Editorial Staff Senior Advisory Board Associate Editors The Professional Counselor (TPC) is the official journal of the National Board for Certified Counselors, Inc. and Affiliates (NBCC), dedicated to publishing original and innovative peerreviewed research and scholarship in an electronic, open-access format to inform counselors and members of related helping professions. About The Professional Counselor National Board for Certified Counselors, 3 Terrace Way, Greensboro, NC 27403-3660 The Professional Counselor © 2024 NBCC, Inc. and Affiliates J. Richelle Joe, Editor Catherine Clifton, Managing Editor Gretchen C. Porter, Editing Team Lead Rachel P. Sommers, Graphics Team Lead Kristin Rairden, Sr. Graphics Specialist Kylie P. Dotson-Blake, Publisher Editorial Review Board Hannah Acquaye Kathryn Alessandria Ellen Armbruster Jennifer Beebe Susan Boafo-Arthur Amy Broadwater Kathleen Brown-Rice Matthew R. Buckley Rebekah Byrd Joel Carr Robin Dufresne Jeri Ellis Kelly Emelianchik-Key Adrienne Erby Shuhui Fan Courtney E. Gasser Gary G. Gintner Barry Glick Charlotte Hamilton Gregory Hatchett Shannon Hodges Franc Hudspeth Maribeth F. Jorgensen Elizabeth Keller-Dupree David S. King Kristen Langellier Huan-Tang Lu Miles J. Matise Carol McGinnis Cherise M. Murphy Allison Paolini John Petko Michael M. Tursi Alwin E. Wagener Diane Walsh Jeffrey M. Warren Heather Zeng Chelsey Zoldan-Calhoun Angela Banks-Johnson Lynn K. Hall Paul C. Harris Danica G. Hays Gerard F. Lawson Theodore P. Remley, Jr. James P. Sampson, Jr. S Anandavalli David E. Jones Michael T. Kalkbrenner Jason H. King Yanhong Liu Katharine Sperandio Statistical Consultants Stephanie Dorais Holly L. Scott Special Issue Guest Editors Susan F. Branco Jennifer M. Cook Camille Y. Humes
383 Bridging the Gap: From Awareness to Action Introduction to the Special Issue Jennifer M. Cook, Camille Y. Humes 385 “A Learning Curve”: Counselors’ Experiences Working With Sex Trafficking Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, Kendra Smith 404 Ableist Microaggressions, Disability Characteristics, and Nondominant Identities Melissa D. Deroche, Lee Za Ong, Jennifer M. Cook 418 Using the Cultural Formulation Interview With Afro Latinx Immigrants in Counseling: A Practical Application Kirsis Allennys Dipre, Diana Gallardo, Susan F. Branco, Ladylanis Grullon Cepeda 433 Diondre Also Has Bad Days: Cannabis Use and the Criminalization of Black Youth Rommel Johnson 448 Utilizing Collective Wisdom: Ceremony-Assisted Treatment for Native and Non-Native Clients Julie Smith-Yliniemi, Krista M. Malott, JoAnne Riegert, Susan F. Branco 462 Taking Action: Reflections on Forming and Facilitating a Peer-Led Social Justice Advocacy Group Sunanda M. Sharma, Jennifer E. Bianchini, Zeynep L. Cakmak, MaryRose Kaplan, Muninder K. Ahluwalia 473 Comorbidity of Obsessive-Compulsive Disorder in Youth Diagnosed With Oppositional Defiant Disorder Nelson Handal, Emma Quadlander-Goff, Laura Handal Abularach, Sarah Seghrouchni, Barbara Baldwin 486 Bridging the Gap Between Intentions and Impact: Understanding Disability Culture to Support Disability Justice K. Lynn Pierce Volume 13, Issue 4 Contents In This Issue
383 The Professional Counselor™ Volume 13, Issue 4, Pages 383–384 http://tpcjournal.nbcc.org © 2024 NBCC, Inc. and Affiliates doi: 10.15241/jmccyh.13.4.383 Bridging the Gap: From Awareness to Action Introduction to the Special Issue This special issue of The Professional Counselor (TPC) is in honor of the NBCC Foundation (NBCCF)’s 2023 Bridging the Gap Symposium: Eliminating Mental Health Disparities. The theme for the 2023 Symposium, From Awareness to Action, represented the importance of attendee reflection on current issues and the need for intentional engagement in meaningful work that empowers underserved and never-served clients and communities. The event was attended by over 500 counselors and counselors-in-training who connected with peers and had the opportunity to learn from presenters of 70 sessions. Unique to this year’s Symposium was the celebration of the 10th anniversary of the Minority Fellowship Program (MFP). Members of the inaugural cohort, affectionately known as the Dream Team, came together to share memories of receiving their awards and spent time engaging in discussions about their remarkable contributions to the counseling profession over the past decade. In this special edition of TPC, guest editors from the first and second cohorts of the MFP reviewed submissions and selected articles for publication. Keeping the 2023 Symposium theme in mind, we worked hard to ensure that the articles in this issue reflect the purpose and vision of the event. Submissions covered a wide range of topics that provided perspectives about mental health disparities across diverse populations. Our hope is that this issue, like Symposium, will provoke thought and promote action. We divided the articles in this issue into two sections: The first section is comprised of articles that align with the special issue theme but were not presented at Symposium. The second section is comprised of articles that were written by authors who presented at this year’s Symposium and transformed their presented work into articles. The three articles in the first section of this issue are those that align with the Symposium’s theme. Although the authors of these articles did not present at Symposium, we think you will find what the authors share captures the Symposium’s purpose beautifully. In “‘A Learning Curve’: Counselors’ Experiences Working With Sex Trafficking,” the authors present findings from their qualitative study with clinicians who work with clients who have experienced sex trafficking to offer recommendations for working with this population. “Ableist Microaggressions, Disability Characteristics, and Nondominant Identities” reveals how ableist microaggressions manifest most frequently for people with a range of disabilities and sociocultural identities, and the authors suggest ways to better support clients with disabilities. In the third article of the issue, “Using the Cultural Formulation Interview with Afro Latinx Immigrants in Counseling: A Practical Application,” the authors utilize a case study to demonstrate how to use this assessment tool with an Afro Latinx immigrant client from Mexico. In the second section of the issue, “Diondre Also Has Bad Days: Cannabis Use and the Criminalization of Black Youth” and “Utilizing Collective Wisdom: Ceremony-Assisted Treatment for Native and Non-Native Clients” introduce readers to communities, concepts, and skills with which they may be less familiar. The authors convey clearly that counselors must develop these skills in order to serve populations who are in need of their identity-affirming, empathetic services. In “Diondre Also Has Bad Days,” the author challenges readers to examine how they treat Black and Jennifer M. Cook, Camille Y. Humes
384 The Professional Counselor | Volume 13, Issue 4 White youth and to overcome potentially biased approaches that have traditionally served one group more affirmatively than the other. “Ceremony-Assisted Treatment for Native and Non-Native Clients” presents readers with intervention options that integrate Indigenous practices, such as smudging and drumming. The final three articles in the second section are “Taking Action: Reflections on Forming and Facilitating a Peer-Led Social Justice Advocacy Group,” “Comorbidity of Obsessive-Compulsive Disorder in Youth Diagnosed With Oppositional Defiant Disorder,” and “Bridging the Gap Between Intentions and Impact: Understanding Disability Culture to Support Disability Justice.” In “Reflections on Forming and Facilitating a Peer-Led Social Justice Advocacy Group,” the authors provide their individual insights about their experiences as students who established a social justice advocacy group for peers in their counseling program. “Comorbidity of Obsessive-Compulsive Disorder in Youth Diagnosed With Oppositional Defiant Disorder” gives readers insight into the complexity of distinguishing between OCD and ODD in youth and the potential for misdiagnosis, while “Bridging the Gap Between Intentions and Impact” offers counseling professionals strategies for competent care and allyship for disabled clients through a disability justice framework. As you read the articles in this issue, we hope you will accept the opportunity to discover new ways to engage in the profession and to reflect on the why behind your commitment to your work. May this special issue serve as an inspiration for lifelong learning and lasting impact in the spaces where it is needed the most. Jennifer M. Cook, PhD, NCC, ACS, LPC, is an associate professor in the Department of Counseling at the University of Texas at San Antonio. Dr. Cook is a multiculturally focused counselor educator who utilizes strength-based methods, culturally relevant practices, and social justice advocacy in her work and teaching. Her research focuses on counselor preparation and counselor cultural competence development, with emphasis on social class, socioeconomic status, and multiple identities. Dr. Cook has published extensively, completed over 40 national and international peer-reviewed presentations, and will publish a co-edited multicultural counseling textbook, Multicultural and Social Justice Counseling: A Systemic, Person-Centered, and Ethical Approach, later this year. Dr. Cook is a 2013 NBCC doctoral Minority Fellowship Program recipient, part of the Dream Team cohort. Camille Y. Humes, EdD, NCC, LCPC (IL), LPC (MI), I/ECMH-C, is an assistant professor in the School of Counseling at Divine Mercy University in Sterling, Virginia. Dr. Humes holds an Endorsement® from the Michigan Association for Infant Mental Health, where she currently serves on the Board of Directors. For over 20 years Dr. Humes has worked as a counselor, mental health consultant, and leader in the mental health profession, advocating both nationally and internationally to inform policies that support mental health services. She is a writer, professor, and a regular grant reviewer for the United States Department of Education. Dr. Humes enjoys speaking to audiences about various topics, including the social/emotional health of young children.
385 In this transcendental phenomenological study, we interviewed 10 counselors who have clinical experience working with sex trafficking survivors. Through in-depth individual interviews, participants discussed their lived experiences providing counseling to this population. Our analysis revealed four primary themes: (a) counselor knowledge: “learning curve,” (b) counselor skills: “creating a safe space to dive into work,” (c) counselor attitudes: “being able to listen to the client’s story,” and (d) counselor action: “more than just a counselor.” The findings indicated that counselors working with sex trafficking survivors needed to understand and address the different aspects of trauma. Our findings also demonstrate that working with sex trafficking survivors requires additional competencies such as recognizing the signs of sex trafficking, vulnerable populations, and the processes by which traffickers force people into sex trafficking. We discuss these findings in more detail and identify implications for counselor training and practice. Keywords: sex trafficking survivors, counseling, phenomenological, trauma, competencies Sex trafficking of any individual is a significant concern globally. In 2000, the United States government enacted the Victims of Trafficking and Violence Protection Act of 2000, which defined sex trafficking as “the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery” or “when the person induced to perform such act has not attained 18 years of age” (§ 103). Although the United States’s efforts fully meet the minimum standards established by the Victims of Trafficking and Violence Protection Act of 2000 to eliminate severe forms of trafficking, the Department of Justice initiated a total of 210 federal human trafficking prosecutions in 2020, of which 195 involved predominantly sex trafficking (U.S. Department of State, 2021). As stated in the Trafficking in Persons Report (U.S. Department of State, 2021), all 50 states, the District of Columbia, and U.S. territories have reported all forms of human trafficking over the past 5 years. With an estimated 4.8 million people victimized by sex trafficking (International Labour Organization, 2017), it is important to understand how counselors identify, provide services to, and advocate on behalf of sex trafficking survivors within the counseling setting. Sex Trafficking and Mental Health As a form of human trafficking, sex trafficking exposes individuals to torture; kidnapping; and severe psychological, physical, and sexual abuse. Physical health consequences of sex trafficking include general health complications (e.g., malnutrition), reproductive health consequences (e.g., sexually transmitted diseases, unwanted pregnancies), substance abuse, and physical injuries (Grosso et al., 2018; Lutnik, 2016; Muftić & Finn, 2013). Psychological abuses are numerous and can include intimidation, threats against loved ones, lies, deception, blackmail, isolation, and forced dependency (Thompson & Haley, 2018). The Professional Counselor™ Volume 13, Issue 4, Pages 385–403 http://tpcjournal.nbcc.org © 2024 NBCC, Inc. and Affiliates doi: 10.15241/cgis.13.4.385 Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, Kendra Smith “A Learning Curve”: Counselors’ Experiences Working With Sex Trafficking Claudia G. Interiano-Shiverdecker, PhD, LPC-A, is an assistant professor at the University of Texas at San Antonio. Devon E. Romero, PhD, LPC, NCC, is an assistant professor at the University of Texas at San Antonio. Katherine E. McVay, PhD, LPC, is an assistant professor at Texas A&M University–Corpus Christi. Emily Satel is a graduate of the master’s program in clinical mental health counseling at the University of Texas at San Antonio. Kendra Smith is a graduate of the master’s program in clinical mental health counseling at the University of Texas at San Antonio. Correspondence may be addressed to Claudia G. Interiano-Shiverdecker, College of Education and Human Development, One UTSA Circle, San Antonio, TX 78249, claudia.interiano-shiverdecker@utsa.edu.
386 The Professional Counselor | Volume 13, Issue 4 Constantly experiencing atrocious physical and psychological abuses creates mental health consequences such as depression, post-traumatic stress, dissociation, irritability, suicidal ideation, self-harm, and suicide (Cole et al., 2016; O’Brien et al., 2017). Survivors of sex trafficking may exhibit severe mental illness, including schizophrenia and psychotic disorders, increased risk of compulsory psychiatric admission, and longer duration of psychiatric hospitalizations (Oram et al., 2016). Moreover, social distancing and the global economic downturn due to the COVID-19 pandemic increased online sexual exploitation and the number of individuals vulnerable to sex trafficking (U.S. Department of State, 2021). Because of the prevalence of sex trafficking, the health consequences that result from it, and the diverse areas in which counselors practice (e.g., community clinics, private practices, behavioral health departments, college/universities, K–12 schools), counselors must be prepared to work with sex trafficking survivors (Interiano-Shiverdecker et al., 2022, 2023; Litam, 2017, 2019; Romero et al., 2021; Thompson & Haley, 2018). Standards required by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) prepare counselors to demonstrate clinical competencies to address a variety of circumstances, including traumatic experiences, across various continuums of care (e.g., inpatient, outpatient). Clinical mental health counselors with specialization in substance abuse and marriage, couple, and family counseling can also address other comorbid issues typically encountered with sex trafficking clients such as substance abuse and relational difficulties (CACREP, 2015; Litam & Lam, 2020). Early incidence of sex trafficking (12–16 years for girls, 11–13 for boys and transgender youth; Franchino-Olsen, 2019) demands the attention of school counselors trained to promote the academic, career, and personal/social development of school-aged children (American School Counselor Association [ASCA], 2022; CACREP, 2015). Therefore, firsthand accounts of counselors providing services to this population can provide an overview of current needs, challenges, and recommendations for clinical practice and research. Sex Trafficking Research in the Counseling Profession A recent review of the literature showed increased attention to sex trafficking coverage in top-tier counseling journals. Conceptual pieces reviewed relevant information on sex trafficking, counselor awareness, and counseling implications (Browne-James et al., 2021; Burt, 2019; Litam, 2017; Thompson & Haley, 2018). Empirical studies explored counselors’ attitudes toward sex trafficking (Litam, 2019; Litam & Lam, 2020), assessment for the screening of sex trafficking (Interiano-Shiverdecker et al., 2022, 2023; Romero et al., 2021), mental health treatment programs and modalities for sex trafficking (Johnson, 2020; Kenny et al., 2018; Schmidt et al., 2022; Woehler & Akers, 2022), and survivors’ recovery stories (Bruhns et al., 2018). Thompson and Haley (2018) reported a need for more training and education for counselors on sex trafficking. In a study done by Litam and Lam (2020), results indicated that counselor training in sex trafficking increased awareness. As a response, InterianoShiverdecker et al. (2023) developed an initial list of child sex trafficking competencies for counselors. Although these studies provide relevant information for counselors’ work with sex trafficking, they do not focus on the experience of providing care for sex trafficking victims and survivors. Exploring counselors’ experiences provides a significant breakdown of current mental health care for this population. In other words, what does providing care for this population look and feel like in reality and what competencies work when serving sex trafficking victims and survivors? Only one phenomenological study focused on this inquiry, but this study examined therapists’ experiences working with foreign-national survivors of sex trafficking in the United States (Wang & Park-Taylor, 2021). Although this study presents important findings, it explored counselors’ work with only a certain group of sex trafficking individuals. Despite incomplete records, most data indicate that U.S. citizens are equally vulnerable to sex trafficking. For example, the National Human Trafficking Hotline (n.d.),
The Professional Counselor | Volume 13, Issue 4 387 which maintains one of the most extensive data sets on human trafficking in the United States, indicates that U.S. citizens comprised approximately 40% of their callers. The current study seeks to expand on the work of Wang and Park-Taylor (2021) by obtaining first-hand accounts of counselors providing services to sex trafficking clients in the United States and providing an overview of needs, challenges, and recommendations for clinical practice and research. The guiding research question for this study was: What are the lived experiences of counselors working with sex trafficking survivors in the United States? Method Using transcendental phenomenological research, the researchers—Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, and Kendra Smith—sought to understand counselors’ experiences working with sex trafficking survivors. A transcendental phenomenological method was best suited for this study because it allowed us to provide thick descriptions of the phenomena while employing bracketing techniques to explore participants’ experiences outside of our perspectives (Hays & Singh, 2012). Utilizing Moustakas’s (1994) modification of Van Kaam’s method, we sought to explore the occurrences of counselors working with sex trafficking survivors and collectively met to address any biases that came up during data analysis. Researchers as Instruments At the time of the study, Interiano-Shiverdecker and Romero were counselor educators at a university in the Southern United States with recent sex trafficking publications and experience working with youth vulnerable to sex trafficking in community and school settings. McVay was a doctoral candidate and a licensed professional counselor who was practicing as a social–emotional wellness counselor at a private school. Satel and Smith were master’s students in a clinical mental health program. Our desire to explore this topic stemmed from a limited discussion of sex trafficking in the literature and sought to include the voices of counselors. As the research team, we are all involved in a research lab dedicated to understanding sex trafficking and how counselors can better serve sex trafficking survivors. As such, we had varying levels of experience with research and engagement with sex trafficking. Satel and Smith were new to research, including topics surrounding sex trafficking. Therefore, Interiano-Shiverdecker and Romero’s broader understanding of the topic could have influenced newer members. For example, Interiano-Shiverdecker assumed that codes would resemble counseling competency categories (e.g., knowledge, skills, awareness). To reduce researcher bias, we engaged in weekly debriefing meetings for approximately 5 months for ongoing discussion of our perspectives and preconceived notions throughout data analysis. We documented our biases in journals, checked in on them during meetings, and referenced participants’ quotes to prevent imposing our assumptions of the data. Participants and Sampling After receiving IRB approval from the university, we sought participants through purposeful sampling and snowball sampling. Purposeful sampling strategies included reaching out directly via email to counselors who fit the study criteria and sending two calls for participants on an email mailing list for counselors and counselor educators (i.e., CESNET). For direct emails, McVay created a list of individuals who fit the criteria from Interiano-Shiverdecker and Romero’s professional network and an internet search. We also engaged in snowball sampling methods through recruited participants involved in the study. Inclusion criteria included counselors over the age of 18, who had previously or were currently working with children or adults who had been sex trafficked. Participants confirmed meeting the inclusion criteria by responding to a demographic questionnaire before beginning the interview. Following the qualitative researcher’s recommendation of sample size, we sought a range between five and 25 participants for this study (Creswell, 2013; Moustakas, 1994). Counselors who
388 The Professional Counselor | Volume 13, Issue 4 agreed to participate completed the consent forms, a demographic form, and a one-time Zoom interview. Participants received a $25 gift card for their involvement in the study. We recruited for about 5 weeks after interviewing 10 counselors. After the tenth interview was completed and we concluded the first round of analysis for all interviews, we felt that data saturation was achieved when similar codes showed up throughout the data. The resulting participant pool consisted of 10 counselors (nine female and one male) ranging in age from 27 to 61 years (M = 40.7, Mdn = 38.5, SD = 11.1). Seven participants identified as White, two participants identified as Hispanic, and one participant identified as Asian. The participants also identified their employment setting: university (n = 1), agency (n = 3), and private practice (n = 6). Participants disclosed providing services in one or several states such as Alabama (n = 1), Florida (n = 1), Missouri (n = 1), Nevada (n = 1), North Carolina (n = 1), and Texas (n = 7). One participant also reported providing services to sex trafficking survivors in the United Kingdom. Years working with survivors of sex trafficking ranged from 1 to 13+ years, with a range of three to 50+ clients who disclosed their sex trafficking experience. One participant (Alejandra) who had worked primarily with survivors of sexual abuse did not indicate their number “since a lot of clients I have worked with do not readily admit to being sex trafficked, I’m not sure.” Table 1 outlines participant demographics in more detail. Table 1 Participant Demographics Pseudonym Age Gender Race/ Ethnicity Work Setting Years of Service # ST Clients CACREP Kimberly 48 Female White Private Practice 11 30 Yes John 38 Male White University 11 5 Yes Stacy 33 Female White Private Practice 8 3+ Yes Alejandra 54 Female Hispanic Agency Unsure Most of career No Fen 39 Female Asian Private Practice 5 4 Yes Cassandra 33 Female White Private Practice 5 50+ Yes Tiffany 27 Female White Private Practice 1 25 Yes Amanda 29 Female White Private Practice 4 5 Yes Ana 61 Female Hispanic Agency 13+ 20 Yes Cristina 45 Female White Agency 3 10+ No Note. Years of Service = Years providing services to ST survivors; ST = Sex trafficking; CACREP = Program accredited by the Council for Accreditation of Counseling and Related Educational Programs.
The Professional Counselor | Volume 13, Issue 4 389 Data Collection Procedures To follow phenomenological research methods, Interiano-Shiverdecker trained the doctoral student (McVay) in conducting semi-structured interviews. The researchers developed interview questions based on the purpose of the study and from a review of the literature. Interiano-Shiverdecker and McVay completed the interviews. Following Moustakas’s (1994) recommendations, the interview protocol consisted of 12 semi-structured, open-ended questions that invited an in-depth discussion of their experiences. To create our interview protocol, we reviewed current literature in counseling on sex trafficking, particularly qualitative studies (Browne-James et al., 2021; Bruhns et al., 2018; Johnson, 2020; Wang & Park-Taylor, 2021; Woehler & Akers, 2022). Based on this review and Interiano-Shiverdecker’s experience in qualitative research, we decided to focus not only on counselors’ experiences with working with this population but also on their perspectives on the identification, prevention, and impact of sex trafficking on their clients. The complete interview protocol can be found in the Appendix. Interviews lasted from 26 to 69 minutes in length and occurred via Zoom because data collection occurred in 2021 and it was the most appropriate medium to respect social distancing and obtain a national sample. According to our IRB approval, our data collection presented no more than minimal risks for the participants. All interview questions followed a respectful disposition using open-ended questions to engage participants. However, McVay explained before beginning the interviews that participants could stop, pause, or opt out of the interview if the questions brought too much emotional distress. No participant requested the interview to be stopped or paused. During the interviews, we used counseling skills to facilitate the conversation and to build upon the experiences discussed. We recorded and de-identified all interviews for verbatim transcription. Participants also completed a demographic questionnaire before the interview to confirm their eligibility for the interview and obtain information on their age, gender, race/ethnicity, work setting, CACREP accreditation and degree, years working with sex trafficking survivors, and the number of clients they worked with who identified as trafficked. Data Analysis Utilizing Moustakas’s (1994) modification of Van Kaam’s data analysis, the research team engaged in the seven steps proposed by this approach. Data analysis and management relied on the use of NVivo software (Version 12). Interiano-Shiverdecker provided training in data analysis to McVay, Satel, and Smith. Interiano-Shiverdecker, McVay, Satel, and Smith engaged in the first step by individually analyzing transcripts and engaging in horizontalization of meaning units (Hays & Singh, 2012) to create in vivo codes for all nonrepetitive, nonoverlapping statements (meaning units). Second, we merged all files to determine the invariant constituents through a process of reduction and elimination. This first process of reduction allowed us to determine what was necessary and sufficient data to understand the phenomenon (Moustakas, 1994). The team then assigned themes or clusters of meaning to similar statements (third step). From the clusters of meaning, we created an initial codebook based on the discussions and findings from individual data analysis. We used the initial codebook to examine the themes against the dataset, ensuring that it was representative of participants’ experiences (fourth and fifth steps). As a team, we discussed any disagreements and worked on the data until we achieved a consensus. We worked out disagreements by discussing any opposing views and voting as a group on the best decision. We subsequently created textural descriptions through participants’ verbatim quotes, as well as created structural descriptions by examining the emotional, social, and cultural connections between what participants said (sixth step). Finally, we created composite textural-structural descriptions that outlined the reoccurring and prominent themes across all participants by organizing the themes into subthemes and ensuring that
390 The Professional Counselor | Volume 13, Issue 4 they represented all (if not most) participants’ experiences. After this analysis, we felt we achieved data saturation. After the completion of the initial analysis, Romero reviewed the data as a peer reviewer and offered suggestions. The entire research team reviewed the suggestions and came together to incorporate them until we reached a consensus and developed the final codebook. Strategies for Trustworthiness To limit the effects of researcher bias, we employed several strategies for trustworthiness. These included reflexive journals, triangulation of researchers, peer debriefers, an external auditor, member checking, and thick descriptions to ensure ethical validation, credibility, transferability, confirmability, sampling adequacy, and authenticity of our analysis (Hays & Singh, 2012). We engaged in reflexive journaling and weekly bracketing meetings during our individual and group data analysis to discuss codes, potential themes, and our assumptions shadowing the participants’ words. Researchers on the team brought varying levels of experience with research and the topic of sex trafficking, which we believe helped balance our subjective analysis of the data. We engaged in two rounds of member checking with the participants, one occurring after the transcription of the interviews and the second one after we wrote the themes. No participants changed the transcription of their interview or disagreed with the presentation of the themes. After the formulation of the themes from the original coding team, Romero served as a peer debriefer and reviewed the themes, key terms, and raw data, allowing participants to make recommendations on the content presented. This division in the research team allowed for another check outside of the original designated research team. An external auditor, a counselor educator with experience in conducting qualitative research, also reviewed the NVivo file and the write-up of the findings. The external auditor agreed with our data analysis procedures and presentation of the findings. He did provide suggestions to reduce the repetition of our first and second themes, which we implemented. Finally, we provide thick descriptions of our data collection and analysis procedures and present our results with direct quotes to ground our work. Results We identified four prevalent themes about mental health counselors’ experiences with sex trafficking survivors: (a) counselor knowledge: “learning curve,” (b) counselor skills: “creating a safe space to dive into work,” (c) counselor attitudes: “being able to listen to the client’s story,” and (d) counselor action: “more than just a counselor.” We use pseudonyms to present our results. Counselor Knowledge: “Learning Curve” All participants emphasized the importance not only of understanding trauma but also of gaining sex trafficking–specific knowledge throughout their work with survivors. Tiffany noted a “learning curve” when working with this population, despite working with trauma for most of her career. We categorized this theme into two subthemes: (a) understanding trauma work and (b) understanding sex trafficking and survivors. Understanding Trauma Work To work with sex trafficking, all counselors spoke about the importance of having general knowledge of trauma work. The most prominent topics included multicultural, legal, and ethical considerations. Important multicultural considerations for counselors involve understanding group differences between their clients (e.g., gender, race, age) and working from a culturally sensitive framework. Kimberly emphasized that “we really need people to not only have cultural sensitivity but also encourage those who are of other races to counsel these girls,” adding that “they need someone that’s like them from the same culture . . . to relate culturally to somebody.” Legal
The Professional Counselor | Volume 13, Issue 4 391 implications included understanding consent, informing clients of their limits of confidentiality when assessing for risk, and their role as mandated reporters. In reference to ethical practices, consultation and supervision arose as with any other trauma work. Stacy noted that it was “important for us to talk to one another if something’s going awry.” Many participants conveyed how crucial it was for them to understand healing and its complexities. Cristina shared that clients are “going to have their ups and downs,” with Amanda echoing that there are “so many layers to the healing process.” Kimberly felt it important to remind herself that “you’re probably not going to see the seeds that you plant develop a lot of times.” Another important aspect of healing trauma, mentioned by half of the sample, was understanding clients’ stages of change. Stacy shared that one of her clients “went back to her hometown and relapsed immediately. And that’s also a hard thing to deal with—to know that I felt like we had some good sessions . . . and then it’s, ‘Wait a minute. You went back to the relapse [sex trafficking].’” Cristina noted that “especially [when they’re] first out and they’re not quite sure, that pre-contemplation if they want to leave or stay” was very important. Another important aspect of their work included boundaries and self-care. All participants acknowledged that at some point in their careers, it was challenging to practice healthy boundaries. Cassandra acknowledged the following when working with individuals forced into sexual acts, “I wish I could take all the ladies I’ve ever worked [with], that have danced on stripper poles for money, unwillingly, and just like put clothes on them and wrap them up and hug them.” She added, [It] can get really tricky when we start answering our phone because it’s an emergency all the time . . . and it’ll wear you out, your batteries will wear out, and you’ll end up having this dual relationship that will end up hurting her because . . . you’re not her friend. It was helpful for Cassandra to remind herself that she was not the client’s parent. Rather, she shared, “when I hear things like that, I have to remind them that this is my job, this is what I do for a living.” Implementing healthy professional boundaries reduced burnout and facilitated self-care. Participants highlighted activities such as meditating, doing yoga, or taking the occasional day off. The counselors heeded that self-care also included managing their caseload to limit emotionally heavy clients or seeing a personal counselor themselves, as Cassandra and Amanda respectively noted. Amanda said, “you definitely have to secure your oxygen before you can secure other people’s.” Understanding Sex Trafficking and Survivors All participants explained that working with this population required them “to understand what sex trafficking is and . . . the many different ways that it looks,” as stated by John. He elaborated that “it takes many different forms and shapes,” some of which may not be immediately recognized as trafficking. Participants agreed that sex trafficking can often be much more discreet than one might anticipate. Tiffany commented on media portrayals like the film Taken, stating that the real experience is often much less dramatic: “Listening to their stories, it’s very, very subtle . . . like, if you do this then I’ll pay for your college tuition . . . and then from there it gets bigger.” Similarly, Cassandra noted that sex trafficking “can be, like, a bunch of underaged females, thrown in the back of a truck and trafficked across the United States” or people that “have their own residences, that don’t actually live with the trafficker, or they live with a family member that’s trafficking them.” Counselors learned that although anyone can be trafficked, some populations are more vulnerable. According to Fen, these populations include clients with cognitive disabilities, immigrants, emotional
392 The Professional Counselor | Volume 13, Issue 4 abuse survivors, clients with PTSD, and clients with addictions. Other populations mentioned included the LGBTQ+ population, people recently released from jail/juvenile detention centers, college students with debt, and people in financial need. The participants’ work also required them to learn how clients were recruited and what kept them from leaving sex trafficking. John and Amanda noted that many survivors knew their traffickers or were introduced to them by family, friends, or a romantic partner. Ana explained that traffickers may kidnap people from big sporting events or from opposing gang(s) or may train survivors to recruit and groom for them. She also worked with women recruited online from abroad and trafficked once they arrived in the United States. Counselors also learned about the numerous tactics used by traffickers, including the trauma bond, coercion, and control. John noted that traffickers often use manipulation: “The common theme was ‘If you do this, you’d really be helping me out. You wanna see me be okay?’ or ‘You don’t want me to go to jail, do you?’” Cassandra reported working with a client whose parents used “an odd twist on Christianity” and the principle of “respect your elders” to traffic her. Other tactics mentioned were threats of violence against survivors and their families, branding or tattooing survivors, stalking, taking survivors’ IDs, gaslighting, and fear. Cassandra also observed that trafficking was “so alluring . . . there’s a lot of money in that . . . so much about leaving sex trafficking is starting from zero and creating something new.” Amanda recalled a client who “was very upscale and so they lived kind of a lavish lifestyle, and I could see and understand, really emphasize the struggle to like give that up,” particularly when they were worried about providing for their families. Factors that forced individuals into sex trafficking were multilayered. Amanda continued, “so many other facets and like layers to this. It’s like an onion.” As a result, counselors learned about the overall impact of sex trafficking on survivors’ mindsets, behaviors, and presenting symptomology. As noted by Kimberly, sex trafficking impacted every aspect of survivors’ lives. Tiffany noticed that many of her clients were initially very fragile and mistrusting of everyone, while Cristina and Stacy shared that it was common for their clients to display guarded and closed-off body language. John’s work taught him that sex trafficking “affects [clients] in terms of intimacy and trust, and that trickles into their relationships, whether it’s with family, roommates, or romantic partners.” The counselors’ work with sex trafficking survivors included clients with an array of presenting concerns. Cassandra observed clients with complex PTSD, substance use issues, self-harm behaviors, suicidal ideation, self-hatred, self-blame, feelings of insecurity, an inability to trust, and eating disorders. Ana also noted that clients presented with anxiety, depression, paranoia, and physical concerns such as sexually transmitted diseases (STDs) and sleep problems. Counselor Skills: “Creating a Safe Space to Dive Into Work” All participants recognized that because of the nature of their work and their clients, they needed to “create a safe space to dive into work,” as stated by Tiffany. To do so, they needed to build skills in two main categories: (a) assessment and ensuring safety and (b) processing trauma. Amanda explained, “I think all of that stuff [assessment and ensuring safety] really has to come first before we can do any really heavy work and therapy. . . They have to be stable before they can really dig into whatever they want to dig into.” Although this separation provides clarity, counselors’ experiences were also more fluid, at times requiring them to use skills particular to ensuring safety while processing trauma and vice versa. Assessment and Ensuring Safety All counselors’ experiences of assessment and ensuring safety consisted of effectively engaging with their clients during the intake interview, assessing risk, applying crisis skills, and formulating
The Professional Counselor | Volume 13, Issue 4 393 personalized treatment plans. Based on her experiences, Cristina spoke about the importance of building rapport during that initial interview: “When I do our initial assessment with them . . . I have the assessment, but I’m having a conversation with them.” She also learned to discuss confidentiality and mandated reporting with her clients to explain her role as the counselor while also giving them a choice: “I tell them straight out, like, ‘Hey, you tell me this, I have to report it, I have to call law enforcement . . . so how do you want to do it?’” Cassandra found that obtaining a thorough history of the client was a critical part of the process: When addressing trauma, I don’t just go back to when the trafficking started. I go all the way back, make sure that I have that thorough history, because 99 times out of a 100, from my experience, that was not the first trauma that person experienced. Seven participants spoke about learning the signs of sex trafficking and knowing what questions to ask to obtain more information and determine a person’s exposure to sex trafficking. Amanda explained, “I don’t think I’ve ever had somebody start off within an intake session be, like, ‘Hiya, so I was trafficked.’” Participants learned to ask about phone use and the number of phones owned, the extent of drug use, sexually transmitted diseases, wanted and unwanted pregnancies, boyfriends and their ages, and sexual behaviors such as the use of a condom. When assessing, Alejandra learned to “ask questions that minimize you coming across as being shaming or judging.” At the same time, some counselors spoke about the lack of sex trafficking assessments that could facilitate this part of their work. Alejandra explained that she “did an assessment at work yesterday, and there, there are no questions about sex trafficking. . . . There are questions about abuse, but it is inferring more [about] sexual abuse, physical abuse, emotional abuse versus sex trafficking.” Fen echoed this sentiment by wishing there was a more rigorous psychosocial interview that assessed risks associated with sex trafficking because “at times people do hide and at times people don’t disclose.” All counselors agreed that a significant aspect of ensuring safety for their clients was collaborating with clients on safety plans. Counselors took the time to develop a “well thought out” safety plan with their clients, as stated by Alejandra. Stacy explained how she helped the client brainstorm ways to feel safer, including leaving town for a while or taking steps to “create a new account, changing her look a little bit . . . getting [a] new phone number.” Collaboration was not only utilized to respect clients’ autonomy but also to instill hope—“Hope that you know that you have a future,” stated Cristina. Ana elaborated, “seeing what they want for themselves and their lives, like, where do you want to go with your life . . . if you didn’t have this going on, you know, what is it you would like to do for yourself?” Processing Trauma To process trauma, all counselors listed skills, interventions, and therapies they found helpful with this population. Utilizing foundational skills (e.g., reflection, open-ended questions, appropriate selfdisclosure) to build rapport was the most referenced code in this section, addressed by all participants. Cristina saw the benefit of learning how “to connect very quickly.” Stacy added, “I would definitely start relying a lot more on the rapport when I work with trauma.” Counselors also found it helpful to have a toolbox that included creative approaches and interventions that helped clients reclaim power, develop a support system, improve self-esteem, build and discover resiliency, and utilize the client’s strengths. Psychoeducation, mentioned by nine participants, included teaching their clients about sex trafficking because as John explained, “clients don’t always know that they are being trafficked.” Psychoeducation of sex trafficking requires explaining fraud, force, and manipulation. Kimberly explained how a client did not think she was trafficked because her partner did not have her “locked in a closet. I don’t got chains around me. I’m not his slave . . . I get up and get myself dressed.
394 The Professional Counselor | Volume 13, Issue 4 I go out there and meet these guys . . . I cooperate when he’s taking pictures of me.” To help her client reevaluate her situation, Kimberly utilized motivational interviewing–based questions such as “Would you let your sister do this?” or “What would be the benefits of leaving your situation?” Although most counselors felt that an integrative approach to counseling worked best with sex trafficking clients, the therapies most mentioned included dialectical behavioral therapy, narrative therapy, and eye movement desensitization and reprocessing therapy. Counselors recommended individual treatment to process trauma, although four participants also mentioned family and group counseling. Fen found family therapy helpful “if the family wants to get involved in the practice” and “if there are family members who are ready to support them and come with them and who are aware of this.” Other participants mentioned the benefits of providing group counseling for sex trafficking survivors. Cassandra recalled how members of a support group she facilitated “connect with each other, they know that they’re not alone, they give each other honest feedback. . . . It has been super empowering.” Yet Alejandra, Fen, and Tiffany found that group counseling may not be well suited for all clients. “Group therapy doesn’t work really well because you know every survivor is different, and they don’t want to open up in front of others until they have worked through the process for a long time,” explained Fen. Because of the nature of their work, counselors recognized that an essential skill to processing trauma was learning how to manage countertransference. Cristina spoke about how as “clinicians, we want to save all of them.” For this reason, Kimberly recognized that it was important for her to understand her attachment style. Cassandra recalled nights when she would go home and “worry about [if] I am going to see this client again.” Ana left sessions “shaking sometimes from those places . . . ’cause the stories I would hear.” Stacy highlighted that it was also difficult at times to manage the lies. She explained, “I was a little frustrated because I knew that she was hiding things . . . obviously it just wasn’t that time and that’s okay.” As a result, counselors found it essential to process their emotions. Kimberly explained that “if you haven’t emptied your cup of all the sad, mad, bad before you come into that office with them . . . you’re going to flip your lid whether it’s in front of them or behind closed doors.” Counselor Attitudes: “Being Able to Listen to the Client’s Story” All participant interviews illuminated thought patterns and beliefs they needed “to listen to the client’s story,” as stated by John. Counselors learned to personify certain attitudes by (a) valuing empathy and validation and (b) embodying a sense of safety. Valuing Empathy and Validation All participants highlighted the importance of embracing a philosophy of empathy and validation in their work with clients by being warm, genuine, open-minded, patient, and nonjudgmental. Participant interviews described various mechanisms to embody these attitudes. For instance, a consistent approach they took was to respect and empower the clients’ choices and, ultimately, believe in and provide client autonomy through supportive and nonjudgmental means. Ana emphasized, “I think that’s huge for those whose choices were taken away. . . . It’s offering them a choice, and I think that’s very empowering for them.” Fen echoed this message stating, “You can’t push—you can definitely motivate—but you cannot just push.” Kimberly learned to be patient: “You’ll end up getting there eventually, just take your time. . . . You have to build that rapport and trust.” Cassandra stated, “Another thing I would say is don’t make any assumptions. . . . Everybody’s experiences, although there are similarities, every experience is so different.” Cristina described the shock value of hearing survivors’ stories and how essential it was for her to remain nonjudgmental and aware of her biases. Amanda embodied “those Rogerian qualities, like that open-mindedness, empathy, warmth,
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