traumas, such as sexual, emotional, physical and spiritual abuse,” she explains. But for individuals who become traffickers, “there is a distortion that happens in the way that they respond to the trauma.” Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, acknowledges this is an area of research that mental health professionals do not fully understand yet. But initial clinical findings, as well as Hershberger’s own professional experience, indicate that traffickers often seem to have empathy deficits and endorse trafficking myths such as “people like this way of life.”

Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University, says that traffickers and victims of trafficking often get enmeshed in that world for similar reasons. “There is a need for belonging in all of these individuals,” she says. Both groups often lack support systems, have limited work opportunities and are tempted by the promise of a “better” life, she explains.

Once individuals get involved in trafficking, it becomes difficult for them to leave, Dunlap points out. “It becomes almost an institutionalization for them too. … They don’t know how to function outside of that.”

“Getting those individuals into your office to do this hard work is really going to be tough,” she admits. “If you’re a counselor and you do happen to have these clients, the last thing they need is for your own biases to be stopping them from getting help, because they’re doing good just to be there.”

Hershberger hopes counselors continue to research ways to better help both the survivors and perpetrators of human trafficking. In doing so, she encourages counselors to consider a larger question: How as a society are we creating spaces in which people don’t know what a healthy relationship looks like so that they’re seeking out this subculture for a sense of belonging?

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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