Tag Archives: Multiculturalism & Diversity

Multiculturalism & Diversity

ACA anti-racism statement

June 22, 2020

 

After discussion and discernment, the ACA Governing Council has issued the following statement on anti-racism. The ACA leadership is listening to a cross section of members and volunteers in order to develop an action plan that will give life to this statement.

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ACA Anti-Racism Statement

Racism, police brutality, systemic violence, and the dehumanizing forces of oppression, powerlessness, and White supremacy have eroded the very fabric of humanity which ideally binds our society together. Macrolevel systemic racism extends to disparities in institutional policies and procedures in physical and mental healthcare, education, the judicial system, employment, sports and entertainment, and the brutal violence of law enforcement. These larger societal oppressions lead to inaccessibility to resources and social marginalization, which descend finally to individual racist attitudes, implicit biases, stereotypes, microaggressions, and even death. The ongoing and historical injustices are not acknowledged by those who want to be in power or protect their entitlements. Some who do acknowledge, do so reactively, temporarily, or superficially and thus, no meaningful change occurs. Anti-Black racism is often reframed as accidental, an unfortunate incident, or as the criminality of the victim.

Words cannot truly capture our feelings. We are angry, exhausted, grieving, suffering, furious, and in despair. The American Counseling Association is pained by the murders of George Floyd, Rayshard Brooks, Ahmaud Arbery, Breonna Taylor, Tamir Rice, Eric Garner, Sandra Bland, Michael Brown, and countless other Black/African Americans who unfortunately remain nameless. We stand in solidarity with our Black siblings in denouncing the historical legacy and destruction caused by institutionalized racism and violence against Black people, perpetuated at the hands of law enforcement, the hatred bred of White supremacy, the deafening silence of dehumanizing and complicit inaction to address these systemic ills within our society. As counselors, we listen, we empathize, and agree with protestors that when absolute justice is established, peace will follow. Enough is enough, we cannot continue to watch fellow Black Americans being murdered, as the very life force is suffocated out of them.

The American Counseling Association is built on enduring values and a mission that promotes: human dignity and diversity, respect, the attainment of a quality of life for all, empowerment, integrity, social justice advocacy, equity, and inclusion. If we remain silent, and do not promote racial justice, these words become harmful and meaningless for our members and the counseling community. Given the rapidly evolving double pandemic of COVID-19 and the continued exposure of Black people to institutionalized racism, ACA wants to be clear about where we stand and the ongoing actions we will take. As proactive leaders, counselors, mentors, supervisors, scholars, and trainers we will break away from this structure of racism trauma, and the violence born on the necks of Black people.

Our stance is: Black Lives Matter. We have a moral and professional obligation to deconstruct institutions which have historically been designed to benefit White America. These systems must be dismantled in order to level the playing field for Black communities. Allyship is not enough. We strive to create liberated spaces in the fight against White supremacy and the dehumanization of Black people. The burden of transgenerational trauma should not be shouldered by Black Americans even though they have remained resilient.

All ACA members must be willing to challenge these systems, but also confront one’s own biases, stereotypes, and racial worldview. Moving forward, our actions will be based on input from our members and the voices of others. We are committed to change.

 

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Learn more

ACA has compiled a number of resources focused on cultural competencies and combating racism: https://bit.ly/2BuNZ1Y

 

The historical roots of racial disparities in the mental health system

By Tahmi Perzichilli May 7, 2020

Racial disparities, or unfair differences, within the system of mental health are well documented. Research indicates that compared with people who are white, black, indigenous and people of color (BIPOC) are:

  • Less likely to have access to mental health services
  • Less likely to seek out services
  • Less likely to receive needed care
  • More likely to receive poor quality of care
  • More likely to end services prematurely

Regarding racial disparities in misdiagnosis, black men, for example, are overdiagnosed with schizophrenia (four times more likely than white men to be diagnosed), while underdiagnosed with posttraumatic stress disorder and mood disorders. Additionally, concerns are compounded by the fact that for BIPOC, mental health care is often provided in prisons, which infers a multitude of issues.

BIPOC are overrepresented in the criminal justice system, as the system overlays race with criminality. Statistics show that over 50% of those incarcerated have mental health concerns. This suggests that rather than receiving treatment for mental illness, BIPOC end up incarcerated because of their symptoms. In jails and prisons, the standard of care for mental health treatment is generally low, and prison practices themselves are often traumatic.

The vast majority of mental health treatment providers in the United States are white. For example, approximately 86% of psychologists are white, and less than 2% of American Psychological Association members are African American. Some research has demonstrated that provider bias and stereotyping are relevant factors in health disparities. For nearly four decades, the mental health field has been called to focus on increasing cultural competency training, which has focused on the examination of provider attitudes/beliefs and increasing cultural awareness, knowledge and skills.

Despite such efforts, racial disparities still exist even after controlling for factors such as income, insurance status, age, and symptom presentation.Established barriers for BIPOC are the following:

  • Different cultural perceptions about mental illness, help-seeking behaviors and well-being
  • Racism and discrimination
  • Greater vulnerability to being uninsured, access barriers, and communication barriers
  • Fear and mistrust of treatment

In addition to emphasizing culturally competent services, other recommendations to bridging the gaps and addressing barriers have largely focused on diversifying workforces and reducing stigma of mental illness in communities of color.

One area not often noted is the historical (and traumatic) context of systemic racism within the institution of mental health, although it is well known that race and insanity share a long and troubled past. This focus may begin to account for how racial differences shape treatment encounters, or a lack thereof, even when barriers are controlled for and the explicit races of the provider and client are not at issue.

Historical context

In the United States, scientific racism was used to justify slavery to appease the moral opposition to the Atlantic slave trade. Black men were described as having “primitive psychological organization,” making them “uniquely fitted for bondage.”

Benjamin Rush, often referred to as the “father of American psychiatry” and a signer of the Declaration of Independence, described “Negroes as suffering from an affliction called Negritude.” This “disorder” was thought to be a mild form of leprosy in which the only cure was to become white. Ironically Rush was a leading mental health reformer and co-founder of the first anti-slavery society in America. Rush did observe, however, that “the Africans become insane, we are told, in some instances, soon after they enter upon the toils of perpetual slavery in the West Indies.”

In 1851, prominent American physician Samuel Cartwright defined “drapetomania” as a treatable mental illness that caused black slaves to flee captivity. He stated that the disorder was a consequence of slave masters who “made themselves too familiar with the slaves, treating them as equals.” Cartwright used the Bible as support for his position, stating that slaves needed to be kept in a submissive state and treated like children to both prevent and cure them from running away. Treatment included “whipping the devil out of them” as a preventative measure if the warning sign of “sulky and dissatisfied without cause” was present. Remedy included the removal of big toes to make running a physical impossibility.

Cartwright also described “dysaethesia aethiopica,” an alleged mental illness that was the proposed cause of laziness, “rascality” and “disrespect for the master’s property” among slaves. Cartwright claimed that the disorder was characterized by symptoms of lesions or insensitivity of the skin and “so great a hebetude [mental dullness or lethargy] of the intellectual faculties, as to be like a person half asleep.” Undoubtedly, whipping was prescribed as treatment. Furthermore, according to Cartwright dysaethesia aethiopica was more prevalent among “free negroes.”

The claim that those who were free suffered mental illness at higher rates than those who were enslaved was not unique to Cartwright. The U.S. census made the same claim, and this was used as a political weapon against abolitionists, although the claim was found to be based on flawed statistics.

Even at the turn of the 20th century, leading academic psychiatrists claimed that “negroes” were “psychologically unfit” for freedom. And as late as 1914, drapetomania was listed in the Practical Medical Dictionary.

Furthermore, after slavery was abolished, Southern states embraced the criminal justice system as a means of racial control. “Black codes” led to the imprisonment of unprecedented numbers of black men, women and children, who were returned to slavery-like conditions through forced labor and convict leasing that lasted well into the 20th century.

Scientific racism early on indicates motives of control and containment for profitability. Leading health professionals propagated the idea that blacks were “less than” to justify exploitation and experimentation. The mislabeling of behavior, such as escaping slavery, as a byproduct of mental illness did not stop there. Significant transformations in defining mental illness also occurred in the civil rights era, suggesting that institutional racism becomes more powerful in the context of moments of heightened racial tensions in the collective social consciousness.

Prior to the civil rights movement, schizophrenia was described as a largely white, docile and generally harmless condition. Mainstream magazines from the 1920s to the 1950s connected schizophrenia to neurosis and, as a result, attached the term to middle-class housewives.

Assumptions about the race, gender and temperament of schizophrenia changed beginning in the 1960s. The American public and the scientific community began to increasingly describe schizophrenia as a violent social disease, even as psychiatry took its first steps toward defining schizophrenia as a disorder of biological brain function. Growing numbers of research articles asserted that the disorder manifested by rage, volatility and aggression, and was a condition that afflicted “Negro men.” The cause of urban violence was now due to “brain dysfunction,” and the use of psychosurgery to prevent outbreaks of violence was recommended by leading neuroscientists.

Researchers further conflated the symptoms of black individuals with perceived schizophrenia of civil rights protests. In a 1968 article in the esteemed Archives of General Psychiatry, schizophrenia was described as a “protest psychosis” in which black men developed “hostile and aggressive feelings” and “delusional anti-whiteness” after listening to or aligning with activist groups such as Black Power, the Black Panthers or the Nation of Islam. The authors wrote that psychiatric treatment was required because symptoms threatened black men’s own sanity as well as the social order of white America.

Advertisements for new pharmacological treatments for schizophrenia in the 1960s and 1970s reflected similar themes. An ad for the antipsychotic Haldol depicted angry black men with clenched fists in urban scenes with the headline: “Assaultive and belligerent?” At the same time, mainstream white media was describing schizophrenia as a condition of angry black masculinity or warning of crazed black schizophrenic killers on the loose. A category of paranoid schizophrenia for black males was created, while casting women, neurotics and other nonthreatening individuals into other expanded categories of mood disorders.

The black psyche was increasingly portrayed as unwell, immoral and inherently criminal. This helped justify the need for police brutality in the civil rights movement, Jim Crow laws, and mass incarceration in prisons and psychiatric hospitals, which at times was an exceedingly thin line. In general, attempts to rehabilitate took a back seat to structural attempts to control. Some state hospitals, presided over by white male superintendents, employed unlicensed doctors to administer massive amounts of electroshock and chemical “therapies,” and put patients to work in the fields. Deplorable conditions went unchallenged as late as 1969 in some states.

Deinstitutionalization, a government policy of closing state psychiatric hospitals and instead funding community mental health centers, began in 1955. Over the next four decades, most state hospitals were closed, discharging those with mental illness and permanently reducing the availability of long-term inpatient care facilities. Currently, there are more than three times as many people with serious mental illnesses in jails and prisons than in hospitals. The shifts in defining what constitutes mental health reflects the reality that the definition is shaped by social, political and, ultimately, institutional factors in addition to chemical or biological ones.

Conclusion

Looking at the historical and systemic context of the mental health system may provide insight into why racial disparities continue to exist and why these disparities have been resistant to interventions such as cultural competency training and standardized diagnostic tools. Focusing primarily on the race of the provider and the client, while valid, is an approach that does not consider the system itself, the functions of the diagnosis, and its structurally developed links to protest, resistance, racism and other associations that work against the therapeutic connection.

Racial concerns, including overt racism at times, were written into the mental health system in ways that are invisible to us now. Understanding the past enables new ways of addressing current implications and identified barriers, including how schizophrenia became a “black disease,” why prisons emerged where hospitals once stood, and how racial disparities continue to exist in the mental health system today.

 

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Additional resources

 

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Tahmi Perzichilli is a licensed professional clinical counselor and licensed alcohol and drug counselor working as a psychotherapist in private practice in Minneapolis. Contact her through her website at www.tahmiperzichilli.com.

 

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

Voice of Experience: The dangers of cultural un-awareness

By Gregory K. Moffatt March 6, 2020

I know this is hard to believe, but the first class I ever had on cultural awareness was one that I taught. My graduate programs in the 1980s didn’t have a single class on the importance of understanding the diverse backgrounds of our clients. The best we did in those days was a short paragraph at the end of each textbook chapter tipping a hat to cultural awareness. My first exposure to the issue was with Derald Wing Sue and David Sue’s text Counseling the Culturally Diverse. This book, now in its eighth edition, is used in many graduate programs. I still use it today.

For more than 30 years now, I have taught this course on cultural awareness to both graduate and undergraduate students pursuing counseling degrees, and each time I realize the importance of this topic. Frankly, I’d rather see graduate programs drop a personality theory class or something else and add a second or third required course on diversity. In one semester, I can only introduce the topic. Competence is still far from the reach of these young clinicians.

It was during one semester teaching this course when one of my students related the following story. With her permission, I have shared it with every class since that time because she passionately and succinctly conveyed the importance of cultural awareness. Addressing an experience with one of her clients during an internship, she wrote to me the following:

Just yesterday I interviewed a man at the psychiatric hospital while keeping my eyebrow raised in suspicion that he wasn’t being truthful with me. This tall, obese, African American gentleman looked as though he had not bathed for days. The mucus stains and dandruff that covered his shirt immediately triggered thoughts in my mind. As he denied his drug use and other suspecting issues, I secretly assumed he was lying and trying to avoid consequences. Through his missing teeth, he smiled and told me he had never, ever drank alcohol. Flash-forward to the phone call I made to his sister where I learned that he had suffered severe head trauma in the 1960s. This gentleman had been the victim of a riot started over racial disputes and ended by police beating his head to a bloody mess. The man had, indeed, never drank alcohol and was only at the hospital for medication adjustment for his schizophrenia. I went back and apologized for not believing this sweet man. The only head shaking I did yesterday was at myself.

This story is so powerful and moving that when I read it to my students, I sometimes have a hard time holding back tears. Imagine the dangers of cultural un-awareness. I know this is poor English, but I want to emphasize just not being aware. In contrast with the years of my graduate experience when cultural awareness was largely neglected, now most of us know that it matters. But I suspect we hear about it so often that we don’t really give much thought to its implications.

The graduate student I quote above was an intake intern at a major hospital. The least experienced person in the system was the first to have contact with the client. That alone is frightening, but it is not an uncommon situation. If this intern had not discovered her error, the gentleman easily (and errantly) could have been tracked as an addict. At the same time, his real issues would have been ignored. This victim of racial violence would have again been victimized by the systemic racism that had put him across from the intern in the first place.

And what is most frightening of all is that my student was as culturally sensitive as any of us at that stage of our education. She was simply doing what she had been trained to do by an educational system that can overlook important cultural clues.

Someone once said that “the most insidious form of racism is covert racism.” When racists rant on street corners or wear icons indicating their perspective, they are easy to spot and thus easy to avoid. Subtle biased thinking and, more importantly, systemic racial discrimination is much harder to combat because well-intentioned therapists, like my student, don’t even recognize it.

My students are often angry with the Sue and Sue text because the authors are very confrontational in their approach. I experienced the same anger the first time I read it. But I know why the authors approach it this way. Novelist Flannery O’Connor was once asked why she wrote such graphic novels, and she replied, “If you want to communicate with the blind, you must paint large, startling images, and in the world of the deaf, you have to shout.”

I have heard Derald Sue speak several times. He is a brilliant and gentle man, but he isn’t afraid to talk about hard topics. This quiet man isn’t afraid to shout or to paint large, startling images. Maybe this is what it takes for a deaf and blind society to get it.

 

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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.

A collective voice: Indigenous resilience and a call for advocacy

By Roni K. White, Alaina Hanks, Susan Branco, Nicola Meade and Isaac Burt February 11, 2020

Resilience is one of the characteristics hallmarking the experience of North America’s indigenous tribes. These tribes predate the European exploration and colonization that led to the renaming of these inhabited lands to the United States of America. These acts of occupying launched the dominant discourse and fallacious narrative that Original People no longer exist and began long before the Occupy movement. This ability not just to endure but to remain resilient, despite more than a quincentenary of atrocious acts, government policies, and intentional genocide, speaks to the strengths that exist within Native communities.

With modern technologies expanding platforms for Native people to share history and current events, professional counselors have the opportunity to further their understanding, increase competencies, and expand efficacy. Perhaps the perceived silence of Native voices is not because they are not speaking, but because few are listening.

Too often, professionals who interact with or provide services to a Native tribe record a narrow view. This limited representation misinforms others about the realities that exist and undermines the plurality that is alive. As counselors committed to improving social justice, promoting growth, supporting healing, and championing thriving, we offer a pathway to consider a more informed perspective and tools for advocacy.

Historical relevance

When truth is hidden or unheard, it leads to false teachings and misinformation. Historical accounts are complex, and tribal nations carry their own histories. Explorers, traders and colonizers disrupted the way of life for millions of human beings across North America from the 15th through the 20th centuries. By some accounts, as many as 112 million people — a number that can never be resolved or agreed upon — lived in North America in tribal nations prior to the arrival of European explorers and colonies. The people, constituting self-sufficient nations deeply connected to the lands of North America, have endured immense psychological pain, physical abuse, genocide, and torture at the minds and hands of European colonizers and their descendants.

Despite the intentional disregard and destruction of human life and communities, Native nations continued to promulgate their existence through advocacy and engaging with the U.S. government. In 1824, the U.S. government established the Bureau of Indian Affairs (BIA). In 1830, then-President Andrew Jackson signed the Indian Removal Act, forcing a massive and involuntary migration that resulted in immeasurable fatalities, internment, and the disruption and loss of customs and culture. Persistent broken treaties, ill treatment and racism did not deter Native nations from standing up to the U.S. government or against injustice, discriminatory laws, and other methods to prevent prosperity, equity and health.

From a space of incredible resistance and intelligence, Native nations have effectively changed U.S. laws and practices and transformed the BIA over the years, including the governance and collaboration of sovereign nations. The BIA led the implementation of the Indian Self-Determination and Education Assistance Act of 1975 and the Tribal Self-Governance Act of 1994, which changed how the federal government and sovereign tribal nations interact and conduct business with one another. 

Impact of trauma

The great Oglala Sioux chief Red Cloud understood change and the implication of actions. Red Cloud shared that one’s actions impact seven generations. Change is slow, and the impact of change continues over numerous decades. When we look at the undesirable conditions and circumstances various tribes have faced, it is imperative to comprehend the ways in which the ripple effects of history and laws can impose complex trauma on these individuals and communities.

Science reiterates Red Cloud’s sentiments by demonstrating how prolonged stress, inequality and trauma change neurobiological responses. These changes, also known as epigenetics and psychoneuroimmunology (PNI), support understanding of the increased levels of stress hormones found in Holocaust survivors and their children, resulting in high levels of anxiety and depression, ineffective coping abilities, and decreased social functioning. People from Native nations live under perpetual inequality and discrimination and endure many social injustices. It is reasonable to apply scientific understanding to appreciate the epigenetic and PNI changes experienced within Native nations.

Honoring the privilege to serve Native populations includes incorporating a neuroscience-informed traumatology framework. Having this competency promotes a multifaceted lens to conceptualize the presenting problem and address the underlying root causes that might be outside of the client’s awareness. Neuroscience-informed traumatology provides a pathway of healing, growth, advocacy and improved agency. 

Present snapshot

The U.S. government consistently uses “less than 1%” to describe the population of Native people, but that number represents millions of human beings. Today, there are 573 federally recognized tribes and an unknown number of unrecognized tribes, which at some counts may be around 196. The number of unrecognized tribes fluctuates due to determination of petition to the U.S. government.

Despite the federal government having recognized tribes, a person may be of Native ancestry and not have tribal membership. Not every person with an identity that acknowledges Native ancestry or who has tribal membership lives on land known as an Indian reservation. Tribal governments have the sovereignty to govern tribal land, and these structures vary from tribe to tribe. When working with these clients, understanding their individual experience and relationship to ancestry and identity is essential in establishing and maintaining a healthy therapeutic alliance. One size does not fit all; history teaches us a fraction of one’s experience.

SEATTLE: Indigenous activists march in solidarity with the people of the Standing Rock Sioux in their fight against the Dakota Access Pipeline, September 2016. John Duffy image/Wikimedia Commons https://bit.ly/31NrgqQ

Cultural revitalization efforts

Even with a long history of oppression, violence and genocide, many tribal communities today are reclaiming their histories through cultural revitalization efforts. In areas with high Native populations, you will often see efforts to bring back cultural knowledge in many ways. These efforts expand beyond the occasional localized community event; instead, they intertwine in the very fabric of daily living in these communities.

Although most cultural programs and initiatives are located within tribal territories, you can often find similar efforts in cities with larger Native populations. Look to the American Indian corridor on Franklin Avenue in Minneapolis as an example of the efforts of urban Indians to stay connected through culture. This neighborhood houses an American Indian Center, urban tribal offices, culturally centered schools, Native housing projects, art galleries and more.

The Indian Pueblo Cultural Center is another example of restoring connection. The Pueblos constructed this center on reclaimed land in the city of Albuquerque, New Mexico. It supports cultural, social, educational and economic needs for the 19 Pueblo communities and other Nations of the Southwest. In many major cities, you can often find at least one entity that supports Native people with culturally specific services and programs.

Reclaiming cultural connections is also a global focus. The United Nations declared 2019 as the year of Indigenous languages, and you can see language revitalization efforts everywhere within heavily populated Native communities. These efforts include immersion programs in day care facilities and schools, language camps, community classes, language bowls and the reproduction of media with Indigenous languages. The fact that children are now able to watch the Berenstain Bears in Lakota is evidence of language immersion and acknowledgement. For many tribes, various cultural values are embedded within their respective language. Thus, language efforts closely interconnect to ways of being.

In addition to the multitude of cultural initiatives and programs that exist, Native people are becoming more actively involved in mental health. In October 2010, Dirk Lammers wrote about the outstanding work conducted by the Urban Indian Health Center throughout the cities of South Dakota to improve both the physical and mental health of Native people living off reservations (see https://sduih.org to learn more).

In June 2011, White Swan reported on a program called Dream Makers in Washington state that youth started to assist other students who were struggling with suicide. The youth made small cards with supportive contact information that the students received. This effort, along with training from a specialist from Indian Health Services, led to zero loss of life due to suicide and an unprecedented referral to the school counselor for mental health needs.

In April 2017, Dan Beaton, from the Iroquois Nation, wrote about his work to assist in culture and ceremonies in Canada, and particularly his encounter with the Attawapiskat Nation. He described the beauty of sharing stories and prayers between different tribes and the healing that such events bring through a common reconnecting to a tribal heritage. Mental health continues to be a priority among Native nations. 

Promoting wellness

A plethora of organizations and professional communities are dedicated to promoting wellness among Native nations. The American Indian Health Service (AIHS) serves the urban Native American community in Chicago. It works to address health holistically and has developed innovative medical and behavioral health programs to address the unique needs of indigenous communities. Among these include a Youth Development Program that aims to address emotional health and cultural resiliencies and offers Youth Mental Health First Aid training (visit http://aihschgo.org to learn more about AIHS).

The National Indian Health Board strives to promote successful strategies, identity challenges, support prevention and increase awareness for the behavioral health needs of all American Indian and Alaskan Native people. To acquire valuable resources, visit https://www.nihb.org/behavioral_health/resources.php. Intentional efforts to address prevention and evidence-based treatment for Native people are ongoing. For example, One Sky Center upholds and advocates for culturally appropriate treatment and training to provide mental health and substance abuse services for Native people.

The resilience of Native people encompasses surviving, advocating, healing and thriving. Native Nations and American Indians continue efforts to this day, working on policy issues and engaging in policymaking. The National Congress of American Indians organizes efforts into five policy areas:

  • Community and culture
  • Economic development and commerce
  • Education, health and human Services
  • Land and natural resources
  • Tribal governance

Each year, multiple bills are introduced on the floor of the House of Representatives, and multiple cases are heard in the Supreme Court concerning policies in the aforementioned areas. Today, Vice President of Special Projects for the Cherokee Nation Kimberly Teehee is advocating along with Cherokee Nation Principal Chief Chuck Hoski Jr. to enact the 1835 Treaty of Echota, which would seat a delegate in the House of Representatives. 

Ethics in advocacy

Distinguished endeavors and strides to achieve equity and fairness for Native people have support from collaborative and cooperative organizations, individuals and agencies. Codes of ethics call on professional counselors on multiple levels to advocate with and on behalf of the communities in which they serve. Specifically, the  2014 ACA Code of Ethics includes promoting social justice in its preamble. Furthermore, Standard A.7.a. charges counselors to engage in advocacy efforts to remove barriers to access and equity for their clients. Ratts, Singh, Nassar-McMillan, Butler and McCullough provide professional counselors with guidelines to include advocacy efforts in their work with clients in the 2015 Multicultural and Social Justice Counseling Competencies (MSJCC). Counselors can use these tools in considering how to best collaborate with Native American clients.

Corresponding with the MSJCC, the idea of humility is of utmost importance when an outsider (non-Native) wishes to serve Native American clients. In certain tribes (such as the Navajo), the act of being humble is a primary concern. Although counselors receive education in empathy, techniques and self-awareness, the ability to be humble is not normally taught.

Non-Native counselors looking to work in Native American communities need to acknowledge that they are outsiders. Even though counselors may have good intentions, they will nevertheless need to prove themselves. Having to go through this vetting process is difficult and something that many counselors find arduous and time-consuming. The mindset of the non-Native counselor can mirror the following: I want to help and cannot quite understand the rationale for the resistance I am encountering. However, the belief of the Native American community can mirror the following: People have come and gone and did not have our best interests at heart. It is clear to see the disconnect between these two mindsets.

One way to resolve this issue is to utilize a combination of humility and the MSJCC. For example, consistent with the MSJCC, non-Native counselors need to have self-awareness and critically comprehend their clients’ worldview. This multicultural outlook includes understanding historical privileges and marginalization.

Counselors who operate within this culturally competent framework understand that it is not entirely about their self-identification but also about how one’s identity may be perceived by others. For non-Native counselors whose self-concept is one of overcoming poverty, stress and discrimination, they may see themselves as having a connection to the communities they wish to serve. Conversely, for those in the Native American community, instead of the personal image the counselor wishes to display, they could potentially see an individual who represents past brutalities and halfhearted efforts to help. It takes movement (e.g., courage, patience, openness) on both parties (primarily the counselor) to understand this mindset and have the humility to accept it and be able to move forward positively.

To gain more in-depth understanding of advocacy efforts, it is beneficial to begin learning about a particular Nation or topic area. Attend meetings or sessions on a Nation or topic, learn about the existing efforts and challenges, and use your skills and time with the permission of the appropriate Native leader. Given Native histories, it is important for non-Native counselors to be aware that there might be times when they need to wait for a leader to invite them into a group they are looking to serve. It will also take time for them to be valued as an ally; interest does not equal automatic acceptance.

Sometimes the best gift one can offer is to be the student. History is ever being amended and recorded; remaining open to learning, increasing awareness of one’s relational existence to others, and identifying noninjurious ways to contribute to the change you imagine will allow you to share in amplifying voices and dismantling inequalities.

 

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Roni K. White is the founder of Apricity Wellness Counseling and designer of the “Women in the Workplace: Leadership, Barriers, & Struggles” series. She is a national certified counselor and licensed graduate professional counselor. She aspires for equity in a decolonized world. Contact her at rkwcounseling@gmail.com.

Alaina Hanks is Anishinaabeg and enrolled in the White Earth Nation in Minnesota. She is a licensed professional counselor-in-training and a community advocate with HIR Wellness Center in Milwaukee. Contact her at alaina.hanks@gmail.com.

Susan Branco is a clinical assistant professor with Counseling@Northwestern’s clinical mental health counseling program. Contact her at Susan.Branco@northwestern.edu.

Nicola Meade is an adjunct professor with Old Dominion University. Contact her at nicolaameade@gmail.com.

Isaac Burt is an associate professor at Florida International University. His research interests entail working with historically disenfranchised and marginalized populations. Contact him at iburt@fiu.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.

Fostering immigrant communities of healing

By Lindsey Phillips January 28, 2020

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

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

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

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

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

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

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

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

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

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

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

Overcoming language barriers

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

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

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

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

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

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

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

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

Prioritizing family

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

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

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

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

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

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

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

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

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

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

Partnering with the community

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagnosing the person, not the culture

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clearing the way for immigrants

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

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

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

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

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

 

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

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

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

Letters to the editor: ct@counseling.org

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