Tag Archives: Social Justice

Social Justice

Peer support, mad pride and disability justice

By Luke Romano February 9, 2022

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Do the phrases peer support, mad pride or disability justice ring any bells? If your graduate education was anything like mine, probably not very many. In this article, I’d like to offer an introduction to these terms and the social movements with which they are associated. My goal is for every counselor to walk away from this article with increased curiosity regarding these terms’ significance and relevance to our work and equipped with some practical tools to enhance our professional skill sets.

Some of the perspectives presented in this article are critical of the mental health professions. As counselors, we know that integrating critical feedback from our clients allows us to repair ruptures and ultimately strengthen the therapeutic work. The point isn’t to agree or disagree with client feedback but rather to take it seriously. Similarly, my belief in the importance of these perspectives is related to how they enhance my counseling practice. Putting new ideas on the table doesn’t mean taking other ideas off.

My personal background might contextualize my familiarity with the content presented in this article. Prior to my career trajectory as a counselor and educator, I had devoted more than 10 years to participation in various social justice movements and organizations. In the course of my journey, I had encountered and involved myself in peer support, mad pride and disability justice ideas and social spaces.

I’m now an early career counselor working toward licensure in Pennsylvania. My primary occupation is as a child and youth outpatient counselor in a community mental health clinic in Philadelphia. I also work part time with adults at another practice and recently gained experience as a course instructor in a counseling graduate program. Many of the lessons and principles I learned from my experience as an activist underpin my clinical work. My hope is to bring these lessons and principles to a wider audience in the world of professional counseling.

What is peer support?

Peer support is a tool of the mad pride and disability justice movements, in addition to recovery communities such as Alcoholics Anonymous. Peer support generally refers to acts of care that exist outside of the mainstream health care system, provided by and for those with lived experience who are critical of the hierarchy between professionals and individuals. You may be familiar with the existence of publicly funded peer support specialist certifications and practitioners in states such as Pennsylvania, Tennessee and New York. However, prior to the professionalization of peer support services, peer support practice arose as a grassroots response to the systemic mistreatment of patients in mental hospitals. Peer support represented a pushing back against harmful and coercive functions and practices evident in the medical model of mental illness.

The medical model of mental illness is here defined as an understanding of mental distress wherein symptoms indicate an underlying pathology related to the structure and function of the brain. Although counselors more often cite a “biopsychosocial” model that incorporates biological, developmental and societal factors in conceptualizing mental distress, the “bio” component remains the most prominent foundation on which the mental health system functions. Regardless of our individual inclinations toward developmental conceptualizations of distress or trauma-informed care, most of our clients still require a diagnosis out of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to receive treatment.

Robert Whitaker’s 2002 book Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill thoroughly reviews the history of systemic mistreatment of those with psychiatric labels. In Whitaker’s view, current psychiatric and mental health practices remain impacted by and situated within a historical legacy of discrimination and mistreatment. Forced hospitalization and inadequate informed consent related to medication use are two common examples of mistreatment cited by peer support, mad pride and disability justice activists. Peer support practice arose as an alternative to mainstream mental health while demonstrating that communities of mad or disabled individuals can care for themselves, sometimes with better results than when left in the hands of so-called experts.

The peer support movement simultaneously arose out of necessity. The onset of neoliberal domestic policy during the 1970s and 1980s in the United States involved closing down psychiatric hospitals and filling prisons with those who were mentally ill. It was under this context that communities of those with psychiatric labels learned how to care for themselves without the assistance of professionals. Texts to further investigate the successes and lessons from these movements include Outside Mental Health: Voices and Visions of Madness, edited by Will Hall, and We’ve Been Too Patient: Voices From Radical Mental Health, edited by L.D. Green and Kelechi Ubozoh.

Practical applications

It can help to have knowledge of peer support resources in your area. Peer support groups (whether institutionally sanctioned or autonomously organized) can serve as a useful supplement to traditional one-on-one counseling. They may serve as an alternative for some. Project LETS is a national resource offering a peer crisis line along with various programs, trainings and workshops. It has chapters on college campuses across the United States. Trans Lifeline is an excellent peer resource for our transgender and nonbinary clients. Whether our clients choose to use these resources as a supplement or an alternative to professional counseling, we can respect their self-determination in finding services that suit their self-identified goals and needs.

We can integrate lessons from the peer support movement by centering the self-reported lived experiences of our clients. This could mean using our DSM-5 diagnostic framework and following associated treatment protocols. This could also mean tempering or modifying that approach to better suit client preferences. For instance, the Hearing Voices Network in the United Kingdom is a peer support network that includes members who view psychosis as transformative or spiritually significant and reject medication and hospitalization as helpful forms of treatment. If we encounter such individuals in our practice, we can operate out of a place of respect for their choices while weighing other ethical and professional considerations.

As we aspire to combat racism in our profession, we should also be aware of non-Western cultures that celebrate or revere those with symptoms that we might label psychotic, further integrating these individuals into their communities rather than forcibly isolating them — often with better health outcomes. The 2016 documentary Crazywise explores this topic in depth, albeit from a predominantly Western lens. 

Standard E.5.b. of the 2014 ACA Code of Ethics asks us to “recognize that culture affects the manner in which clients’ problems are defined and experienced.” It is an ethical imperative to acknowledge the limitations of our profession and to allow outside resources and non-Western perspectives to shape how we conceptualize our work with each client.

What is mad pride?

In the 1960s and 1970s, organizations led by psychiatric survivors (individuals who identified as having survived harmful or abusive psychiatric interventions) began to emerge. Groups such as the Insane Liberation Front and the Network Against Psychiatric Assault organized demonstrations across the country, including demonstrations in San Francisco against the use of electroconvulsive therapy (ECT) that led to the city discontinuing use of ECT for 10 years. Psychiatric survivors began to organize under the banner of “mad pride” in the early 1990s, with the term uniting many social movements composed of current and former users of mental health services.

The psychiatric survivor and mad pride movement is not to be confused with the anti-psychiatry movement. The anti-psychiatry movement was pioneered by thinkers such as R.D. Laing and Thomas Szasz who were critical of psychiatry but who were not psychiatric survivors themselves. One difference between the anti-psychiatry movement and the modern mad pride movement is that mad pride activists are careful not to criticize or shame those who have benefited from conventional psychiatric interventions.

Judi Chamberlin’s 1977 book, On Our Own: Patient-Controlled Alternatives to the Mental Health System, was an important text in the psychiatric survivor movement. In it, she used personal experience to critique involuntary hospitalization and coercively administered medication as well as expose human rights abuses in psychiatric wards. However, the mad pride movement offers more than just a critique of the mental health system.

The mad pride movement views mental distress as situated within social, political and economic circumstances. Fireweed Collective is a prominent organization associated with mad pride. I have had personal involvement with an earlier iteration of this organization known as the Icarus Project. According to the Fireweed Collective website, the Icarus Project “conceived mental health struggles not as faulty brains, but in the context that we live in a world that is not healthy for us.” Oppressive structures — colonialism, white supremacy, patriarchy and more — are seen as implicated in, if not directly responsible for, individual experiences of mental distress.

Furthermore, healing from trauma is seen as a tool in the fight for a better world. The Fireweed Collective “seeks to disrupt the harm of systems of abuse and oppression, often reproduced by the mental health system.” This falls in line with the ethical imperative stated in Standard E.5.c. of the ACA Code of Ethics for counselors to “recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and strive to become aware of and address such biases in themselves or others.”

Practical applications

We can integrate the values and lessons from the mad pride movement into our practice by affirming what kind of relationship the client has, or wants to have, to their diagnosis. Some people feel validated or empowered by receiving a diagnosis that they believe reflects their lived experience. Others feel boxed in or inappropriately pathologized by their diagnosis. Standard E.5.d. in the ACA Code of Ethics states that counselors “may refrain from making and/or reporting a diagnosis if they believe that it would cause harm to the client or others.”

Similarly, some people have a positive relationship to their medication, feeling they benefit from it. Others feel disinterested in psychiatric medication or harmed by their experience with it. We can advocate for our client by collaborating with their doctor or psychiatrist to center the treatment goals and preferences of our client. By centering the self-reported lived experience of our client, we avoid harm while encouraging a sense of self-determination in treatment and, by extension, life — a healthy developmental marker for which we should be aiming.

Mad pride activists are often opposed to the practice of involuntary hospitalization. A growing body of research finds higher suicide rates post-discharge among those involuntarily hospitalized compared with the general population, raising questions about the effectiveness of involuntary hospitalization. One study published by JAMA Psychiatry in 2016 revealed a suicide rate approximately 15 times the U.S. national suicide rate within three months post-discharge. 

Regardless of the meaning we make or don’t make of such findings, counselors should consider them alongside mad pride narratives when faced with the decision to hospitalize someone. We can include these considerations in our ethical decision-making processes alongside “consultation; consideration of relevant ethical standards, principles, and laws; generation of potential courses of action; [and] deliberation of risks and benefits” as outlined in Standard I.1.b. of the ACA Code of Ethics.

What is disability justice?

According to Leah Lakshmi Piepzna-Samarasinha, author of Care Work: Dreaming Disability Justice, disability justice “centers sick and disabled people of color, queer and trans disabled folks of color, and everyone who is marginalized in mainstream disability organizing.” Disability justice asserts that ableism — discrimination against and oppression of the disabled — is “locked up tight” with all systems of oppression. The idea that disabled people require “fixing” underpins ableism. The disability justice framework arose out of a critique of the disability rights movement for failing to examine the roles of oppression and identity in experiences of ableism. It advocates for leadership by those most affected.

The disability justice framework builds off of the social model of disability. This model defines disability as resulting from an impairment (including pain, paralysis, fatigue, etc., that would exist regardless of society) plus inaccessibility. Inaccessibility is understood as a society that accommodates the needs of nondisabled people (such as the construction of stairs in buildings) while failing to accommodate the needs of disabled people. As such, disability is a social construct that happens only when an impairment meets an inaccessible society.

Although many issues raised by disability justice writers and activists are of relevance to counselors, the concept of sanism — discrimination and oppression of those who have (or are judged to have) a particular mental trait or condition — is of particular significance in mental health settings. Sanism is understood as a form of ableism. Some disability justice advocates view involuntary hospitalization as an example of sanism, conceptualizing the practice as a violation of basic human rights enabled by cultural stigma toward those with a mental illness or disability. Furthermore, we can consider the ways in which this stigma may be compounded by racial and other biases with the inclusion of an intersectional feminist lens.

Practical applications

Center and adopt your client’s identity and use of language on a case-by-case basis. Many counselors are taught to use person-first language (e.g., Sam has autism). However, increasing amounts of disabled people are asking to be referred to using identity-first language (e.g., Sam is autistic). This is why I’ve chosen to use identity-first language in this article. 

The rationale for this shift is due to an increasing acceptance of disability as an identity or part of who someone is rather than an illness or something to be cured or extinguished — the latter notion having historical roots in the eugenics movement. The nuances of language vary from individual to individual and disability to disability. If you are unsure what type of language your client prefers, simply ask.

Adopting a curious stance that avoids assumptions will assist you in your work with disabled populations and any marginalized or oppressed population with which you might not be familiar. Use the motto of the disability rights movement — “Nothing about us without us” — as your guide. Where did you learn what you know about disability? If it wasn’t from a disabled person or source, you should revisit and examine your knowledge base and assumptions.

Consider the ways in which explicit and structural ableism show up in your practice or at your workplace with the following questions: Is your workplace wheelchair accessible? Do you frame disability as either tragic or inspirational? Do you conceptualize the needs of your disabled clients with the same amount of depth and complexity as you would with your nondisabled clients? Is your workplace scent free? Do you speak for your disabled clients in situations in which they are able to speak for themselves? Have you ever asked invasive questions about the medical history of your disabled client? Do you view disability as something to cure? Do you feel like you need to rescue your disabled clients from their disability? How does ableism intersect with other forms of oppression to create unique social and institutional barriers for each client?

Also take some time to examine your internalized ableism. Do you ever feel like you’re a burden when you have a need? Do you ever feel like you don’t belong because of a perceived deficit? Do you feel “lazy” when you are unproductive? Do you blame yourself when you are unable to accomplish something? How comfortable are you when you need to ask for an accommodation? Do you compare yourself to more “successful” people? How does your internalized ableism interact with other forms of internalized oppression such as racism or sexism? Consider how the answers to these questions might influence how you conceptualize and work with your disabled clients.

There is an entire world of discourse and activism related to disability justice, the surface of which has barely been scratched in this article. Prominent scholars and activists to look to include Patty Berne, Mia Mingus, Stacey Milbern, Leroy F. Moore Jr., Eli Clare and Sebastian Margaret.

Conclusion

The mad pride movement understands external circumstances (poverty, racism, transphobia, etc.) as implicated in individual experiences of mental health. Similarly, disability justice views our dominant culture as “disabling” rather than locating disability exclusively within the individual. Peer support is a method with which these communities care for themselves, whether due to necessity, rejection of professional services or both. 

Knowledge of these perspectives enrich the tools of our profession rather than detract from them. Turning toward critical feedback allows us to repair historical and individual ruptures, broaden the scope of our practice and advocate for our clients while connecting them to helpful resources.

 

Links to referenced organizations and resources:

A woman at a march in Amsterdam in March 2020 holds a sign that says “Nothing about us without us,” the motto of the disability rights movement, in Dutch. ElenaBaryshnikova/Shutterstock.com

 

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Luke Romano is an early career mental health counselor, educator and psychoanalytic candidate in Philadelphia. With a background in mad pride and other political activism, Luke is interested in the intersections of decolonial and anti-capitalist values and practice, psychoanalysis and the counseling profession. Contact Luke at luke.j.romano@gmail.com.

 

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

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

Fear and anxiety at the ballot box

By Laurie Meyers October 22, 2020

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Word began to filter out late morning on Tuesday, Oct. 13, the last day that Virginia residents could register to vote in the 2020 general elections. A severed fiber-optic cable had brought down the commonwealth’s voter registration portal. Officials said the cut was an accident caused by roadwork; skeptics on Twitter had “accidentally” trending. Paper registration was still available — if postmarked or dropped off at local voter registration offices.

By midafternoon, after an approximately six-hour outage, the site was back up. A federal judge ordered an extension of the deadline to compensate would-be voters for lost time. Everyone would still be able to register to vote. All’s well that ends well, right?

And yet. To many people, the snafu seemed like just one more alarming plot twist in the tale of an election season — and year — so fraught with unprecedented crises that it would most likely evoke reader skepticism if found within the pages of a novel.

The U.S. national elections are already set to serve as a proxy for the country’s stance on climate change, universal health care, racism, police brutality and (dueling visions of) democracy. The maelstrom of events that is 2020 has brought everything to the forefront in Technicolor. The death of George Floyd under the knee of a police officer. The ensuing protests against police brutality and the continuing demands for an end to racial injustice. The spread of violence by white supremacist groups. Record-breaking wildfires in California and Oregon. An incredibly active — and ongoing — hurricane season. The death of Supreme Court Justice Ruth Bader Ginsburg and the rush to appoint her successor. All of it amidst a pandemic unlike any other seen in the past 102 years.

When most Americans started staying home in March in hopes of bringing down the levels of infection by the novel coronavirus, they most likely didn’t expect that almost everything about COVID-19 would become partisan. The degree of threat posed by the virus. Whether to close businesses and restrict community movement. To mask or not to mask? In some quarters — albeit fairly fringe ones — the very existence of the novel coronavirus became a partisan matter. Now, less than one month before the election, more than 225,000 Americans are dead — a total that includes a disproportionate number of Black, Indigenous and people of color — and voters have spent months wondering about the best way to cast their vote.

In response to voter anxiety about going to the polls in person, most states expanded absentee mail-in voting by allowing anyone to use COVID-19 to justify their request. But the U.S. Postal Service, which had been preparing for the surge, was subject to organizational and equipment changes that made the mail less timely. So, many voters worried: If they requested an absentee ballot, would it arrive in time? The requirements for mail-in ballots vary from state to state, leaving some voters baffled and bemused. A process that is usually fairly straightforward has become yet another tangle to unravel in a year that has been fraught with knots.

“Our ability to cope with uncertainty is maxed out,” says licensed professional counselor (LPC) Keri Riggs, an American Counseling Association member with a private practice in Richardson, Texas. The pandemic has also effectively put most of our previously established timelines in question.

“We can’t make plans,” Riggs, whose areas of specialization include depression and anxiety, says. “The thing about the election is that we have a theoretical deadline.” We’ve always thought we understood when voting for the election was over, but this year, we can’t even have a sense of certainty about when it might end and when an undisputed winner in the presidential election might be declared, she says. Part of this year’s election anxiety is tied to not being able to rely on that usual deadline as an endpoint to at least one source of uncertainty.

With the exception of the contested vote count in Bush vs. Gore in 2000, modern Americans are used to learning who the winner of the presidential election is on election night or the morning after. But because so many people are voting by mail this year and it will take time to process those ballots, the votes amassed on Election Day will not be the final tally.

“If there is a contested election, it could drag on for a very long time,” Riggs points out. “Everything has already been dragging on for a very long time.”

And it’s not just about the endpoint. Many voters see this election as more than a mere partisan contest; to these voters, it is something upon which the future of bigger picture issues such as climate change, immigration and racial justice rests. In fact, a recent Pew Research Center survey found that 83% of registered voters say it really matters who wins the presidency. These results are an increase from the 74% of voters who said the same thing four years ago and the highest share of voters saying this in two decades of Pew Research Center surveys. In keeping with the anxiety surrounding the election, approximately 50% of survey respondents said they expected that voting will be difficult.

The stories that we tell ourselves play a critical role in how we cope with stress, anxiety and the seeming chaos around us, Riggs says. Too often, clients focus on the “what ifs” of a doomsday future that may or may not come to pass, she explains.

“The Islamic theologian, Sufi mystic and poet Rumi once said, ‘The words you speak become the house you live in,’’’ notes Ryan Thomas Neace, an LPC who is the founder and CEO of Change Inc., a St. Louis counseling practice that focuses on healing and personal growth in the face of pain. A similar dictum is contained in the Hebrew Scriptures, “The power of life and death is on the tongue,” he continues. “In other words, what we say matters.”

Neace is not denying that voters are facing weighty issues as they cast their ballots, but he maintains that the narratives we construct are not solving anything. Instead, people get caught in the trap of thinking that constant worry and panic are somehow equal to civic engagement or political purpose.

Clients can break their “doom” loops with present-moment awareness, Riggs says. For example, when fear of the future and visions of disaster threaten to take over, she has clients practice telling themselves that they and everyone they love are safe in that moment.

Riggs also advises clients to consume social media and news in moderation and to take breaks. She urges clients to channel their energy into productive action, either by engaging in the political process with a campaign donation or volunteering at the polls, or via a smaller personal outlet such as journaling or even cleaning the bathroom.

Riggs says it is also essential to exercise self-compassion and what one of her clients calls “grace.”

“We need to give ourselves and each other grace — the benefit of the doubt,” she says. “We’re not all on our A-game.”

Neace reminds clients that it is OK — indeed helpful — to tell themselves resilience-building stories such as, “There’s a lot at stake here, but we’re going to get through this together, no matter what.”

President Donald Trump and former Vice President Joe Biden, pictured in a nationally-televised debate on Sept. 29.

Fear of racial violence

“There is a lot of evidence that there are a number of groups that actively want to hurt and disenfranchise Black Americans,” says Harrison Davis, an LPC in Atlanta who specializes in depression, anxiety, resentment and helping people overcome personal obstacles. These groups have come out of the shadows and appear to feel empowered by what they — and many Black Americans — perceive as support from the police and from forces within certain parts of the government and judicial system, he says.

The clients and community members he’s spoken to say their sense of security has diminished over the past year because they feel betrayed by people they believed were their allies. Some of his Black clients have told Davis that instead of standing by them in the fight for racial justice and an end to police brutality, some of their white neighbors and friends supported these law enforcement actions and were actively critical of the ensuing protests.

On top of this vulnerability, some of his Black clients have expressed concern that President Trump has not committed to a smooth transition of power if he loses, while white supremacists are threatening violence or even war, Davis says.

Some clients have an almost panicky need to prepare for an emergency — as if by doing so they can keep their darker fears from manifesting, he continues. This sense of catastrophe is fueled not just by the election, but by the many deaths the coronavirus has brought to the Black community.

Although the threat is real, his clients’ response — living in a constant state of anxiety and panic — is neither healthy nor sustainable, Davis says.

Like Riggs and Neace, when working with clients struggling with election anxiety, Davis zeroes on how much news and social media they are consuming. Not only are clients being bombarded with a sense of overall catastrophe—they are engaging in conversations that are often vitriolic and damaging.

“When I grew up, you would just watch the polictical coverage on the TV networks,” he says. Now, everyone can watch a developing story or scandal in real time. So Davis asks clients to notice how they are responding as they track this torrent of information. “Is it causing you to tense up?” he asks. “Lose sleep?” Clients also report irritability and constant worry–not just about the election, but everything. Right now, the constant urgency and concern of news and social media has such a marked effect on clients, that Davis has moved away from recommending that they balance their use. Instead, he has them do a complete detox.

“Channel that energy into positives instead of arguing with people,” he urges clients. Rather than trying to convince others of their viewpoint, they could be helping people register to vote or get to the polls on Election Day. Davis also encourages clients to find hobbies and outlets that have nothing to do with politics or current events.

On a deeper level, he finds that clients are struggling to accept the world as it is. They may have believed that we had grown as a nation and society over the past decade but now may see that things haven’t changed significantly. One way to cope with that reality and find greater peace is to identify ways to help the community, Davis says.

In his own life, Davis’ father, who was an activist in the civil rights era, told him and his siblings that they might have thought things had changed, but they really hadn’t. Black Americans are still engaged in the struggle for racial equality that has been denied them for generations.

That doesn’t mean that clients need to live in fear, Davis says. Living like that only gives power to those who want Black people to be afraid. He urges clients to find a space where they feel like they belong and to be thoughtful about who they invite into their inner world. They may not yet be able to change the world, but they can control elements of their world by removing unsupportive friends or by leaving environments which make them feel triggered or unsafe—such as social groups or toxic work environments.

A number of his clients are very spiritual, Davis adds. They find strength through the Bible, which holds many stories of people who experienced tragedy and injustice but prevailed by relying on faith and their community.

Power and connection amid chaos

Although many of us view the cacophony of the election cycle as something to endure while keeping our sanity in check, ACA member Laura Brackett is encouraging clients to find their personal power in the chaos.

The year 2020 and the years leading up to it have been traumatic in myriad ways, and exploring personal power is a constant component of trauma work, she says. “The beauty of it is that personal power takes countless forms,” says Brackett, the director of community engagement at Change, Inc., in St. Louis. “For some clients, this has meant outward action in the form of voting, protesting and becoming active in the community. For others, it has meant embracing their own emotional reactions and how that is influencing their behavior and empathy toward self and others.”

Often the process involves a combination of both external and internal work, she says. Brackett’s goal is to encourage clients to embrace their personal power without losing sight of how its expression affects others.

“If there is one thing this year has shown us, it’s that we don’t live in a vacuum,” she says. “Our words and actions have real impact on others. I want to help my clients see this interconnectedness and learn how they can best live within it in a way that is compassionate as well as empowered.”

 

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Related reading, from ACA’s Department of Government Affairs and Public Policy: “Counselors Are Voting in 2020”

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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.

The historical roots of racial disparities in the mental health system

By Tahmi Perzichilli May 7, 2020

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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 at tperzichilli@gmail.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.

Human Rights 101: Implications for counselors and the counseling profession

By Michael P. Chaney, Carman Gill and John Super November 19, 2019

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On April 30, an on-campus shooting at the University of North Carolina at Charlotte left two people dead and four others injured.

On January 6, Dana Martin, a 31-year-old, transgender woman of color was found in her vehicle—which had crashed into a ditch—with a fatal gunshot wound to the head, in Hope Hull, Alabama.

In 2017, two doctors and a clinic manager in the Detroit area were accused of performing or facilitating female genital mutilation (FGM) on nine girls—at least two of whom were only 7 years old.

Since 2017, the Chinese government has been detaining at least one million and perhaps as many as three million Uighur and other ethnic Muslims in internment camps in the Xinjiang region.  The camps are a part of a years-long effort to wipe out the ethnic and religious traditions of the Uighur and other Muslim ethnic groups. Former prisoners describe torture and constant political indoctrination designed to force detainees to give up their religious beliefs, language and ethnic identity.

At first glance, these incidents seem to have little in common with each other; however, the link that bonds them together is that they are all human rights violations. A next logical question some might ask is what do these issues have to do with counselors and the counseling profession? Many professional counselors do not think human rights issues are related to or comfortably fit within the counseling profession and/or are outside of the traditional job description of counselors. This is partially due to the difficulty of separating human rights issues from political issues, which may create values conflicts for some counselors. Second, many counselors may not have a clear understanding of what human rights are beyond the rights that people know about, particularly if the rights directly impact them. Thus, values conflicts and lack of understanding often lead to professional counselors’ cautious involvement with human rights.

 

We are past and current members of the American Counseling Association’s Human Rights Committee (HRC) whose stated mission is to bring awareness to human rights and social issues that impact the counseling profession and to address barriers that impede human rights. We believe that human rights issues are inextricably linked to both the practice of counseling and the overall profession. We’ve developed this two part series, consisting of two separate articles that explores why human rights issues are important to counselors and counselors-in-training. This first article provides a general background of human rights issues and its relevance to practitioners, whereas the second article is solely focused on human rights issues and counseling students and counselor training.

We start with a question: What are human rights?

The concept of human rights entered the international realm with the founding of the United Nations (UN) in 1945. The term “human rights” was mentioned seven times in the UN’s founding charter, establishing that the promotion and protection of human rights is a key purpose and guiding principle of the organization. In 1948 the UN issued a document drafted by representatives from all regions of the world — The Universal Declaration of Human Rights — which for the first time set out fundamental human rights recognizing the inherent dignity and equal and inalienable rights of all humans regardless of race, gender, nationality, religion, language, social status, place of birth or other factors (such as sexual orientation, which is not specifically mentioned in the declaration). Human rights may include civil, political and cultural rights. Simply, human rights are freedoms and liberties that are due to people solely based on their status as human beings. The foundation of human rights is built upon respect for the individual, which aligns with counselors’ primary ethical responsibility to respect the dignity of our clients and students. According to the UN, everyone is entitled to basic human rights.

Although it is impossible to list all human rights issues in this series, there are defined categories. The first category pertains to the right to personal and physical safety, which includes freedom from slavery or unwilling servitude; torture; and inhuman, cruel or degrading treatment or punishment. From a counseling perspective, issues that may fall under this category include but are not limited to mental health consequences associated with interpersonal and domestic violence, gender-based harassment, human trafficking, and community gun violence. The second category includes political rights and civil liberties such as the right to express one’s ideas and beliefs freely and to fair treatment in the judicial system. For counselors, examples of this dimension include addressing mental health consequences associated with racial disparities in incarceration rates and forced treatment of mentally ill offenders. The third category of human rights centers on social and economic rights, which include the right to quality education, gainful employment, housing, health and an adequate standard of living. This dimension has implications for counselors who provide services to clients or students who live in poverty, are unemployed, struggle with health concerns or experience psychological distress as a result of systemic oppression. These examples demonstrate that human rights issues can potentially affect anyone. Therefore, human rights have a seat at the counseling table.

Human rights in the helping professions

Because human rights violations impact mental wellbeing, several of the member organizations affiliated with helping professionals specifically name human rights in their mission or vision statements. For example, one of the five general ethical principles included in the American Psychological Association’s code of ethics is respect for peoples’ rights and dignity. The Society for the Psychological Study of Social Issues describes itself as an organization that promotes research and education on psychological aspects of critical social issues and brings science and evidence to human problems. The statement of ethical principles created by the International Federation of Social Workers–the global body for the social work profession– states that members and the profession as a whole strive for social justice, human rights, and inclusive, sustainable social development.

Although the American Counseling Association (ACA) is in a unique position to be a leader at the intersection of counseling and human rights, presently, it does not name human rights in its vision and mission statements. However, ACA’s recently developed strategic plan includes social justice and empowerment as a core value, whose guiding principles can be summarized with the catch phrase: Human rights are right.

Because counselors are often on the front lines treating the mental health consequences of human rights violations in the lives of clients and students, we should have a clear understanding of our professional responsibilities as it pertains to human rights issues. First, we have a responsibility not to violate the human rights of other people including our clients and students. Second, we should work to build a culture where human rights are respected.

Why human rights are relevant to counselors and the counseling profession

As counselors, we must recognize the crucial role human rights play in mental health and wellness. Human rights violations often result in serious emotional consequences for individuals, families and communities. We began this article by giving recent examples of brutal human rights violations. Unfortunately, these incidents are just a snapshot — a mere fraction of the violations that entire groups targeted for their ethnicity, religion or political beliefs and individuals in marginalized populations experience daily. Many clients encounter multiple forms of harassment, bullying, restriction of freedoms, verbal abuse, threats of violence and life-threatening events.

The long-lasting physical and emotional consequences of exposure to these conditions cannot be understated. As a result of these violations, clients may experience a range of detrimental mental health consequences including but are not limited to — increased loss of dignity, ongoing stress, anxiety, sleep disturbances, physical distress, spiritual distress, increased substance use, decreased productivity, emotional dysregulation, severe depressive symptoms and suicidality. In addition to the impact on holistic wellness, individuals often experience post-trauma stress symptoms and are at risk of developing post-traumatic stress disorder (PTSD). Whether clients experience a single incident or have been subjected to chronic, ongoing human rights violations, their lives are impacted, as are the lives of loved ones, families, and communities. Collectively, we are all diminished as a result.

As counselors, it is incumbent upon us to identify human rights concerns and their impact, to uphold individual human rights and address the negative consequences associated with violating these rights.

The ACA Code of Ethics can serve as a guide to protecting and upholding human rights. In fact, the ethical principles defined in the code’s preamble to directly relate to human rights advocacy. Consider, for instance, the principle of autonomy, which states that counselors have a responsibility to foster an individual’s right to control their life. Control of one’s life pertains not only to the counseling setting, but extends to every life aspect and to all three of the human rights categories listed earlier in this article. Therefore, counselors should be cognizant not to intentionally or unintentionally violate the human rights of clients. This is consistent with an additional ethical principle, beneficence.

As counselors we have a responsibility to treat our clients with justice, equity and fairness. This responsibility incorporates human rights issues as well, as every human being has the right to basic freedoms, human decency and respect. Justice includes advocating on behalf of marginalized populations and treating clients and students fairly. Honoring others and keeping our commitments to those we serve and to the greater social community embodies the principle of fidelity and is in keeping with human rights principles. In doing so, we build trusting relationships with those around us, allowing for positive interactions and improved wellness, building healthier communities. Veracity, the last ethical principle listed in the preamble, bids counselors to deal truthfully with those they encounter professionally. Speaking the truth by identifying and exposing human rights violations creates awareness that can lead to change. Taken as a whole, these principles form a roadmap not just for the counseling-client relationship, but also for respecting the human rights of people not just in our communities but in society as a whole, which can help foster a healthier world.

Global human rights initiatives and mental health

As stated above, the UN’s Universal Declaration of Human Rights (UDHR) was originally adopted in 1948 and reinforces the ideals behind bettering our communities through endorsing fundamental human rights, understanding the mental health consequences of violating these rights and advocating. Consistent with ACA’s ethical principles, this declaration includes language such as autonomy, freedom and justice. This document heavily endorses the ideas of personhood, dignity and freedom for every human being, which complements the core values of the counseling profession.

Key to any discussion on human rights is the UN’s Commission on Human Rights (UNHRC) and its relationship to mental health and counseling. Established in 1946 for the purpose of incorporating legal responses into human rights problems globally, the UNHRC included 53 member states, whose delegates met at annual sessions in Geneva. The commission reviewed reports on specific human rights issues, adopted resolutions, issued statements and made decisions regarding human rights issues. It also provided a forum for countries, non-governmental organizations (NGOs) and human rights advocates to voice their concerns.

The UNHRC established the committee that drafted the UDHR and was tasked with upholding it until 2006 when the Human Rights Council replaced the commission. Currently, the council promotes and protects human rights worldwide. Consisting of 47 members, including the United States, the Human Rights Council meets three times per year in Geneva, but may also hold a special session as needed to address urgent human rights violations. The council focuses much of its work on pervasive issues such as cultural rights, adequate housing, the rights of indigenous people, the rights of people with disabilities, racism, slavery, human trafficking and violence against women.

Addressing human rights violations in counseling

Understanding the professional and clinical importance of human rights issues is valuable to the counseling profession in general and in clinicians specifically. Knowing how to assess and treat the negative effects of human rights violations is paramount to treating [client] symptoms in sessions. A counselor’s primary role is to help clients address the issues that brought them to counseling and to advocate on their behalf. In fact, the ACA Code of Ethics encourages us to advocate at individual, group, institutional and societal levels to address potential barriers and obstacles that inhibit access necessary to the growth and development of clients. For clinicians to effectively advocate on behalf of clients’ human rights, understanding how and why the issue affects clients, society, and the counseling relationship is a must.

For many counselors, human rights violations assessment was not likely taught in their respective counseling programs. Therefore, it is crucial that counselors hone their assessment skills by understanding how violations of human rights may manifest in clients. Identifying the words and behaviors hinting at trauma that may stem from human rights violations can help the counselor to further assess the client. Just as counselors should assess for histories of abuse, substance use and suicidal or homicidal ideation, gathering information about experiences of human rights violations is essential.

At the onset of clinical work with clients who have experienced trauma associated with human rights violations, we recommend four guiding principles with which to frame the therapeutic relationship. First, create a safe environment in which trauma symptoms can be stabilized and explored. Second, counselors would serve their clients well by asking direct, open-ended questions about potential human rights violations and exploring issues that help uncover related trauma. Third, do not discriminate, remain nonjudgmental and avoid victim-blaming as clients share their violation experiences. Fourth—and last—assist clients in empowering themselves. Once these fundamental principles are in place, the following counseling strategies may be effective in treating trauma symptoms associated with human rights violations.

  • Manage the level of emotional stimulation and expression in sessions. While avoiding overstimulation is beneficial, clients who limit their emotional expression may be resisting stepping outside of their comfort zone, which could prevent adequate processing and growth. In contrast, clients who are highly expressive emotionally may become overstimulated, which could cause trauma symptoms to get worse.
  • Mindfulness of emotions helps clients develop a level of awareness of their feelings and teaches clients how to examine the emotions they experience without judging whether or not they are “good” or “bad.”
  • Teach clients coping strategies for intense human rights violations, trauma symptoms and feelings. Techniques such as relaxation training, cognitive disputation and stress reduction can be helpful.
  • Educate clients on normal reactions to trauma. This includes validating and normalizing clients’ affective reactions to human rights violations.
  • Grounding techniques that make use of all the senses help clients to stay focused and in the present when processing distressful human rights violations. Three effective techniques include having the client listen to the counselor’s voice, have the client feel bare feet on the ground, and allow client to name 5 things they see, 4 things they feel, 3 things they hear, 2 things they smell, 1 thing they taste (5-4-3-2-1).
  • Eye movement desensitization and reprocessing (EMDR) has been shown to be effective for many clients to alleviate symptoms of trauma and distress such as those connected to human rights violations.
  • Group therapy for trauma survivors may be an effective complement to individual therapy.

The strategies mentioned above are by no means an exhaustive list of all potentially effective interventions at a counselor’s disposal for treating the mental health consequences of human rights violations. We encourage readers to consult professional literature for additional interventions.

ACA has done a phenomenal job of addressing the intersection of mental health and human rights — yet more can be done. As the counseling profession evolves and ACA continues to grow, we offer three recommendations that we believe would place it at the forefront of counseling and human rights issues. These recommendations stem from the World Health Organization, and we adapted them for the counseling profession.

ACA and the counseling profession should:

  1. Continue to raise awareness and advocate for change by educating clients and advocating for targets of human rights violations.
  2. Develop and support mental health policies and laws that promote human rights.
  3. Train stakeholders on the human rights of people with mental health issues. Stakeholders include anyone who has an impact on people with mental health issues, including but not limited to counselors, law enforcement, schools and the judicial system.

 

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Michael P. Chaney is a licensed professional counselor, an approved clinical supervisor and an associate professor in the Department of Counseling at Oakland University in Rochester, Michigan. He is the immediate past co-chair of ACA’s Human Rights Committee and currently serves as the editor-in-chief of the Journal of LGBT Issues in Counseling. Contact him at chaney@oakland.edu.

Carman S. Gill is a licensed professional counselor, a national certified counselor and an approved clinical supervisor. She is also a professor and the doctoral program coordinator at Florida Atlantic University in Boca Raton, Florida. She is the immediate past co-chair of ACA’s Human Rights Committee and a past president of the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC). Contact her at carmangill@gmail.com

John T. Super is a faculty member in the University of Central Florida’s counselor education program. After receiving his master’s degree in marriage, couples and family counseling, he worked in and developed a clinical private practice with a focus on helping LGBTQ+ couples with relational issues. He is a national certified counselor and is also a licensed marriage and family therapist in the state of Florida. Contact him at jsuper@ucf.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.

The use of evidence-based practices with oppressed populations

By Geri Miller, Glenda S. Johnson, Mx. Tuesday Feral, William Luckett, Kelsey Fish and Madison Ericksen December 3, 2018

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Therapy must always be tailored to the individual; there is no one-size-fits-all model. However, certain approaches have been empirically verified for use with a variety of clientele. It is critical that all counselors, especially those working with client populations that are oppressed, have both an overview of evidence-based practices and specific techniques related to these approaches in their clinical toolboxes to help them provide the best counseling services possible.

Counselors are frequently required to use evidence-based practices and need to know how to use them effectively in counseling clients who are oppressed. Specifically, the unique development of the therapeutic relationship between oppressed clients and privileged clinicians must be understood and addressed. Multicultural counseling experts Derald Wing Sue and David Sue maintain that the dynamics of oppression shift the influence of the therapeutic relationship. Thus, counselors must alter their application of evidence-based practice techniques.

Solution-focused brief therapy and low socioeconomic status

Take a moment to think about what the basic needs of your own life are. What is impossible for you to live without? For many of us, our basic needs are continually met. Therefore, they often go unnoticed — they are woven into our everyday lives and ways of being in the world.

For others, questions such as “Will I eat today?” or “Will I have a safe and warm place to sleep tonight?” are asked daily. Often, the answer is “no.” Concerns such as clean drinking water, access to hygiene products and finding adequate shelter affect an inordinate number of individuals in the United States. School counselors and licensed professional counselors have a moral and ethical obligation to address these matters, with the intention of removing barriers and cultivating a safe space for clients in both the therapeutic relationship and the environment beyond our office walls.

Glenda Johnson (one of the co-authors of this article) worked as a school counselor and an advocate in a school system in which the majority of students came from low socioeconomic status (SES) backgrounds. Many of the students were on free or reduced lunch plans because their families’ financial resources were severely limited. At the core of Johnson’s work was the intent to ensure that every child’s basic needs were met while they were at school. She emphasized the importance of working collaboratively with other school staff members to build a team and a foundation for connecting these students and their families to resources.

It is also vital to assess an individual’s behaviors, emotions and reactions through a holistic, biopsychosocial approach rather than focusing only on the school context. Learned behavior concerns, inattention, difficulty with emotion regulation (anger), sadness and loss of hope are often the result of a lack of resources. Johnson recalls that if a student acted out, one of her first questions would be, “Did you have breakfast this morning?”

Johnson shares an anecdote that highlights the powerful act of providing a safe, therapeutic space for students to identify and voice their emotions openly with peers. As a school counselor, she infused the identification of various emotions into a game of musical chairs, and what transpired was completely unexpected. A student identified a “sad” emotion and explained that their father recently had lost his job. The student was experiencing fear about not having enough food to eat during this time. Then, other students began to share similar stories without prompting. The game of musical chairs transformed into a collaborative and touching experience as the students identified common ground and connected on deeper levels of understanding and empathy.

When providing services to individuals from a low SES, counselors may find it helpful to use a strengths-based therapeutic approach. The evidence-based practice of solution-focused brief therapy (SFBT) zeros in on the therapeutic relationship and the clinician’s way of being. In this relationship, there is an acknowledgment of reality but also an emphasis on solution-focused thought and reframing. Focusing on strengths, the counselor and client work together to identify and move toward making small changes in any area because a small change in one area often leads to change in another area.

SFBT often introduces the “miracle” question: “Suppose that when you go to sleep tonight, a miracle occurs that solves your problem, but because you were sleeping, you did not realize what happened. When you wake up in the morning, how will you realize a miracle happened? What will you notice that you are doing differently?” These questions enhance and expose glimpses of solutions that an individual may struggle to identify in everyday life situations.

Additionally, SFBT places great value on successes. The counselor and client celebrate achievement and may use scaling to note the client’s progress. When working in a school system, the counselor could develop a creative and motivating way for children to rate themselves and their progress toward goals. For example, Johnson created a rating scale, complemented by the colors green, yellow and red, for kindergartners and first-graders. Green identified a completed goal, yellow identified progress toward a goal and red identified room for improvement. Similarly, she used a rating scale of 1-5 for students in second through fourth grades. Under this scenario, a student could check in with a rating, such as, “I am at a 3 and working toward a 5.” The counselor might respond, “What would it take to get to a 3.5?” The scale provided a visual for children to identify, track and celebrate their successes.

In SFBT, the counselor acknowledges client strengths and walks alongside these clients as they create and work toward their goals and future successes. “Flagging the minefield” is another technique counselors can introduce to help clients generalize and apply what they learn in counseling to future situations. Flagging the minefield is a particularly important facet of SFBT because it assists individuals in recognizing potential obstacles or barriers that will appear in their lives. The counselor and client work together to identify tools and resources the client can apply in other settings and relationships.

When working with students living in poverty, counselors should introduce a strengths-based approach and identify and gather resources to assist students and their families in removing barriers and meeting basic needs. Cultivating a safe, therapeutic relationship with students that focuses on solution building can assist them in building a stronger sense of self.

Motivational interviewing, SFBT and rural adolescent substance abusers

Adolescence is a vulnerable time and a critical period for developmental outcomes. During this stage of life, adolescents are exploring and forming their peer relationships and personal identities while beginning to distance themselves from family. Experimentation with substances often begins during this time. In 2012, Tara Carney and Bronwyn Myers found a correlation between the early onset of substance use and an elevated risk for later development of substance use disorders. Additionally, because early substance use may impact the growth of the adolescent brain, it has the potential to heighten one’s risk for delayed social and academic development.

Adolescents living in rural areas are marginalized in multiple ways. Children are an underserved minority population, as are rural populations. Sheryl Kataoka, Lilly Zhang and Kenneth Wells (2002) found that among youth with a recognized mental health need (estimated at 10 million to 15 million people), only 20-30 percent receive specialized mental health care. Rural communities are more likely to have fewer clinicians or require a long drive to see those clinicians, making it more difficult to obtain care. These disadvantages are exacerbated by the tumultuous nature of adolescence.

Motivational interviewing and brief interventions are two evidence-based practices particularly suited to this population because these approaches are generally influential in their therapeutic role while also being cost-effective. Motivational interviewing facilitates behavior change through exploration and resolution of ambivalence, and it focuses on being optimistic, hopeful and strengths-based. It uses principles of empathy, discrepancy, self-efficacy and resistance, and offers specific techniques such as OARS (Open questions, Affirmations, Reflective listening, Summarizing). SFBT emphasizes solutions, changes clients’ perceptions and behaviors, helps clients access their strengths and uses techniques such as exception to the problem, specification of goals and the miracle question.

Individual interventions with the use of the same interventions for multiple sessions are ideal, and research suggests that the earlier the intervention, the better the outcome. Early intervention shows better results than both preventive measures and later interventions because it reduces the need for more specialized interventions and provides applicable and useful tools and tactics for adolescents as they enter into various student, peer, familial and professional roles.

Challenges certainly exist when working with children and adolescents, particularly because many biological, environmental and social shifts occur organically during this time. As children and adolescents rapidly transition on a continuum of development, they become “moving targets.” Interventions that prove effective for those ages 11-12 often cease to be effective by ages 13 or 14. It is vital that counselors remain aware of this across the life span. Although adolescents are beginning to distance themselves from their caregivers, familial relationships and parental involvement remain crucial during this period.

To appropriately and competently involve the families of rural adolescents, some understanding of cultural values is necessary. In 2005, Susan Keefe and Susie Greene identified core Appalachian values, including egalitarianism, personalism, familism, a religious worldview, a strong sense of place and the avoidance of conflict. In the Appalachian region, assuming authority without demonstrating an authoritarian attitude is important. Language tends to be simple, direct, honest and straightforward. Family is extremely important, exemplified by the adage “blood is thicker than water.” Individuals’ relationship to the land is complex, and it can be beneficial to explore how clients view economic deprivation. In 2016, Sue and Sue also pinpointed some tendencies of rural clients, including having a “street-smart” attitude and way of being, depending on systems due to living in poverty and valuing survival at all costs.

As a result, subtle techniques such as stages of change, motivational interviewing and SFBT may be useful for this population. In stages of change, the intervention is matched to the stage of the client’s readiness to change (precontemplation, contemplation, preparation, action, maintenance, termination). Motivational interviewing facilitates an invitation to engage, and its strengths-based, hopeful tone can be helpful for clients living in an environment populated by deficits such as poverty and lack of education. The practical nature of brief therapy fits well with the no-nonsense worldview of clients coming from rural backgrounds.

Unfortunately, published rural studies often focus on specific regions or populations. Few interventions have been tested in rural settings, and the evidence from systematic reviews is often too general and not specific to the rural context. Ideally, rural communities could review interventions tested with various target populations in a range of settings. Such information is not usually available, however, and the strength of evidence is unlikely to be the only factor considered in choosing an intervention. The research on rural adolescent populations is limited, and little consistency exists across studies related to measurement tools. Furthermore, disseminating evidence-based practices to schools, families and community settings in rural areas is difficult due to the lack of resources.

However, it is important to note that there have been great improvements in substance abuse treatment and prevention with children and adolescents who live in rural areas. A 2016 Monitoring the Future survey of eighth-, 10th- and 12th-graders by the National Institute on Drug Abuse found the lowest ever reported rates of use for all illicit drugs, including alcohol, marijuana and nicotine. As further research is conducted, it will be important to delve into this information to identify what is already working with these individuals and what can be improved to better serve them moving forward.

Evidence-based practices with transgender clients

Transgender individuals face discrimination on multiple fronts. Many experience familial rejection, unequal treatment, harassment and physical violence during daily living. The rate of substance abuse within the transgender community is three times higher than that of the general population. There is a profound lack of competent health care for transgender individuals, and the care that is available may be inaccessible to a majority of the transgender population. The rate of unemployment within the transgender community is also three times greater than that of the general population, due in part to factors such as workplace discrimination, poverty and homelessness. Transgender people also face discrimination and mistreatment in shelters.

With high rates of homelessness, substance abuse and mistreatment, transgender people also have frequent interactions with law enforcement, where they can be subject to police brutality and discrimination. Within the criminal justice system, a high rate of physical and sexual assault is perpetrated against transgender individuals, and they are often denied medical treatment while incarcerated or detained.

Poor health outcomes for transgender people correlate with risk factors such as economic and housing instability, lower educational attainment, lack of family support and other intersectional factors such as race, ethnicity, immigration status and ability.

According to the 2015 U.S. Transgender Survey, 18 percent of transgender people who sought mental health services experienced a mental health professional attempt to stop them from being transgender. This correlated with higher rates of serious psychological distress and suicide attempts and an increased likelihood of running away from home, homelessness and engaging in sex work.

Research conducted in 2015 by Samantha Pflum et al. emphasized the lack of access to transgender-affirming resources and communities for individuals living in rural locations. The history of mistreatment and abuse of lesbian, gay, bisexual, transgender and gender-nonconforming clients by medical and mental health professionals must be acknowledged. Gender and sexual minority clients still face discrimination within the helping professions, and for individuals holding multiple marginalized identities, these experiences are compounded.

Even well-meaning providers are likely to make mistakes when working with marginalized clients. According to Lauren Mizock and Christine Lundquist, one of these mistakes is education burdening, or relying on the client to educate the provider about transgender culture or the general transgender experience. Resources exist to facilitate competence in these areas, and clinicians have a responsibility to refrain from placing the burden of their education on the client.

Some counselors participate in gender inflation, or focusing on the client’s gender to the exclusion of other important factors. Other counselors engage in gender narrowing, applying restrictive, preconceived ideas about gender to the client, or gender avoidance, which involves ignoring issues of gender altogether. Gender generalizing occurs when a clinician assumes that all transgender clients are similar. Gender repairing operates from a belief that a transgender identity is a problem to be “fixed.” Gender pathologizing involves viewing transgender identity as a mental illness or as the cause of the client’s issues. Finally, gatekeeping occurs when a provider controls client access to gender-affirming resources.

Acceptance of a client’s gender identity is ultimately not enough to provide competent, affirmative services. Understanding the nuances of these common mistakes will help clinicians provide a safe therapeutic environment that is affirming of these clients’ identity and humanity.

The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, has developed competencies for counseling transgender clients (see counseling.org/knowledge-center/competencies) that focus on the following eight domains:

  • Human growth and development
  • Social and cultural foundations
  • Helping relationships
  • Group work
  • Professional orientation
  • Career and lifestyle development competencies
  • Appraisal
  • Research

Counselors can work within this framework to:

  • Promote resilience by using theoretical approaches grounded in resilience and wellness
  • Conceptualize the development of a transgender individual across the life span
  • Understand internal and external factors influencing identity development
  • Consider how identity interacts with systems of power and oppression (especially for minority transgender individuals)
  • Examine counselors’ own internalized beliefs and how those beliefs affect attitudes toward transgender clients
  • Reevaluate approaches to working with transgender clients as new research emerges

One intervention that has been identified for use with this population by Ashley Austin and Shelley Craig is transgender-affirmative cognitive behavior therapy (CBT). Transgender-affirmative CBT modifies CBT interventions to address specific minority stressors, such as victimization, harassment, violence, discrimination and microaggressions, that transgender people commonly face. This approach uses psychoeducation to help clients understand the connections between transphobic experiences and mental health issues such as stress, anxiety, depression, hopelessness and suicidality. Experiences are processed through a minority stress lens to help clients move from a pathologizing-of-self mindset to an affirming view of themselves as people coping with complex circumstances.

Clinicians are advised to affirm the existence of discrimination and to help these clients identify influences on their mental health by using the transgender discrimination inverted pyramid (see below). 

Transgender individuals internalize messages at each level, and it can be beneficial to have a visual for how these messages trickle down and influence mental health. Clinicians can empower transgender clients by assisting them in challenging internal and societal transphobic barriers. A few examples are challenging negative self-beliefs, connecting with a supportive community and advocating for self and community.

Another approach recommended for use with transgender clients by Joseph Avera et al. in 2015 is the Indivisible Self model, an Adlerian wellness model refined by Jane Myers and Thomas Sweeney that emphasizes strengths. There are five wellness factors of self in this model:

  • Creative Self: Cognitions, emotions, humor and work
  • Coping Self: Stress management, self-worth, realistic beliefs and leisure
  • Social Self: Friends, family and love)
  • Essential Self: Spirituality, self-care, gender identity and cultural identity
  • Physical Self: Physical and nutritional wellness

This model easily can be adapted to a transgender-specific lens, especially regarding the Essential Self, by exploring gender and cultural identity and how they influence client experiences and beliefs. Used in conjunction with the ALGBTIC transgender competencies, the Indivisible Self model offers helping professionals both a conceptual and practical framework for working effectively with transgender clients.

For all clients, and transgender clients in particular, intersectional factors magnify the experience of oppression. Sand Chang and Anneliese Singh recommend addressing the intersectionality of race/ethnicity and gender identity for both clients and clinicians. This involves:

  • Challenging assumptions about the experiences of transgender and gender-nonconforming people of color
  • Building rapport and acknowledging differences within the therapeutic dyad
  • Assessing client strengths and resilience in navigating multiple oppressions
  • Providing a variety of resources that are affirming to transgender and gender-nonconforming people of color

In addition, assisting clients in locating social support is advised. Social support increases healthy coping mechanisms and helps with self-acceptance, thereby reducing psychological stress related to discrimination. Social support can also help to normalize and validate emotions related to discrimination.

Conclusion

Evidence-based practices have consistently been shown to be helpful to clients, but counselors must remember that they operate within the context of a relationship. To use evidence-based practices effectively, we must hold on to our humanness. The implementation of a single technique will look very different depending on who is in the room and what they are bringing with them.

Often, the expectations for using evidence-based practices might create pressure for counselors to follow a strict formula for treatment. Process variables such as honoring the personal relationship between the counselor and the client, maintaining a “therapist’s heart” and respecting the unique aspects of the client may seem to be at odds with the procedure for using a specific intervention. A working knowledge of multicultural issues can provide some context for how to shift evidence-based practices to fit the client rather than pressuring the client to conform to a prescribed, generalized format.

Using interventions with a solid evidence base is good practice. Adjusting their implementation on the basis of the unique identity of the person sitting across from us is great practice.

 

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

Geri Miller is a professor in the Department of Human Development and Psychological Counseling (clinical mental health counseling track) at Appalachian State University (ASU) in North Carolina. She is a licensed professional counselor, licensed psychologist, licensed clinical addictions specialist and substance abuse professional practice board certified clinical supervisor. She has been a volunteer counselor at a local health department since the early 1990s. Her clientele has primarily consisted of women with little opportunity for jobs or education and who experience barriers of poverty. Contact her at millerga@appstate.edu.

Glenda S. Johnson is an assistant professor in the Department of Human Development and Psychological Counseling (school counseling program) at ASU. She is a licensed professional counselor and a licensed school counselor in North Carolina. Her scholarly focus includes school counselors delivering comprehensive school counseling programs, students who are at risk of dropping out of high school and the mentoring of new counseling professionals.

Mx. Tuesday Feral received their master’s degree in clinical mental health counseling and a certificate in systematic multicultural counseling from ASU. They are the support programs director for Tranzmission, a nonprofit organization serving the Western North Carolina nonbinary and transgender community through education, advocacy and support services. Tuesday offers training and workshops in trans cultural competence and cultural humility on local, state and national levels.

William Luckett received his master’s degree in clinical mental health counseling from ASU with a certificate in addictions counseling. He has interests in somatic therapy approaches, mindfulness, religious and spiritual topics in counseling, and substance abuse counseling. He currently provides in-home counseling to rural families in Virginia.

Kelsey Fish is a student in ASU’s clinical mental health counseling program and a clinical intern with Daymark Recovery Services in rural Appalachia. Her clinical interests include expressive arts therapy, adolescents, and gender and sexual minority issues.

Madison Ericksen is a graduate of the clinical mental health counseling program at ASU. She has specialized training and interest in trauma-informed practices that use mindfulness, eco-based and expressive art therapies as complementary treatments alongside traditional therapy. She provides strengths-based and resiliency-focused outpatient counseling for children and families.

 

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.