Bridging the Gap: From Awareness to Action
Introduction to the Special Issue

Jennifer M. Cook, Camille Y. Humes

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 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.

“A Learning Curve”: Counselors’ Experiences Working With Sex Trafficking

Claudia G. Interiano-Shiverdecker, Devon E. Romero, Katherine E. McVay, Emily Satel, Kendra Smith

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).

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, first-hand 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, Interiano-Shiverdecker 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.), 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?


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 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. 

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 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.


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 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 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 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 self-disclosure) 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. 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, genuineness, authenticity—those things are all really important to utilize when meeting with that population, or any population.” Cristina provided an example of how she conveyed this to a client by saying, “I’m here if you need me. . . . There’s no judgment happening, I’m just glad you’re here.”

Counselors also shared a philosophy that validated clients’ experiences. Fen believed in “just making clients feel normal,” while Cassandra noted how helpful it was for her to approach clients’ behaviors as “normal reactions to abnormal situations.” An important attitude communicated by John was that “they are survivors.” Even though others and possibly even the client themselves might use the word victim, he found it helpful to have “the conversation about being a survivor versus a victim.” Tiffany further explained, “I’ve noticed just in working with sex trafficking survivors . . . it seems very hard for them to say the word ‘abuse’ or view themselves as anything other than a victim.” She found value in seeing the client as “a survivor” and teaching this perspective to the client.

Embodying a Sense of Safety
     All participants embraced attitudes that created and maintained a safe environment for their clients. Fen explained that as the counselor, “you’re the only safety net for that person” who provides safety and trust. Cristina reflected on a client who was still in “the life” and returned for help and services when needed. She stated, “she knows that I’m a safe person” and “this [shelter name] is her home, this is where she felt safe. But [she] knew she couldn’t get out of this life yet because she wasn’t ready to.” Fen explained that “there is shame, there is guilt, there is fear, and apprehension of being caught . . . so, one has to make them feel safe.” Some participants communicated and provided safety by creating a “homier and safer” office space or by buying a client’s favorite snacks and beverages, as described by Cassandra. Alejandra spoke of establishing “an environment where it’s safe to talk about taboo subjects” such as “having been a mule or whatever they did, you know, whatever sexual acts.”

Six of the participants also spoke of attitudes that promoted consistency and predictability. Kimberly stated, “That’s something they’ve never had in their life; you know, so while you’re doing all this other stuff, be consistent.” Several participants noted how difficult it was for their clients to have continuity with counselors. Kimberly shared:

Counseling someone who’s had this kind of trauma takes a long time . . . once you leave and can’t continue that counseling process, the likelihood of them going back to the counseling is very slim to none. . . . Even though they were resistant to building that rapport with you at the same time, deep down inside they’re connecting with you.

     Similarly, a few participants learned to be consistent in their messages shared with clients and accessibility to clients. For instance, Stacy spoke of the need for congruency between actions and words when working with these individuals: “Trust is such a fleeting word . . . it has to be action, sometimes, speaks louder than the words.”

Counselor Action: “More Than Just a Counselor”
     All participants realized that working with this population required them to reevaluate their role as the counselor. They learned that clients required “more than just a counselor,” as stated by Kimberly. Therefore, the fourth theme elucidated actions that counselors found necessary to help clients recover from their experiences. We categorized counselor action into two subthemes: (a) client advocacy and (b) engaging with social work/workers.

Client Advocacy
     Over half of our participants spoke about the importance of advocating for clients. Cristina talked about how some clients did not have a caseworker and needed someone “that’s in their corner.” Counselors spoke about specific needs they advocated on behalf of clients in the life or in recovery. Kimberly spoke about advocating for prison reform, particularly for minority women who went to prison for some of the things they got involved in while being trafficked. Cristina advocated for “easier access to get into drug treatment.” She explained that this was necessary because certain insurances did not pay for certain drug treatments, or it would take too long to get clients into treatment. Although clients would sometimes agree to treatment, it would take several days “to get everything going. . . . by then the kids change their minds, or they run. . . .The obstacles shouldn’t be that hard.” Other forms of advocacy focused on working with and educating police officers to best work with this population. Tiffany explained how many women didn’t trust law enforcement. She believed it was crucial to bridge these services because law enforcement could “get them out of that lifestyle, but then on the other hand, they’re very much like, ‘Don’t trust them.’” Stacy also spoke about advocating for shelters specific to sex trafficking. She remembered a client who visited a shelter once a month and loved it because “she felt safe there versus just, like, a domestic violence clinic . . . they had the awareness of sex trafficking versus just, like, you know, an overnight shelter type of place.”

Participants also taught clients how to advocate for themselves while also respecting their choices. Stacy explained, “It’s not my job to fix what they’re going through, but it is my job to be as supportive as I can.” She understood that she needed to “advocate for them but also having the respect that if they don’t want me to advocate for them, then that’s the place that they’re at too.” Stacy also clarified that at times she does not “really know exactly 100% how I would want to advocate” for clients who had been trafficked. Yet as she continued to reflect, she realized her desire to “seek out more education about it because I do think that it needs to be navigated in a specific way.”

Engaging With Social Work/Workers
     The call for advocacy led all counselors to speak about how their work required them to expand their roles to connect clients to resources and collaborate with social workers. Kimberly explained that this population requires “more than just a counselor while they’re in session . . . you’ve really got to start with building a community around them before you get into the deep trauma work.” Counselors provided resources to obtain transportation, financial assistance, government assistance, their GED or college degree, food, employment, stable housing, legal support, childcare, hygiene products, substance treatment, and medical care. Amanda explained that this population requires that their basic-level needs be met to help them feel like they “can function in society and be comfortable,” and Kimberly elaborated:

As a counselor, I used to have a huge list of resources that I could give them, but they also needed guidance from outside of the counseling office. . . . I have, like, eight people with one survivor, that’s how much it took us ’cause it’s so much work for one person. You’re talking about every aspect, everything that you learned as a child growing up. . . . If you want counseling to be successful, they have to have that outside component to help them . . . a counselor can’t do all of that.

     Ana partnered up with organizations already doing this work. She particularly spoke about an organization that not only focused on “educating people but also helping these women with resources.” She added that “the residential places they were able to stay in, they were able to finish their education and get an education there, and they also helped them with finding jobs, which was really important for them, too.” She explained that this was particularly important because many of the women she worked with had a violent criminal history. Many company insurances refused to hire women with criminal records, preventing their clients from a second chance at improving their lives. However, John learned to support clients with resources. “I don’t think it’s sufficient to just say ‘Here you go, here’s the resource guide. They have lots of options in there. Good luck.’ . . . Our job doesn’t end with giving the resources,” he explained.

An important point to make is that although some counselors spoke about collaborating with social workers, it seemed that most believe their work resembled “a little more of that, like, case management–type stuff to make sure that they have the resources if and when they want out,” added Cassandra. Kimberly elaborated, “You’re the one that’s helping to get them to [a] place where they can have a relatively stable life . . . but without the resources that come alongside that, they’re gonna go nowhere, [they’re] going to hit a wall every time.”


We sought to understand counselors’ experiences working with sex trafficking survivors through a phenomenological analysis. The participants in our study needed to understand and address the different aspects of trauma. Because of clients’ traumatic experiences that resulted in psychological injuries (Cole et al., 2016; Grosso et al., 2018; Lutnik, 2016; Muftić & Finn, 2013; O’Brien et al., 2017), counselors benefited from respecting the process of healing, addressing stages of change, and building a safe and trusting relationship. Counselors overall possessed knowledge of the development of post-trauma responses over time. They knew what to look for and how to best treat traumatic symptoms that permeated all aspects of their client’s lives, particularly sex trafficking survivors’ ability to trust others. Counselors believed that having a trauma-informed approach could reduce instances of re-victimization. Counselors also recognized the importance of self-awareness such as assessment of personal trauma, self-care, restorative practice, and biases regarding how youth are trafficked and by whom.

Yet, our findings demonstrate that working with sex trafficking survivors requires additional competencies as illustrated in previous research (Interiano-Shiverdecker et al., 2023). The participants discussed the need to become educated in recognizing the signs of sex trafficking, vulnerable populations, and the processes by which traffickers force people into sex trafficking to obtain a deeper understanding of the client’s worldview and provide appropriate support (Interiano-Shiverdecker et al., 2023). Participants addressed components—namely force, fraud, coercion, exploitation, power, grooming, and solicitation—commonly used in sex trafficking literature (Bruhns et al., 2018). When asked about the nature of their work, their focus naturally divided into sections that focused on assessing risk and safety planning, processing trauma, and helping the client re-establish their life and their identity. Our findings align with CACREP (2015) recommendations for clinical crisis skills and knowledge while also elucidating their application to sex trafficking survivors. Participants learned to assess for specific sex trafficking signs (e.g., phone usage, boyfriends and their ages, sexual behaviors) and to ask questions that differentiated sex trafficking from other forms of abuse.

Counselors must also understand the differences between sex work (i.e., the voluntary exchange of sexual services for compensation) and sex trafficking (i.e., subjection to the exchange of sexual services due to force, fraud, or coercion or from any person under the age of 18). As Ana shared, most counselors felt that the notion to detect was on their end “because I don’t always think it’s the responsibility of the client to be able to say ‘Hey, I’ve been trafficked.’” Thus, participants indicated that possessing these competencies could help increase the identification of sex trafficking. As such, some counselors may desire more guidance on specific sex trafficking assessments, which scholars have previously noted (Interiano-Shiverdecker et al., 2022; Romero et al., 2021). A content analysis on sex trafficking instruments (Interiano-Shiverdecker et al., 2022) illustrated the importance of asking specific questions to assess for control, confinement, threat, and isolation, as these are the main indicators of sex trafficking. Example items included: “Have you ever felt you could not leave the place where you worked [or did other activities]?” (confinement; Simich et al., 2014, p. 20); “Are you kept from contacting your friends and/or family whenever you would like?” (isolation; Mumma et al., 2017, p. 619); “Do you have to ask permission to eat, sleep, use the bathroom, or go to the doctor?” (control; Mumma et al., 2017, p. 619); and “Has anyone threatened your family?” (threat; Mumma et al., 2017, p. 619).

Moreover, for some sex trafficking victims, the relationship with their traffickers represented an affirming, reliable, and secure relationship in their lives, later used to coerce or force them into sexual, violent, or illegal behavior. Therefore, participants realized that processing trauma would require attitudes and skills that provided emotional safety, patience, and a nonjudgmental process. Survivors’ lack of choice throughout their sex trafficking experience fomented counselors’ abilities to empower clients over their bodies, boundaries, and choices, and help clients reintegrate into society (Interiano-Shiverdecker et al., 2023; Thompson & Haley, 2018). Participants seemed to emphasize that without all the elements mentioned, clients might not disclose their situation or trust the counselor enough to open up, and they might even terminate counseling abruptly.

This last point is connected to our fourth finding, counselor action. Aligned with the Multicultural and Social Justice Counseling Competencies (Ratts et al., 2016), the participants in our study recognized the need to engage in work that advocated for clients within and outside of the session. Despite their dedicated work with clients to process the emotional repercussions of sex trafficking and rebuild their lives, their efforts did not seem enough to support clients in their recovery. So much of what ailed their clients fell on systemic or external forces (e.g., poverty, employment, lack of resources). Although that existed outside of the counselor’s role and verged into another profession, our participants embraced these responsibilities or connected with other professionals. They believed that otherwise, clients would not succeed in their recovery. Our findings present an important reminder that sex trafficking, a modern form of human slavery, is an act of social injustice affecting individuals vulnerable to historical and systemic oppression.

     Our themes add to the existing research with implications for counseling practice, supervision, and education. Scholars (Romero et al., 2021; Thompson & Haley, 2018) have identified counselors as first-hand responders to the early detection and prevention of sex trafficking. Although each trafficking scenario is unique, counselors need to refer to sex trafficking indicators, recruitment and grooming tactics, and manipulative dynamics that prevent individuals from disclosing or leaving sex trafficking. It is important for counselors to dispel common myths of sex trafficking and understand that sex trafficking may appear differently than one may expect. Amanda alluded to clients who defined their experience as a “lavish lifestyle” and were lured by the financial benefits of sex trafficking. We caution counselors not to misinterpret sex trafficking as a “lifestyle,” as this implies choice. There may be a myriad of invisible factors contributing to their circumstances such as trauma bonding and financial instability.

Participants agreed that an integrative approach with interventions that addressed complex trauma (e.g., dialectical behavior therapy, eye movement desensitization and reprocessing therapy) worked best when working with sex trafficking. We encourage counselors to not only become familiar with such modalities but also to conceptualize any treatment modality through a trauma-focused lens that considers how sex trafficking impacts all aspects of a client’s life and how they will interact in session. Participant narratives indicated that clients could present with defiant behaviors, distrust, angry or irritable mood, and refusal to comply with treatment. These themes underscore the importance of a counselor’s ability to create safe, trusting, and empathic relationships that allow the client to disclose risk and eventually process trauma. Counselors should also integrate a strong rapport with sex trafficking clients by demonstrating unconditional positive regard, authenticity, and empathy with any treatment modality chosen. Although counselors establish a strong therapeutic relationship, they can integrate other counseling goals, including psychoeducation, assessing for risk, supporting clients through the stages of personal change, and helping the client rebuild and reintegrate into society. Based on the nature of their work, managing countertransference and self-care represents an essential instrument to maintain balance while engaging in emotionally draining clinical work. We encourage counselors to seek supervision, connect with colleagues, and practice regular self-care routines to avoid experiencing burnout, secondary trauma, and countertransference. Additionally, counselors should connect clients to services that provide basic needs (e.g., safe and stable housing, food). When clients lack basic physiological needs, they may struggle to focus on higher-order needs such as developing a safety plan or emotion regulation. Counselors can engage in legislative advocacy by writing letters to judges, sharing clinical experiences with senators, and providing training on sex trafficking victim identification and treatment. It is important for counselors to build constituency groups with education, governmental task forces, and legislators to lobby for bills that benefit clients, as sex trafficking exists in an ecosystem of community and social contexts (Farrell & Barrio Minton, 2019). Our findings also underscore the limitations of intake interviews when assessing for sex trafficking risk. Although identification and screening tools exist (Interiano-Shiverdecker et al., 2022; Romero et al., 2021), counselors are not always in a setting where a formal assessment is appropriate or accessible.

We encourage educators and supervisors to emphasize the value of informal assessment methods with counselors-in-training. Counselor knowledge of signs, symptoms, and questions to ask during an intake can improve identification efforts. Our findings also hold some implications for training beyond counselor education. Because of the complexities of working with trauma and sex trafficking, counselors intending to work with this population should seek out specialized training. For instance, they may review conference programs for trauma or sex trafficking–specific education sessions. At the same time, counseling programs should evaluate their preparation for counselors to work with sex trafficking. Requiring a trauma course, including content on sex trafficking and complex trauma throughout the curriculum (e.g., trauma, grief, addiction counseling courses), inviting guest speakers, and providing training opportunities and workshops for students and community counselors are all suggestions to ensure that counselors obtain the necessary knowledge and skills to work with this population. We believe that more training opportunities can minimize any possible misunderstanding of sex trafficking, expectations on clients to disclose, and re-victimization of clients that leads to early termination of counseling.

Limitations and Future Directions
     The nature of our sample holds some limitations for the interpretation and application of the themes from this study. We collected data from single data sources (i.e., individual interviews); additional interview sources (e.g., focus groups) may have contributed more information. Moreover, lack of racial and gender diversity was a limitation in this study because most participants identified as White and female. We noticed that participants did not discuss racial and gender differences in clients’ experiences of sex trafficking. This result could have originated from our interview protocol that sought to gain an overall understanding of sex trafficking experiences and therefore did not request this information. Participants’ demographic profiles may have also provided a limited perspective of the experiences of Black, Indigenous, and/or people of color. We also did not require CACREP accreditation or specific years of practice as part of our inclusion criteria. Although all our participants were licensed professional counselors, they had different degrees in mental health, a variety of clinical practice, and did not all graduate from CACREP-accredited programs. During our interviews, we did not define sex trafficking to the participants and engaged in open-ended questions that inquired about their experiences. Participants’ responses are based on their definition of sex trafficking, which can vary and might not be accurately distinguishable from sex work. As is the case with all qualitative research, counselors and scholars should consider the transferability of these findings to other client populations and with counselors. For example, the findings of this study can be applicable to professional school counselors, but the recruitment of school counselors as participants would have provided greater insight into the roles and responsibilities of counselors in schools. Furthermore, we did not include client perspectives in this study; therefore, even though our participants’ perspectives when working with sex trafficking survivors is very insightful, they may not have an accurate representation of clients’ experiences in session.

Based on these limitations, we recommend scholars explore individual and external factors that can impact counselors’ work with sex trafficking survivors. For example, we did not explore within-group differences (e.g., race, gender, sexual orientation, religion) between counselors and cross-cultural interactions between clients and counselors. These factors are important to consider and reflect on when building trust and a sense of safety for the client, particularly when considering current conversations around racial tension in the United States. A more in-depth analysis of these considerations could facilitate a better understanding of how multicultural traits play a role in counselors’ experiences when working with sex trafficking survivors. Participants’ emphasis on the need for specialized knowledge and skills to work with sex trafficking also warrants research on evidence-based interventions for sex trafficking survivors. Moreover, an examination of the client’s experiences is necessary to garner a holistic picture of the impact of sex trafficking on the client’s healing and counseling process. We also believe that researchers should consider external factors that might impact counselors’ experiences when working with sex trafficking. Considering participants’ discussion of advocacy and engaging with social work/workers, it seems necessary to consider sociopolitical and institutional elements that either hinder or support clients’ ability to leave sex trafficking and obtain access to services that allow them to heal and flourish. As such, counselors working with sex trafficking survivors must consider specific training that allows them to assess for risk, process the emotional ramifications of sex trafficking, and rebuild their lives.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.


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Claudia G. Interiano-Shiverdecker, PhD, LPC-A, is an assistant professor at the University of Texas at San Antonio. Devon E. Romero, PhD, NCC, LPC, 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,  




  • Please tell me a little about yourself, your professional background, and clinical experience.


  • What is important for counselors to know when working with sex trafficking survivors?
  • How can counselors best detect when individuals are being sex trafficked or are vulnerable to sex trafficking?
  • How can counselors support individuals while they are being trafficked?
  • How can counselors help individuals leave their traffickers?
  • How can counselors support individuals from returning to their traffickers?
  • What do counselors have to know about supporting sex trafficking survivors after sex trafficking?

Personal Experiences and Mental Health

  • Please share, to the extent that you are comfortable, your experiences with working with sex trafficking survivors.
    • What is the age range in which most of your clients experienced sex trafficking?
  • How have these experiences impacted your clients?
    • Emotionally and mentally?
    • Physically?
    • Relationships with others?
    • Spiritual/religious beliefs?
  • What do you believe has helped them overcome the impact of sex trafficking?
  • What services or resources do you believe were most helpful to them?
  • What is important about your experience that I haven’t asked you and you haven’t had the chance to tell me?

Ableist Microaggressions, Disability Characteristics, and Nondominant Identities

Melissa D. Deroche, Lee Za Ong, Jennifer M. Cook

Microaggressions are commonplace overt and covert forms of discrimination that convey disparaging messages to individuals who hold marginalized identities, including people with disabilities (PWD). Although PWD are a prevalent nondominant identity group in the United States, little is known about the occurrence of ableist microaggressions in this culturally diverse community, including how ableist microaggressions are experienced based on disability characteristics and other nondominant identities. A sample consisting of 201 PWD completed an electronic survey that examined the occurrence of ableist microaggressions based on visibility of disability, type of disability, and nondominant sociocultural identities. We found that PWD have a moderate level of lifetime occurrences with ableist microaggressions, the visibility of disability impacts the occurrence of ableist microaggressions and the types of ableist microaggressions experienced, and sociocultural identities may predict minimization types of ableist microaggressions.

Keywords: microaggressions, disability, nondominant identities, ableist, visibility

People with disabilities (PWD), similar to other minoritized groups, encounter stereotypes, stigma, prejudice, and discrimination. Stereotypes are generalized beliefs about a group with shared characteristics that can result in prejudice (Sue & Spanierman, 2022). Discrimination occurs when individuals or systems act on prejudices by limiting or restricting access to opportunities, resources, and services (Olkin et al., 2019). Discrimination results in ableism when it is perpetrated against PWD based on their disability status. Microaggressions are one form of discrimination and are defined as intentional or unintentional verbal, non-verbal, and/or environmental slights that convey disparaging messages to individuals based solely on their marginalized group membership status (Sue & Spanierman, 2022).

In recent decades, scholars have examined the occurrence of microaggressions with individuals who hold several different minority group identities and found that microaggressions are present in everyday life for minoritized individuals, negatively impacting their mental health (Capodilupo et al., 2010; Keller & Galgay, 2010; Nadal et al., 2014). Although there are a significant number of studies addressing microaggressions associated with race and ethnicity (Forrest-Bank & Cuellar, 2018; Nadal et al., 2014) and gender and sexual identity (Capodilupo et al., 2010), research regarding microaggressions experienced by PWD is only in its infancy.

In their foundational work, Keller and Galgay (2010) qualitatively explored the existence of microaggressions directed at PWD. Using two focus groups (N = 12) with PWD who had a range of visible and hidden disabilities, they identified eight microaggression domains experienced by PWD: (a) denial of identity, (b) denial of privacy, (c) helplessness, (d) secondary gain, (e) spread effect, (f) patronization, (g) second-class citizen, and (h) desexualization. Their work spurred both qualitative and quantitative studies focused on the ableist microaggression experiences within the general disability community (Kattari, 2020; Lett et al., 2020) and specific disability communities, including people with mental illness (Gonzales et al., 2015), physical disabilities (Conover et al., 2017a), and intellectual disabilities (Eisenman et al., 2020). Also, researchers have examined ableist microaggressions within specific settings such as schools (Dávila, 2015), the workplace (Lee et al., 2019), and higher education (Lett et al., 2020). Collectively, these results supported the initial eight ableist microaggression domains Keller and Galgay identified and expanded how they were understood.

The multidimensionality of disability has led scholars to examine the influence of disability characteristics—including visibility, severity, type, and age of onset of disability—on the occurrence of ableist microaggressions. Visible or apparent disabilities are defined primarily by the use of an adaptive aid or accommodation such as a cane, crutches, service animal, hearing aid, or wheelchair that results in others immediately labeling the person as disabled; whereas people with hidden, invisible, or non-apparent disabilities are likely to pass as nondisabled and must navigate how, when, and to whom to disclose their disability status. Using two different ableist microaggression scales with relatively large samples of PWD, both Conover et al. (2017a) and Kattari (2020) reported that level of visibility of disability impacts the occurrence of ableist microaggressions, with individuals with visible disabilities consistently experiencing more ableist microaggressions than their counterparts. Further examination of these differences resulted in Andreou et al. (2021) reporting that people with visible disabilities encountered more helplessness- and otherization-related ableist microaggressions, while persons with hidden disabilities encountered more minimization-type ableist microaggressions. In contrast, the impact of severity, age of onset, and type of disability on the occurrence of ableist microaggressions have yielded mixed findings, suggesting more research is warranted. For instance, Conover et al. (2017a) found that people with severe and early onset of disability (i.e., 0–40 years) reported greater lifetime experiences of ableist microaggressions, while Andreou et al. (2021) noted no differences based on severity or age of onset. With respect to type of disability, Conover et al. (2017a) reported no differences, while Andreou et al. (2021) found overall differences in the occurrence of ableist microaggressions, as well as type of ableist microaggressions, experienced by people with different types of disabilities.

Although some scholars have considered PWD’s intersecting cultural identities in their research studies, including sexual minorities (e.g., Conover & Israel, 2019; Hunt et al., 2006), gender identities (measured as male and female; Conover et al., 2017a), women with visible and invisible disabilities (Olkin et al., 2019), and racial or ethnic minorities (Conover et al., 2017a; Dávila, 2015), few studies have added to our understanding of ableist microaggressions across intersecting sociocultural identities. For example, Conover and Israel (2019) found that PWD who were also sexual minorities encountered ableist microaggressions in sexual minority communities, while Conover et al. (2017a) discovered that gender (as measured by male and female) and race (as measured by White or Person of Color) did not impact the occurrence of ableist microaggressions; these results contrast Dávila (2015), who found that Latinx PWD encountered microaggressions that aligned with both racial and disability microaggressions.

Although scholars have provided valuable data about ableist microaggressions they have not considered the full range of sociocultural identities PWD hold or the differences in the types of ableist microaggressions (i.e., helplessness, minimization, denial of personhood, and otherization) PWD experience combined with their nondominant sociocultural identities. The purpose of this study was to examine the occurrence and types of ableist microaggressions PWD experience and whether their nondominant sociocultural identities impact their experiences of ableist microaggressions. Our intention was to reveal critical information counselors can use to better serve their clients who have disabilities and experience ableist microaggressions.


For this quantitative study, we utilized surveys and online data collection to investigate our three research questions that aligned with the study purpose.

  • Research Question 1: What are the participants’ experiences of ableist microaggressions based on the Ableist Microaggressions Scale (AMS; Conover et al., 2017b) scores and subscale scores?
  • Research Question 2: Do AMS scores and AMS subscales (i.e., Helplessness, Minimization, Denial of Personhood, and Otherization) have a relationship with the type of disability and the visibility of the disability?
  • Research Question 3: Are other nondominant sociocultural identity factors associated with or predictive of AMS scores and AMS subscales?

We anticipated participants would report differences in the occurrence and types of ableist microaggressions they experienced based on visibility of disability and disability type and that having nondominant identities would influence the occurrence of ableist microaggressions. More specifically, we expected people with visible disabilities to report higher occurrences of ableist microaggressions than their counterparts and that disability visibility would influence the type of ableist microaggressions. We anticipated variations based on disability type regarding frequency and type of ableist microaggressions. Finally, we expected PWD nondominant sociocultural identities to be associated with the occurrence of ableist microaggressions.

     This study was approved by the first author’s IRB. We recruited participants through targeted disability organizations (e.g., Council of State Administrators of Vocational Rehabilitation, Wisconsin’s Centers for Independent Living, Alabama Department of Rehabilitation Services) and social media platforms, many of which were specifically for PWD (e.g., Blind Pen Pals, VR Professionals, Cerebral Palsy Support, and Spinal Cord Injury Peer Mentor Program Facebook groups). Additionally, we sent email invitations to professional and personal contacts and posted on listservs of various professional organizations that serve PWD. The email invitation and posting included a brief description of the research study; inclusion criteria; an informed consent document; and a URL link to the secure, confidential survey via Qualtrics. To proceed to the study questionnaires, participants had to meet the following criteria: 1) at least 18 years old, 2) have a high school diploma or GED, and 3) have a diagnosed disability. The online survey portal was divided into six parts: informed consent, consent, screening questions, demographics, AMS questions, and two optional open-ended questions regarding their personal microaggression experiences and their interest in participating in future related studies. This study was Section 508 compliant and accessible to participants with disabilities. In total, 254 participants responded to the online survey; 53 participants were excluded because of vastly incomplete or unusable data, resulting in a final sample of 201 participants.

Data Collection
Demographic Questionnaire
     We used a self-report demographic questionnaire to collect information about age, sex, gender identity, sexual orientation, racial/ethnic identity, religion/spiritual identity, education, employment status, and source of income (see Table 1). In light of the diversity within the disability community and to allow for within-group comparisons, we asked for type of disability (i.e., physical, sensory, psychiatric, and neurodevelopmental) and visibility of disability (i.e., visible/apparent, invisible/hidden, or both). Participants reported their highest level of education and their job responsibilities as they apply to their training, education, and skills. Because income level is subjective in terms of individual needs and geographic U.S. region, and PWD often have more than one income source, we asked participants to name their sources of income instead of a dollar amount.

Ableist Microaggressions Scale
     The AMS (Conover et al., 2017b) is a 20-item self-report measure of PWD’s lifetime experiences with disability-related microaggressions. The AMS has four subscales: Helplessness, Minimization, Denial of Personhood, and Otherization. Item examples include: “People offer me unsolicited, unwanted, or unneeded help because I have a disability” (Helplessness); “People are unwilling to accept I have a disability because I appear able-bodied” (Minimization); “People don’t see me as a whole person because I have a disability” (Denial of Personhood); and “People suggest that living with a disability would not be a worthwhile existence” (Otherization). Participants were instructed to think only about their personal ableist microaggression experiences when responding to the AMS items.

Responses were rated on a 6-point Likert-type scale, ranging from 1 (never) to 6 (very frequently), and three items included a not applicable response option, as these items may not be relevant for individuals with invisible/hidden disabilities. Possible total scores range from 17 to 120, with higher scores indicating greater levels of lifetime experiences with ableist microaggressions. The overall internal consistency reliability was .92 (Conover et al., 2017a) and .95 (Conover & Israel, 2019), and the internal consistency reliability scores for the AMS subscales were .85 for Helplessness, .65 for Minimization, .90 for Denial of Personhood, and .84 for Otherization (Conover et al., 2017a). Cronbach’s alpha for the AMS in this sample was .90.

Data Analysis
     All statistical analyses were performed using IBM SPSS Statistics Standard V27. To answer Research Question 1, we ran descriptive statistics for all measured variables of AMS scales and subscales (see Table 2). For Research Question 2, we conducted factorial analysis of variance (ANOVA) and multivariate analysis of variance (MANOVA) to understand whether the AMS scores and subscale scores differed based on the type of disability and the visibility of the disability as independent factors. To answer Research Question 3, we utilized multiple regression analyses to investigate the predictive variables of participants’ sociocultural identities and AMS scores and subscale scores.

Table 1
Demographic Characteristics of Participants (N = 201)

Variable    n   %
Disability Type a
Physical 100 49.8
Sensory   89 44.3
Psychiatric/Mental   61 30.3
Neurodevelopmental   43 21.4
Disability Type
Physical only   55 26.8
Sensory only   55 26.8
Psychiatric/Mental only   12   5.9
Neurodevelopmental only   11   5.4
Two or more disabilities   68 33.2
Disability Visibility
Visible/apparent   62 30.8
Invisible/hidden   84 41.8
Both visible and invisible   55 27.4
18–29   33 16.4
30–39   44 21.9
40–49   57 28.4
50–59   39 19.4
60–69   20 10.0
70+     8   4.0
Biological Sex
Female 158 78.6
Male   43 21.4
Gender Identity
Woman 150 74.6
Man   43 21.4
Gender queer     5   2.5
Self-identify in another way     3   1.5
Affectual/Sexual Orientation
Heterosexual 155 77.1
Bisexual   20 10.0
Gay     5   2.5
Lesbian     3   1.5
Pansexual     5   2.5
Queer     7   3.5
Self-identify in another way     6   3.0
African American/Black   15   7.5
Asian or Pacific Islander American     5   2.5
Variable    n   %
Euro American/White 153 76.1
Jewish     6   3.0
Latino/a or Hispanic     8   4.0
Native American     1     .5
Middle Eastern     3   1.5
Biracial     2   1.0
Multiracial     2   1.0
Self-identify in another way     6   3.0
Religious/Spiritual Identity
Agnostic   34 16.9
Atheist   20 10.0
Buddhist     2   1.0
Christian: Catholic   32 15.9
Christian: Protestant   72 35.8
Jewish     6   3.0
Muslim     2   1.0
Self-identify in another way   33 16.4
High school diploma/GED   15   7.5
Some college, but no degree   27 13.4
Associate or trade school degree   19   9.5
Bachelor’s degree   44 21.9
Master’s degree   72 35.8
PhD, EdD, JD, MD, etc.   24 11.9
Employment Status
Full time   94 46.8
Part time   30 14.9
Unemployed   34 16.9
Student   22 10.9
Retired   21 10.4
Training/Education/Skills Compared to Job Responsibilities
On par   85 42.3
Exceeding   54 26.9
Lower     4   2.0
Not applicable   58 28.9
Source of Income
Job 120 59.7
SSI   27 13.4
SSDI   37 18.4
Retirement/pension   22 10.9
Unemployment benefits     2   1.0
Other income sources   43 21.4

Note. SSI = Supplemental Security Income; SSDI = Supplemental Security Disability Income.
a Participants had the option to indicate more than one response; therefore, totals are greater than 100%.

Table 2
Descriptive Statistics for AMS Items by Subscale

    M   SD
Total AMS score 61.01 20.60
Overall AMS item   3.05   1.03
Subscale: Helplessness   3.30   1.34
H1. People feel they need to do something to help me because I have a disability.   3.29   1.61
H2. People express admiration for me or describe me as inspirational simply because I live with a disability.   3.65   1.80
H3. People express pity for me because I have a disability.   3.11   1.59
H4. People do not expect me to have a job or volunteer activities because I have a disability.   2.95   1.82
H5. People offer me unsolicited, unwanted, or unneeded help because I have a disability.   3.47   1.76
Subscale: Minimization   3.60   1.56
M6. People are unwilling to accept I have a disability because I appear able-bodied.a   3.63   2.01
M7. People minimize my disability or suggest it could be worse.   3.62   1.81
M8. People act as if accommodations for my disability are unnecessary. a   3.56   1.76
Subscale: Denial of Personhood   3.07   1.47
D9. People don’t see me as a whole person because I have a disability.   3.32   1.66
D10. People act as if I am nothing more than my disability.   2.66   1.52
D11. People speak to me as if I am a child or do not take me seriously because I have a disability.   3.16   1.74
D12. People assume I have low intelligence because I have a disability.   3.08   1.84
D13. Because I have a disability, people attempt to make decisions for me that I can make for myself.   3.11   1.70
Subscale: Otherization   2.63   1.22
O14. People think I should not date or pursue sexual relationships because I have a disability.   2.09   1.54
O15. People indicate they would not date a person with a disability.   2.93   1.73
O16. People suggest that I cannot or should not have children because I have a disability.   2.37   1.60
O17. People stare at me because I have a disability. a   3.18   1.93
O18. Because I have a disability, people seem surprised to see me outside my home.   2.42   1.65
O19. Because I have a disability, people assume I have an extraordinary gift or talent.   2.49   1.72
O20. People suggest that living with a disability would not be a worthwhile existence.   2.91   1.74

Note. AMS = Ableist Microaggressions Scale; H = Helplessness; M = Minimization; D = Denial of Personhood;
O = Otherization; M = Mean; SD = Standard Deviation
a Item includes “not applicable” response option.



For Research Question 1, there was substantial variability in participants’ responses to individual AMS items (see Table 2). Participants had an overall total AMS mean score of 61.01 (SD = 20.60). The response mean score was 3.05 (SD = 1.03). The response means for the AMS items ranged from a high value of 3.65 (SD = 1.80) to a low value of 2.09 (SD = 1.54). In the Minimization subscale, the response mean was 3.60 (SD = 1.56) and ranged from a high value of 3.63 (SD = 2.01) for “People are unwilling to accept I have a disability because I appear able-bodied” to a low value of 3.56 (SD = 1.76) for  “People act as if accommodations for my disability are unnecessary.” For the Helplessness subscale, the response mean was 3.30 (SD = 1.34) and ranged from a high value of 3.65 (SD = 1.80) for “People express admiration for me or describe me as inspirational simply because I live with a disability” to a low value of 2.95 (SD = 1.82) for “People do not expect me to have a job or volunteer activities because I have a disability.” In the Denial of Personhood subscale (M = 3.07; SD = 1.47) the responses ranged from M = 3.32 (SD = 1.66) for “People don’t see me as a whole person because I have a disability” to M = 2.66 (SD = 1.52) for “People act as if I am nothing more than my disability.” For Otherization, the response mean was lower than the other subscales (M = 2.63; SD = 1.22) and ranged from a high value of 3.18 (SD = 1.93) for “People stare at me because I have a disability” to a low value of 2.42 (SD = 1.65) for “Because I have a disability, people seem surprised to see me outside my home.”

     For Research Question 2, we conducted a factorial ANOVA to understand the relationship between AMS scores, type of disability, and visibility of disability. Main effect results revealed that ableist microaggression experiences were significantly different for the visibility of disability factor—that is, whether the participant had visible, hidden, or both visible and hidden disabilities, F(2, 189) = 6.12, p = .003, partial ŋ2 = .061; however, ableist microaggression experiences were not significantly different based on disability type, F(4, 189) = 2.26, p = .064, partial ŋ2 = .046. The Scheffe post hoc test revealed visibility categories were significantly different. The invisible/hidden disability group significantly differed in ableist microaggression experiences from the visible/apparent disability group and the visible and hidden group. The invisible/hidden group (M = 2.57, SD = 0.11) scored significantly lower in their AMS compared with the visible/apparent disability group (M = 3.31, SD = 0.14) and visible and hidden disability group (M = 3.41, SD = 0.26). Calculated effect size revealed a small proportion of AMS variance was accounted for by visibility of disability, while interactions between type of disability were not significant, F(5, 189) = 1.69, p = .138, partial ŋ2 = .043.

We utilized a MANOVA to determine the effect of disability types and visibility of disability using four dependent variables that represented the AMS subscales (i.e., Helplessness, Minimization, Denial of Personhood, and Otherization). The Box’s Test was significant (p = .01), indicating that homogeneity of variance was not fulfilled, so we used Pillai’s trace test statistic to interpret the results. The results revealed that visibility of disability, Pillai’s V = .323, F(8, 374) = 8.99, p < .001, ŋ2 = .161, significantly affected the combination of the AMS subscales. The factor interaction indicated no statistical significance, F(20, 756) = .94, p = .535, ŋ2 = .024, nor was there statistical significance for the main effect of types of disability, Pillai’s V = .097, F(16, 756) = 1.17, p = .285, ŋ2 = .024.

The multivariate effect sizes were very small based on univariate ANOVA and Scheffe post hoc tests. ANOVA results indicated that visibility of disability significantly differed for all AMS subscales: Helplessness, F(2, 189) = 17.25, p < .001, ŋ2 = .154; Minimization, F(2, 189) = 16.02, p < .001, ŋ2 = .145; Denial of Personhood, F(2, 189) = 4.74, p = .01, ŋ2 = .048; and Otherization, F(2, 189) = 11.99, p < .001, ŋ2 = .113. Participants with visible disabilities experienced more Helplessness and Otherization microaggression types, while participants with invisible disabilities experienced more Minimization microaggressions. Participants with both visible and invisible disabilities experienced Denial of Personhood microaggressions more frequently. Table 3 presents the adjusted and unadjusted group means for AMS subscales by type of disability and visibility of disability.

Table 3
Adjusted and Unadjusted Means for AMS Subscales by Disability Types and Visibility of Disability

Subscale   Helplessness Minimization Denial of Personhood   Otherization
















Disability Types
Physical only 3.09 3.38 3.00 2.80 2.66 2.85 2.45 2.69
Sensory only 3.57 3.64 3.49 3.41 3.48 3.46 2.77 2.82
Psychiatric/Mental only 2.17 2.17 4.47 4.47 2.25 2.25 1.76 1.76
Neurodevelopment only 2.95 2.25 3.70 3.73 3.05 2.11 2.77 1.88
2 or more disabilities 3.41 3.31 3.85 4.23 3.21 3.23 2.75 2.69
Visible/apparent 4.02 4.07 2.56 2.51 3.29 3.30 3.15 3.19
Invisible/hidden 2.41 2.51 4.17 4.30 2.40 2.51 1.95 2.01
Both visible and invisible 3.54 3.63 3.59 3.76 3.64 3.65 3.01 2.93

Note. AMS = Ableist Microaggressions Scale; ADJ = Adjusted Mean; UA = Unadjusted Mean.


For Research Question 3, predictors were transformed and collapsed into dummy variables so they were useful for data analysis. Standard multiple regressions were conducted to determine the accuracy of the sociocultural identities (i.e., age, sex, gender identity, sexual orientation, racial/ethnic identity, religion/spiritual identity, education, and employment status) to predict AMS scores. Regression results indicated that the overall model does not significantly predict AMS scores, R2 = .052, R2adj = .019, F(14, 186) = .73, p = .74. Although the results did not predict AMS scores overall, they significantly predicted Minimization scores, R2 = .157, R2adj = .093, F(14, 186) = 2.47, p = .003. This model accounts for 9% of variance in the Minimization score. We found that race/ethnicity (β = −.51, p = .04), education level (β = −.69, p = .03), and employment status (β = 1.18, p = .03) significantly predicted AMS Minimization scores.


Our findings both support and extend our understanding of the occurrence of ableist microaggressions and the types experienced by PWD who have different disability characteristics and who have a range of sociocultural identities. Participants in our study reported, on average, higher lifetime occurrences of ableist microaggressions (M = 3.05) than what Conover et al. (2017a) found (M = 1.70). These differences may be due, in part, to an increased recognition and awareness of ableist microaggressions. The high average scores reported in each subscale are consistent with the Helplessness, Minimization, Denial of Personhood, and Otherization scores reported by other researchers (Gonzales et al., 2015; Keller & Galgay, 2010; Olkin et al., 2019).

In our study, visibility of disability differentially impacted the overall occurrence and types of ableist microaggressions PWD experienced. Like in previous studies (Andreou et al., 2021; Conover et al., 2017a; Kattari, 2020), participants in our study with visible disabilities reported higher occurrences of ableist microaggressions than people with hidden disabilities or those with both visible and hidden disabilities, and they reported more Helplessness and Otherization types of microaggressions. It is plausible that people with visible disabilities experience Helplessness and Otherization ableist microaggressions more frequently because of the dominant culture’s perception that disability is catastrophic and results in functional limitations beyond their disability, presuming that PWD need unsolicited help from able-bodied individuals and that PWD are burdensome (Keller & Galgay, 2010; Olkin et al., 2019). Like Andreou et al. (2021) found, participants with hidden disabilities indicated fewer overall ableist microaggression experiences, but they reported higher Minimization microaggressions than their counterparts. Because people with hidden disabilities generally do not fit the stereotypical representation of a person with a disability, they may pass as nondisabled and must prove their disability status. This is consistent with findings that individuals living with concealable chronic and mental illnesses encounter experiences in which the existence or severity of their symptoms are denied by others (Gonzales et al., 2015; Olkin et al., 2019). Unique to our study is the result that participants who identified as having both visible and hidden disabilities experienced more Denial of Personhood microaggressions, indicating PWD being reduced to their disability status (Conover et al., 2017a) and/or PWD’s other sociocultural identities being ignored or denied (Keller & Galgay, 2010).

PWD with different types of disabilities did not differ in the overall occurrence of and types of ableist microaggressions they experienced. Partly, our results concur with Conover et al. (2017a), who noted no differences in the occurrence of ableist microaggressions among people with different types of physical disabilities. In contrast, Andreou et al. (2021) reported that people with medical conditions/chronic illnesses indicated fewer ableist microaggressions than their counterparts and that disability type was related to Helplessness, Minimization, and Otherization. The variability across these studies may be due to real differences or the ways in which scholars classified disability types.

The sociocultural identities we examined did not predict the lifetime experiences of ableist microaggressions, aligning with prior researchers’ results (Conover et al., 2017a). However, unique to our study is that we found that race/ethnicity, education level, and employment status are predictive of Minimization ableist microaggressions for people of color (POC), those with graduate degrees, and PWD who are employed full time. We proffer these results may be understood from the standpoint that microaggressions toward PWD are pervasive and may intersect with other nondominant identities (Sue & Spanierman, 2022). It is not surprising that participants with nondominant racial identities had higher Minimization scores given that POC frequently report being dismissed and ignored within U.S. culture (Nadal et al., 2014); based on our study results, this holds true for POC with disabilities. Additionally, because society typically views people with graduate degrees and those who work full time as more capable, PWD who fit these categories may be more likely to experience microaggressions that minimize the existence or severity of their disabilities because they are perceived as more capable based on education and employment.


Given the ubiquitous nature of ableist microaggressions experienced in the disability community, it is vital for counselors to recognize, acknowledge, validate, and be culturally aware of and sensitive to the presence of microaggressions in the lives of PWD, and in turn, consider that socioemotional problems may be a product of microaggressions rather than attributes related to their disability (Chapin et al., 2018; Sue & Spanierman, 2022). However, counselors must understand that PWD may not use the terms microaggressions, ableist, or ableism explicitly, so they need to listen and attend to client stories that communicate such experiences and determine whether or not these experiences are part of their symptomology. Grounded in the AMS domains evident in the study results, we proffer that clients may share stories that communicate instances in which PWD experience:

  • Helplessness: PWD are given unsolicited assistance, restricted in performing daily activities, denied their independence, or not directly communicated with by others.
  • Minimization: PWD are required to continuously prove, substantiate, or explain the existence of their disability.
  • Denial of Personhood: PWD must endure others’ singular focus on their disability or disregard of their additional sociocultural identities.
  • Otherization: PWD experience others denying, questioning, or expressing irritation regarding accommodation requests or must deal with people assuming that impairment
    in one area results in impairment in other areas.

Failure to appropriately attend to these inequities experienced by PWD or to engage in cultural humility can lead to early termination, impede the working alliance, and/or result in additional psychological harm (Sue & Spanierman, 2022).

Because counselors are products of their environments, they are at risk of developing unconscious biases toward PWD with visible and hidden disabilities, and left unchecked, they can unintentionally communicate these biases within the counseling process. Biased beliefs can unwittingly drive actions that can damage the counseling relationship and result in microaggressions, including seemingly well-intended, innocuous actions like holding a door (i.e., Helplessness) or unilaterally determining a treatment plan without client input (i.e., Otherization). Such actions can usurp the autonomy of clients with disabilities and result in denying clients their basic ethical rights. Additionally, counselors may inadvertently overlook disability identity when they do not include ability/disability status or questions about disability or chronic illness as part of their intake and assessment procedures (i.e., Denial of Personhood; Cook et al., 2020). Without this knowledge, they may mistakenly minimize a client’s hidden, undisclosed disability because they were unaware of it (i.e., Minimization), yet our results support that this may occur with apparent/disclosed disabilities, too. Consequently, we recommend counselors provide intake questions that give clients the opportunity to identify their disabilities, to include additional self-determined relevant information about their disability, and to express how they would like the counselor to refer to their disability. Furthermore, counselors must follow up about intake form information during the clinical interview (Cook et al., 2020).

PWD with multiple intersecting nondominant sociocultural identities experience the inherent complexities associated with possessing overt cultural identities (e.g., POC) and concealed cultural identities (e.g., sexual/affectual orientation). It is essential for counselors to explore clients’ identities that are most important to them (i.e., identity salience; Hunt et al., 2006) and their experiences of privilege and marginalization. Accordingly, counselors must work to understand the privileged and marginalized statuses related to all of their identities and specifically related to ability/disability in order to broach effectively. To do so, counselors must examine their attitudes, beliefs, and assumptions about PWD to combat unconscious biases that could influence their behavior or interpretations in the counseling relationship (Chapin et al., 2018). To do so, Deroche et al. (2020) recommended reading autobiographies or blogs written by PWD (e.g., Heumann & Joiner, 2021), listening to or watching Ted Talks given by PWD (e.g., Young, 2014), following or joining social media pages specific to disability or PWD, and/or reading scholarly literature centered on the lives of PWD. Additionally, we recommend counselors engage in culturally responsive care, including use of disability-inclusive language (Kattari, 2020); discuss specific accessibility and accommodation needs (Chapin et al., 2018); assess office accessibility; and create disability-friendly policies (Chapin et al., 2018; Olkin et al., 2019).

Counselor educators and supervisors are responsible for preparing students and supervisees to work with PWD. Consequently, professional counselors need more than one day slated for disability topics in their multicultural counseling course. Most importantly, professional counselors need to know that PWD have historically been and are continually on the frontlines advocating for their civil rights and promoting social justice and equality. Although it is likely impossible for most programs to add another course to their curriculum, it is reasonable and doable to integrate disability into established courses as they have for other cultural topics and for supervisors to make intentional efforts to address ability/disability within clinical supervision. Strategies include creating case studies that portray PWD or disability identity (see Smart, 2012 for examples); developing activities, assignments, or projects that require counselor trainees to explore negative attitudinal barriers and social inequities experienced by PWD (Deroche et al., 2020); discussing how disability impacts family roles, responsibilities, and dynamics; using cultural broaching in the classroom and in supervision (Day-Vines et al., 2021); and designing program policies and materials that reduce attitudinal and access-related barriers for students and supervisees with disabilities.

Limitations and Future Research

The study results must be understood in the context of its limitations. Self-selection bias may have influenced who decided to participate in the study. Although we included a definition and examples of ableist microaggressions in our informed consent document, PWD who were more familiar with or had an interest in this topic may have chosen to participate compared to PWD who were less familiar or knowledgeable about ableist microaggressions. Our use of the AMS (Conover et al., 2017b) introduces limitations associated with its psychometric properties, as no normative data is available. Additionally, the AMS purports to measure the lifetime occurrence of ableist microaggressions, requiring participants to retrospectively report information from years prior; retrospective recall of ableist microaggressions may result in inaccurate data (Kattari, 2019). Although there is benefit to understanding the long-term effects of ableist microaggressions, we suggest that researchers pursue longitudinal studies rather than utilizing a one-time measure that relies on participants’ recollections.

Although our sample included people with a range of disability types and visibility of disability, the majority identified as White, heterosexual women who are employed and who had some level of higher education experience. The racial (Goyat et al., 2016), educational (Paul et al., 2021), and employment (U.S. Bureau of Labor Statistics, 2023) inequities reported in the disability community are not representative of our sample. We suggest that future studies intentionally sample individuals who are more representative of the disability community. Finally, counseling researchers must continue to investigate how ableist microaggressions manifest in the counseling relationship, best practices for helping clients heal from microaggressive experiences, and appropriate supervision and educational interventions to prepare counselors and counselors-in-training to work with PWD who have experienced ableist microaggressions.


The results of our study add to the paucity of research specific to ableist microaggressions, particularly with respect to visibility of disability and other nondominant sociocultural identities of PWD. Like other studies, we found high average scores in all domains, and that visibility of disability resulted in higher AMS scores and impacted the type of ableist microaggressions experienced. Although the sociocultural identities we examined did not predict the lifetime experiences of ableist microaggressions, we found race/ethnicity, education level, and employment status are predictive of Minimization ableist microaggressions for POC, those with graduate degrees, and PWD who are employed full time. We offered that all counseling professionals—counselors, counselors-in-training, counselor educators, and supervisors—must attend to disability microaggressions regularly within their professional roles and specifically, we urged researchers to increase their attention to ableist microaggression research. Together, we can reduce ableist microaggressions and eventually increase access for PWD within professional counseling.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Melissa D. Deroche, PhD, NCC, ACS, LPC-S, is an assistant professor at Tarleton State University. Lee Za Ong, PhD, LPC, CRC, is an assistant professor at Marquette University. Jennifer M. Cook, PhD, NCC, ACS, LPC, is an associate professor at the University of Texas at San Antonio. Correspondence may be addressed to Melissa D. Deroche, Tarleton State University, Department of Counseling, 10850 Texan Rider Dr., Ft. Worth, TX 76036,

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

Afro Latinx immigrants are an underserved population in the United States and within counseling specifically. The counseling profession has been slow to address the unique needs of this population despite the increased visibility of this group in recent years. Consistent with the codes of ethics from the American Counseling Association and the National Board for Certified Counselors and the Multicultural and Social Justice Counseling Competencies (MSJCC), counselors must continue to expand their repertoire and use empirically supported tools to address these mandates and increase cultural responsiveness in clinical practice. Despite its alignment with the MSJCC, the counseling literature demonstrates that the Cultural Formulation Interview is an underutilized, empirically supported tool. The authors describe how counselors may use the Cultural Formulation Interview in their clinical practice with Afro Latinx immigrants while operating from a multicultural and social justice–oriented framework.

Keywords: Afro Latinx, immigrants, clinical practice, Cultural Formulation Interview, MSJCC

     According to data from the 2020 Census, there are about 62.1 million Hispanics in the United States (U.S. Census Bureau, 2021). Of those, about 6 million identify as Afro-Latinos, accounting for about 2% of all adults and about 12% of all Latinx adults in the country (Gonzales-Barrera, 2022). Considering the Afro Latinx population is increasingly gaining visibility in the United States, there is a growing need for counselors to become well-versed in working with this population. Afro Latinxs have been found to be impacted by multiple systems of oppression because of their intersecting identities (Araujo-Dawson & Quiros, 2014; Hatzenbuehler et al., 2017; Lipscomb & Stevenson, 2022), which can have a detrimental impact on their sense of identity, mental health, and overall functioning as they cope with multiple demands not often acknowledged in the counseling literature (Adames et al., 2016; Newby & Dowling, 2007). The lack of recognition of the compounded impact of being a Black Latinx person in a racialized country, where Black and Latinx communities continue to be perceived as homogeneous groups and subjected to racism and xenophobia, contributes to these difficulties. When immigration status is considered in addition to these highly stigmatized identities, well-being can be drastically impacted as Afro Latinx immigrants are left to negotiate group membership and boundaries within communities that often reject them based on their intersectional identities (Newby & Dowling, 2007).

Current paradigms of intervention for working with multiply marginalized populations within the Latinx pan-ethnic label remain unidimensional, limiting both counselors’ understanding of clients and their ability to help clients understand their unique experiences and how these impact their well-being (Adames et al., 2016; López et al., 2018). When working with this population, it is imperative for counselors to pay close attention to the intersection of identities, oppression, and mental health; embrace a socioecological perspective; and work to balance individual counseling with social justice, as envisioned by the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016). We assert that the evidence-based Cultural Formulation Interview (CFI) is an underutilized intervention tool to support counseling practitioners’ and trainees’ MSJCC responsiveness when working with Afro Latinx immigrants in the United States. In this manuscript, we describe the CFI; highlight its alignment with the MSJCC; and demonstrate how the CFI may be used with Afro Latinx populations, an underserved and minoritized group.

Counseling Latinx Populations
     In the United States, counseling practice with Latinx populations has primarily emphasized the role of cultural values (Ayón et al., 2020; Mancini & Farina, 2021). Cultural values are the customs, beliefs, and guiding principles held in common by a cultural group that often help shape worldview and the perceptions of individuals of that culture (Ratts et al., 2016; Sue et al., 2022). Culture plays an important role in the presentation of illness and the experience of mental disturbance (Jones-Smith, 2018). Therefore, it is imperative for counselors to attend to cultural elements throughout the counseling process. This emphasis on the role of cultural values has made significant contributions to the Latinx mental health literature by providing a foundation for counselors and counselors-in-training (CITs). But there continues to be a lack of emphasis placed on interventions that explicitly consider the role of within-group differences among this diverse ethnic population (Adames et al., 2018; Barragán et al., 2020). Scholars and practitioners have relied on cultural values and categorized the discrimination Latinx individuals and communities experience from ethnic-, language-, and immigration-related factors, while glossing over racial stressors (López et al., 2018).

In a racially charged environment, like that of the United States, culture is often used as a proxy for race across health settings, including mental health settings. Among this population, this has been done through a reliance on the socialization of Latinx people not to identify themselves racially, and instead, use country of origin or immigrant generation to reflect their experiences (López et al., 2018; Telzer & Vazquez Garcia, 2009). With this focus, racialized experiences of Latinx individuals are lost—including the impact of skin color and other phenotypical characteristics on Latinxs and their mental health. Skin color, for instance, is a critical component of identity within the Latinx community because of its historical roots in African, Indigenous, and European cultures (Araujo-Dawson, 2015). This history has contributed to a wide range of skin tones within the population, from very light skin with European features to very dark skin with Indigenous or African features (Telzer & Vazquez Garcia, 2009). A preference for Whiteness within the Latinx community manifests itself through various forms of oppressive systems, such as colorism and anti-Blackness, both of which are associated with within-group discrimination and adverse mental health outcomes among Latinx populations (Araujo-Dawson, 2015; Ortiz & Telles, 2012).

In addition to the within-group differences that are often overlooked in the Latinx mental health literature, Latinx populations are also impacted by immigration demands. Demands such as personal processes like acculturation and resultant acculturative stress may arise because of the pressures of the host country (Ayón et al., 2020; Driscoll & Torres, 2020). Structural barriers put in place by governments and society at large contribute to the stress experienced by Latinx immigrants. These stressors may have adverse impacts on immigrants’ health and mental health (Ayón et al., 2020). For example, researchers suggest that immigrants are already experiencing day-to-day feelings of hopelessness and intense fear of being surveilled by immigration officials. Anti-immigration policies further exploit these feelings, which might significantly impact immigrants’ long-term mental health (Rhodes et al., 2015; Stacciarini et al., 2015).

Afro Latinx Identity and Multiple Marginalization
     Black and darker-skinned Latinos/as may experience higher levels of psychosocial stressors, which can erode the individual’s health through psychological and physiological responses and health behaviors (Capielo Rosario et al., 2019; Cuevas et al., 2016). Greater perceived discrimination based on ethnoracial appearance has been consistently associated with higher stress levels, anxiety, and depression (Ayers et al., 2013; Mena et al., 2020; Ramos et al., 2003). Additionally, the literature demonstrates that Black and darker-skinned Latinos have worse mental and physical health outcomes than White and lighter-skinned Latinos, noticeably resembling the non-Latino Black differences from non-Latino White populations (Cuevas et al., 2016).

Although the Afro Latinx immigrant population is directly impacted by the multiple marginalized social positions that they occupy in the United States, few mental health efforts have been launched to attend to this population explicitly. In the past 20 years, no scholars have explicitly addressed the Afro Latinx immigrant population in the mental health literature, with most researchers addressing the intersection of several marginalized and privileged identities such as ethnic and binary gender identities (López et al., 2018; Ramos et al., 2003); undocumented legal status, immigrant status, and ethnic identity (Ornelas et al., 2020); and legal status, women, and ethnic identities (Ramos-Sánchez, 2020). Adames et al. (2018) drew attention to Afro Latinx queer immigrants through the lens of intersectionality, indicating a shift in the field as it pertains to addressing the mental health needs of the Latinx population. Because of the impact of occupying multiple marginalized positions in the United States, as is the case of Afro Latinx immigrants, more clinical practice recommendations, such as the utility of the CFI, are warranted.


The MSJCC is conceptualized as a map that includes four main components: (a) quadrants of counselor–client interaction; (b) developmental domains of multicultural and social justice competency; (c) aspirational competencies of attitudes and beliefs, knowledge, skills, and action within each domain; and (d) ecological layers of counselor advocacy. The latter component is aimed at highlighting the fluidity and intersectionality of identities—experiences of marginalization that counselors must be aware of (Singh, Appling, & Trepal, 2020). Viewing the MSJCC within the context of the isms that exist within society, which lead to the marginalization of specific groups of people, is essential.

In their editorial review of developments in multicultural and social justice counseling, Lee and Moh (2020) noted that a critical step in realizing multicultural and social justice competence in the counseling profession is through the generation of andragogical practices that effectively promote their development. To do so, counselor educators must rely on empirically supported tools and theories for fostering the development of multicultural competency. With this aim, counselor educators have relied primarily on varying andragogical approaches (Hilert & Tirado, 2019; Killian & Floren, 2020), theories (Zeleke et al., 2018), and models (Cook et al., 2016), with some scholars directly integrating the MSJCC to work with specific populations (Carrola & Brown, 2018; Washington & Henfield, 2019). Zeleke and colleagues (2018) examined the usefulness of self-regulated learning strategies. Killian and Floren (2020) compared the effectiveness of different pedagogical approaches (i.e., didactic, experiential, and community service learning), while Hilert and Tirado (2019) examined contemplative pedagogy in teaching counseling trainees multicultural and social justice competencies. Similar to the examination of contemplative andragogy, Cook et al. (2016) used the professional development school model. These approaches significantly contributed to counselor education by generating knowledge that continues to move the counseling profession forward to centering multicultural responsivity.

Cultural Formulation Interview
     The CFI was first included in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) to guide clinicians on how to conduct a cultural assessment in routine mental health settings (Aggarwal et al., 2015; DeSilva et al., 2018). Table 1 reflects the three versions of the CFI counselors may use with clients and their families. Each version of the CFI aligns with the four core elements of the MSJCC. A crucial prerequisite for conducting a cultural assessment, in tandem with use of the CFI, involves counselor receptiveness and capacity to engage in ongoing self-awareness (Ratts et al., 2016). The CFI helps counselors to culturally conceptualize the client’s presenting problem within systems of culture, oppression, and support. In so doing, the counselor may incorporate the client’s salient intersecting and marginalized identities into their clinical portrait while also maintaining attentiveness to their own personal and professional biases.

Table 1
The Cultural Formulation Interview

CFI Version Applicability Core Components
Core interview To use upon intake

with a client

16 semi-structured questions within 4 cultural domains:

1) Problem formulation
2) Perceptions of problem

3) Coping & help-seeking factors

4) Past coping & help-seeking factors

Informant interview To use with client’s

family members or significant others after initial intake (with

client permission)

17 semi-structured questions within 4 Cultural domains:

1) Problem formulation
2) Perceptions of problem

3) Coping & help-seeking factors

4) Past coping & help-seeking factors

Supplemental modules To explore subtopics of core domains in more detail 12 supplemental modules:

1) The explanatory model

2) Level of functioning

3) Social network

4) Psychosocial stressors

5) Spirituality, religion, and moral traditions

6) Cultural identity

7) Coping and help seeking

8) Clinician-parent relationship

9) School-age children and adolescents

10) Older adults

11) Immigrants and refugees

12) Caregivers


The CFI, a semi-structured instrument, includes instructions and open-ended questions for clinicians to use. Because of the increasing empirical support for how culture influences each aspect of mental health care (Barragán et al., 2020; Cariello et al., 2020; Driscoll & Torres, 2020), the CFI is ideally utilized during the initial evaluation of any client (DeSilva et al., 2018; Sue et al., 2022); however, the CFI can also be incorporated throughout the counseling process (Ramírez Stege & Yarris, 2017). Although the CFI is the most widely used cultural assessment tool throughout the world (DeSilva et al., 2018; Lindberg et al., 2021), there is a disconnect within counselor education wherein little emphasis exists on training counseling students to properly use this tool despite the profession’s mandate to use evidence-based instruments and interventions.

The CFI consists of three components: the core interview, the informant interview, and the supplemental modules (APA, 2013). The core interview totals 16 open-ended questions consisting of four domains: 1) cultural definition of the problem to include the client’s view of their presenting problem; 2) the client’s cultural perceptions of cause, context, and support to clarify what the client and their support group consider the origin of the problem to be and identify the connection between the problem and the client’s cultural identities; 3) cultural factors that affect past self-coping and help-seeking strategies; and 4) cultural factors that affect current help-seeking, including the client’s preferences for future care and concerns about the counselor–client relationship (APA, 2013; DeSilva et al., 2018). The counselor is encouraged to consider and assess how the client’s varying identities influence each domain. Simultaneously, counselors must collaborate with the client to identify the salience and intersection of their specific identities (Aggarwal et al., 2016; Ramírez Stege & Yarris, 2017).

The informant version of the interview consists of the four domains in the core CFI and gathers information related to the client and their presenting problem from the perspective of caregivers and other relevant stakeholders (Aggarwal et al., 2015; APA, 2013). The supplementary modules expand on specific subtopics stemming from the four domains in the core and informant components of the CFI. The modules are designed to help counselors conduct a more comprehensive cultural assessment while focusing on specific needs based on identities and resources (Aggarwal et al., 2015; DeSilva et al., 2018). These modules are 1) the explanatory model; 2) level of functioning; 3) social network; 4) psychosocial stressors; 5) spirituality, religion, and moral traditions; 6) cultural identity; 7) coping and help seeking; 8) clinician–parent relationship; 9) school-age children and adolescents; 10) older adults; 11) immigrants and refugees; and 12) caregivers (APA, 2013).

Aggarwal et al. (2016) noted the most common barrier to implementation of the CFI was the perceived lack of conceptual relevance between intervention and problem, while Jones-Smith (2018) highlighted the CFI’s lack of consideration of the embeddedness of the client in their traditional culture. In considering these limitations, researchers have indicated that information obtained from the CFI should be integrated with other clinical material to achieve the aims of the clinical assessment, including culturally valid diagnosis, social history, treatment planning, and patient engagement and satisfaction (DeSilva et al., 2018; Mills et al., 2017). Jarvis et al.’s (2020) review of CFI research reported that the CFI has been shown to clinically enhance the counselor–client relationship and increases counselor cultural sensitivity. They also noted that even mental health providers with limited CFI training demonstrated improved cultural responsivity with clients. Of relevance to Afro Latinx immigrant clients, Jarvis et al. (2020) found research supportive of the CFI’s success with Latinx-identifying clients. Nonetheless, Jarvis et al. indicated that the CFI may not be an ideal assessment for clients experiencing symptoms of psychosis, suicidal ideation, aggression, or cognitive impairment. Though research is mixed, the CFI provides an innovative way to help practicing counselors and CITs become more culturally responsive (Sue et al., 2022). Next, we consider how the CFI may be specifically applicable to clients who identify as Afro Latinx.

Application of the CFI

The CFI offers an empirically supported instrument for treatment planning and conducting a culturally appropriate assessment and has been shown to increase counselor cultural sensitivity (Jarvis et al., 2020). The following case study demonstrates how the CFI can be applied with a client who identifies as Afro Latinx. After the case study, we provide a description of the domains of the MSJCC, inherent within the CFI, as they relate to counselors working with Afro Latinx immigrants.

Case Study
     Martin is a 33-year-old, dark-skinned Afro Latinx immigrant from Mexico who is seeking counseling for the first time for what he describes as intense nervousness. Martin has noticed that he began experiencing muscle tension, excessive sweating, and increased agitation in the months following his relocation to the United States. Martin relocated about 14 months ago because of his job; he works as an engineer for a well-known firm in the city. Allison is the intern counselor assigned to Martin. Allison identifies as a queer White woman born in the United States. Allison first learned about the CFI during her assessment course. Her university and site supervisors both encouraged CITs to use the CFI as a supplement to the intake session to promote cultural responsivity. In their counseling intake session, Martin describes feeling incompetent at his job, as others often question his decisions. Martin reports that he never experienced the current symptoms before and is confused and scared. Martin responds with hesitancy, although he is willing to engage in the CFI questions.

Cultural Definition of the Problem
     After reviewing the confidentiality limitations and the risks and benefits of counseling, Allison explains that she will ask Martin questions from the CFI to better understand him and his situation. After Martin reports experiencing concerns about his job without offering more details, Allison asks, “Sometimes people have different ways of describing their problem to their family, friends, or others in the community. How would you describe your problem to them?” Martin thinks for a moment then shares, “I would tell them that I thought I finally made it—I have a good job, I am working full time, I earn enough to take care of myself and help my family. But now strange things are happening with me. I get sweaty out of nowhere for no reason. I feel sore in my body. I cannot seem to calm down. I never felt this way before.”

Cultural Perceptions of Cause, Context, and Support
     Following the CFI protocol, Allison asks a causation question: “What do you think is causing this problem for you?” Martin again pauses for a moment and responds, “I miss my friends and other things, but my family is here, so I do not understand why this is happening. Like I said, I was finally able to get the engineering position and it pays really well. I work with a lot of people who are really skilled engineers. So, I am not really sure what is going on.” Allison internally notes Martin’s comment about missing home and decides to return to the topic later. Allison elects to probe a bit more about the new position: “Say more about your new job. It sounds like it is something you worked hard to achieve.” Martin reports, “Like I said, I really like the new position and I try really hard to do my best. I show up early and stay late. I wear a suit and tie everyday even though other people don’t. I guess people are trying to help me because they ask me a lot of questions about what I am doing, if I understand things, and when I will be done.”

Allison states, “There seems to be a lot of attention on you and you’re not used to that,” before transitioning to a CFI question about supports: “Is there anything that makes the sudden sweatiness, body soreness, or trouble calming down better—such as support from family, friends, or others?” Martin quickly responds, “My brothers and sisters are here, and I live with my sister’s family for now. They are great to be around and help me understand how things work in the U.S. Also, I get to hang out with my nieces and nephews a lot after work, playing video games or going food shopping. I really like eating together with them as a family too. I don’t have the sudden sweating thing with them, and I feel tranquilo [calm] around my family.”

Allison continues to the CFI module about the role of cultural identity and explains, “Sometimes, aspects of people’s background or identity can make their problem better or worse. By background and identity, I’m referring to the communities you belong to, the languages you speak, country of origin, race, ethnicity, gender, sexual orientation, faith, religion, that kind of thing. For you, what are the most important aspects of your background or identity?”

Martin takes a moment to consider and responds, “I mean . . . being a Mexican man is really important to me but also, I have no choice about my skin color and people at my job know I’m an immigrant, which I think is why they treat me differently.” Allison notes this and adds, “I remember you just said you missed some of your friends and family who are still at ‘home.’ Tell me more about that too, please.” Martin smiles and his face lights up as he explains he recently immigrated from Mexico where his parents, other siblings, and other extended family members still reside. “Yes, like I was saying, I miss home because, back there, I wasn’t treated differently. We had a common language, so speaking Spanish felt more comfortable than it does now. Even though I speak English, I feel so much pressure to speak properly or act more like my coworkers. There were no hidden expectations—here I feel like, because I’m not from here, I look darker, and I speak Spanish, I have to fit a mold that I’m not sure exists.” Next, Allison responds, “I hear you saying there are cultural differences and an unspoken expectation about your cultural background that are impacting you and how you’re understanding the situation. Can you tell me more about what you’re referring to specifically?” Again, Martin takes a minute to think and responds, “I think the pressure I feel to fit into a box—because of my darker skin, because I’m Mexican, because I’m a Spanish-speaker—causes confusion for me since I’ve never experienced this and I think it causes confusion for my coworkers too, and then people respond to me in ways that make me question my reality. When I started this new job, my coworkers wouldn’t stop asking me why I spoke Spanish if I was Black, and I didn’t know how to respond. Like, I never really thought about being Black. In Mexico we don’t talk about race, and here it seems this is the only important part of a person. I don’t understand it, and I feel trapped because either I have no choice on how they perceive me, or they make assumptions simply based on my skin color.”

Cultural Factors Affecting Self-Coping and Past Help Seeking
     Allison summarizes Martin’s responses and moves to the CFI self-coping strategies: “What have you done on your own to help you manage those things that happen with your body?” Martin reports that when the feelings happen at work, he goes to the restroom to splash cold water on his face. He also might get a glass of water. Sometimes he goes outside to get fresh air. Once, according to Martin, when it was really bad, he called his sister. Later that day, his sister recommended he contact their primary care physician. The physician ruled out any medical origins to Martin’s symptoms and referred Martin to the counseling center where Allison interns.

Because Allison knows Martin never experienced these symptoms before and had already sought medical help, she continues with a modified CFI question on past help seeking: “Martin, you shared this is the first time you experienced this problem; however, I’m wondering if there were other kinds of help you have found to be useful when dealing with difficult situations?” Martin indicates he typically sought help from his siblings first, much like he does now, and secondarily sought guidance from his parents. In this instance, Martin did not want to worry his parents, so he has not informed them of what is happening. Martin also reports finding some comfort in prayer at mass.

Allison continues with a CFI question about barriers to help seeking: “It sounds like not wanting to worry your parents is getting in the way of accessing their support. Are there other things getting in the way of getting help right now?” Martin responds, “It may be hard for me to find a time to meet every week because I do not want my work to start getting messed up. Also, I do not want anyone to know I am coming here because they will think I am crazy.”

Cultural Factors Affecting Current Help Seeking
     Allison moves to the final section of the CFI and states, “You told me that calling your sister was helpful when the sudden sweatiness and uncalm feelings come up. Is there anything you can think of that I can provide you with to help in those moments?” Martin thinks a bit and replies, “I think directions on how to get it to stop would be really important because I do not want people at work to notice. As it is they ask me a lot of questions about what I am doing, and the out-of-nowhere sweating and discomfort makes that worse.”

After providing brief psychoeducation and explaining potential strategies to address his symptoms, Allison moves to the final CFI question, which attends to the counselor and client relationship. She states, “The counseling relationship is unique because the counselor and client can be very different at times. Like you and I are from different places and look different, too. And because of that, we may not necessarily understand each other immediately. Is this something that worries you?” Martin thinks about this and responds, “Well, you are not a man, and you are not from Mexico. So, I am not sure if you will understand. Also, English is something I am pretty good at, but I am still working on it. Do you speak Spanish in case I have to say things in Spanish?”

Counselor Self-Awareness
     The MSJCC (Ratts et al., 2016) and the CFI call for culturally responsive counselors to seek intrapersonal self-awareness and understanding regarding their own social statuses, identities, and worldview (Singh, Nassar, et al., 2020). It is particularly important for counselors working with Afro Latinx immigrants to explore and understand these constructs in relation to their role in the counseling profession, society at large, and in the counseling relationship. As an example, Allison can consider the extent to which her privileged and marginalized identities pertaining to race, ethnicity, and nationality position her in relation to Martin. More specifically, Allison needs to explore how her values and beliefs about these identities influence her views of Martin. Allison can utilize self-reflection to address questions like (a) What are my thoughts, beliefs, and feelings about immigrants who have different ethnic and racial identities than me? (b) What are my thoughts, beliefs, and feelings about immigrants who have similar ethnic and racial identities to mine? and (c) What are my thoughts, beliefs, and feelings about people who are immigrants, regardless of their other identities? These questions will support Allison in developing a greater sense of self-awareness and will encourage openness to understanding Martin’s experiences and worldviews. The CFI helped Allison gain a greater understanding of the systems of oppression that may be actively impacting Martin and his well-being while challenging her bias toward individualistic conceptualizations of clients.

Client Worldview
     Although client worldview is different for everyone regarding culture and lived experiences, being an Afro descendant and an immigrant in the United States comes with unique and ubiquitous challenges. Afro Latinx immigrants have been found to have lower socioeconomic status, lower income, and overall fewer resources than lighter-skinned immigrants entering the United States (Cuevas et al., 2016). In addition to having fewer economic and social resources available to them, the shared experience of migration as a Black person in the United States may predispose clients with these intersecting identities to experience mistrust toward health care workers and others working for government institutions in general (Mancini & Farina, 2021). As a result, they may be reluctant to seek help from licensed professionals or even engage in health-promoting behaviors. Although it is important for counselors working with this population to engage in cultural encounters that allow clients to define their own experiences of living in the United States as a Black Latinx person, it is also important for the counselor to understand that institutionalized beliefs about Black people and immigrants in the United States can represent significant challenges for the counseling process and clients’ growth. As such, the CFI supports the counselor in developing respect for the client’s worldview, understanding the ways in which this worldview aligns—or does not align—with their own worldview, and accepting the client as they are to engage in a nonjudgmental and growth-promoting working alliance.

In the case study, Allison used the CFI to examine key elements of the client’s worldview, particularly as it related to the cultural definition of the problem and perceptions of the causes and context. For example, the client’s concealment of his help-seeking behaviors from some family and friends may be a key point of entry for the counselor’s interventions. Through a closer examination of Martin’s concealment, Allison may gain a greater understanding of her client’s worldview while simultaneously challenging her own biases regarding her beliefs. At the intrapersonal and interpersonal intervention levels, Allison can seek additional awareness and knowledge about the migration experiences of Black Latinx populations through research, supervision, and consultation. At the institutional and community intervention levels, Allison could advocate to increase the awareness of her coworkers and the larger counseling field regarding this population, including specific needs and barriers to consider when working with Afro Latinx immigrants.

Counseling Relationship
     Counselors need to develop an appreciation of the unique aspects of the counseling relationship by building on the gained awareness and understanding of themselves and their clients in addition to considering the unique status of their clients and how they are impacted by membership in marginalized and privileged groups—which in turn impacts how the client relates to others and the counselor (Ratts et al., 2016; Singh, Appling, & Trepal, 2020). With this gained awareness of the client’s worldview and lived experiences, counselors must authentically engage with their Afro Latinx clients and demonstrate unconditional acceptance of the clients and what they bring into the counseling relationship. Because of the unique social statuses of counselor (who may experience a high degree of privilege) and client (who may experience a level of oppression based on the intersection of identities—race x ethnicity x immigration status), the client–counselor relationship requires significant attention from both parties involved. As the counselor is expected to have an awareness of the dynamics of power and privilege both within and outside the counseling environment, it is the counselor’s responsibility to initiate the discourse regarding these dynamics with the clients.

Allison is guided by the awareness of the levels of privilege and marginalization present in the counseling space as emphasized by the MSJCC and put into practice with the CFI. Allison moved beyond this level of awareness by assessing cultural factors affecting current help seeking. The use of the CFI assisted Allison in building the client–counselor relationship but also empowered Martin to collaborate in the direction of their treatment. It should be noted how the CFI instrument in and of itself encapsulates the concept of broaching in counseling, whereby a counselor discusses “those racial, ethnic, and cultural issues that are relevant to a client’s presenting concerns” (Day-Vines et al., 2021, p. 348).

Counseling Advocacy and Interventions
     In the scenario presented above, Martin’s responses illuminated areas in which his counselor could directly engage in advocacy at the individual, intrapersonal, interpersonal, institutional, community, public policy, and global/international ecological levels. At the individual and intrapersonal levels, Allison could continue to strengthen their awareness of possible treatment approaches for this specific client in addition to continuing to develop their self-awareness, particularly around social identities, privilege, and oppression. At the interpersonal level, Allison could make intentional use of the gained knowledge and increased awareness in the counseling process to foster client growth and improvement. At the institutional and community levels, Allison could look for local and national organizations to potentially connect the client to, thereby increasing their community support and network. Allison may also contact the same organizations and seek professional involvement with the goal of advocating with and for Afro Latinx immigrants in the United States. This advocacy may also take the form of presenting webinars and at professional conferences on this particular population.


     As the case study demonstrates, when working with Afro Latinx immigrants, there are multiple ways counselors can integrate the CFI into their counseling practice. Based on their social locations in the United States and considering the sociopolitical climate, Afro Latinx immigrants are likely to experience increased psychological distress (Araujo-Dawson, 2015; Ramos et al., 2003). We illustrated an integration of the CFI to counseling practice as a means to assist counselors and CITs in developing their multicultural responsiveness and further providing culturally sensitive and appropriate services to Afro Latinx immigrants. It must be emphasized that careful explanation of the purpose of the CFI, its confidentiality, and the client’s complete control over the information shared is necessary. Multiple recommendations for counselor educators, CITs, and practicing counselors exist.

Counselor Educators
     Counselor educators should actively strive toward preparing CITs to be effective and culturally sensitive when working with a wide range of populations. The CFI may be introduced in a variety of Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) common core areas: counseling and helping relationships, assessment and testing, social and cultural diversity, and practicum and internship. Counselor educators can disseminate the CFI with small and large group skills practice via role plays and case conceptualization to expose CITs to the instrument. In addition, counselor educators may collaborate with site supervisors to incorporate the CFI in their standard intake practices. With this collaboration, CITs would receive additional support and training as they learn to use the CFI with clients to strengthen their culturally responsive assessment and counseling skills.

The case study featured a client who identified as an Afro Latinx immigrant. We encourage counselor educators to facilitate discussions regarding the challenges that Afro Latinx immigrants may face in their lives and highlight the CFI as a tool to develop case conceptualization through an intersectional lens. Through direct emphasis on Afro Latinx immigrant clients, counselor educators can assist their students in strengthening their development as culturally responsive counselors.

     CITs can apply the CFI to conceptualize their clients’ presenting problems through a comprehensive and in-depth foundation offered by the MSJCC framework. The CFI questions offer opportunities for CITs to reflect on their client’s privileged and/or marginalized statuses and their salient identities, as well as client strengths-based help-seeking strategies. In turn, CITs are challenged to reflect upon their own positionalities and biases. Through continued practice using the CFI both in classroom and clinical settings, CITs can develop and strengthen their counseling competencies in a more intentional and MSJCC-aligned manner. In the case study, Allison, a CIT, had the opportunity to consult with her site supervisor or use the intake session as a case presentation. Both opportunities would provide her with additional feedback on how to effectively use the CFI in her work with this client and other clients with marginalized identities.

Practicing Counselors
     Similar to CITs, practicing counselors may integrate the CFI in their assessment efforts either at intake or throughout the counseling process. Though culture remains an important point of emphasis in the counseling of Latinx individuals, counselors must also consider the stressors involved during the migration process, as the experiences of being an immigrant vary based on the type and cause of migration (Jones-Smith, 2018). Similarly, counselors should also explore with the client any preference concerning skin color in the client’s family, as this preference may affect the assessment, diagnosis, and treatment of the client (Paniagua, 2013). In the case presented above, the CFI provided key points of entry for the counselor to broach the client’s understanding of his presenting problem through his lived experiences of being a Black, Spanish-speaking immigrant in the racialized United States. In allowing for this type of information to be expressed by the client, through the use of the CFI, the counselor would be better prepared to attend to the client’s needs in a more effective and MSJCC-aligned manner.


According to the MSJCC, it is imperative that counselor educators continue to incorporate empirically supported interventions and tools, like the CFI, in their teaching of CITs (Ratts et al., 2016). Using these interventions helps counselors to increase their multicultural responsiveness both through gaining knowledge and awareness and by becoming advocates. As it stands, the counseling profession is in continued need of intentional training of students to adequately use this tool and increase cultural sensitivity. To expand counselors’ roles as advocates and to integrate multiculturalism and social justice counseling competency into practice, as articulated by the MSJCC, we must reach for additional theories and tools that help us conceptualize privilege, oppression, power, and advocacy within the counseling relationship (Singh, Appling, & Trepal, 2020).

The CFI provides a powerful tool for the enhancement of clinical training and practice in counseling and counselor education. Counselor educators who teach their students to use the CFI in their practice will be equipping them with an empirically supported tool for enhancing their work with multiculturally diverse clients, as exemplified by the case study highlighted in this article. In addition, the CFI offers a viable opportunity for enhanced clinical training that could be translated into culturally responsive clinical practice. Considering the usefulness of the CFI and the lack of attention this tool has received in counselor education, it is crucial to expand our repertoire and make use of all available avenues for increasing the quality of counseling training.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Diondre Also Has Bad Days: Cannabis Use and the Criminalization of Black Youth

Rommel Johnson

Black, school-aged youth may experience socioeconomic, psychological, and emotional difficulties that affect their mental health, leading to maladaptive ways of coping, such as cannabis use. Instead of getting treatment and support to help them manage their stressors in positive ways, Black youth often receive punitive school practices, including referrals to the juvenile justice system. Counselors who work with school-aged youth are likely to encounter many Black youth and can thus either be instrumental to their psychological development or inadvertently impede their well-being with over-pathologization and criminalization of their cannabis use. In this article, the author reflects on a particular experience he had working with a Black youth and how it influenced his cultural competency and development as a counselor. The author also discusses the socioeconomic landscape and psychological experience of Black youth and their rationale for cannabis use. The article concludes with implications for professional counselors.

Keywords: Black youth, cannabis use, criminalization, school-aged youth, cultural competency

Even though people of all races use drugs at similar rates, drug enforcement in the United States overly targets low-income communities and people of color in general (Camplain et al., 2020; Centers for Disease Control and Prevention [CDC], 2019). A growing body of research further suggests that the enforcement of cannabis laws not only disproportionately affects marginalized communities, but that those laws particularly affect Black adolescents and young adults, who, in comparison to their White counterparts, often experience more cannabis possession arrests (Ammerman et al., 2015; Bunting et al., 2013; Tran et al., 2020). Hence, for many Black youth who use cannabis, especially those who live in low-income communities, the intersection of race and low socioeconomic status (SES) becomes a prelude to systematic stigmatization and over-pathologization, resulting in the criminalization of their cannabis use.

The two monolithic societal institutions most complicit in the criminalization of Black youth’s cannabis use include the school/educational system and the juvenile justice system (JJS; Bacher-Hicks et al., 2021; Blitzman, 2021; Sheehan et al., 2021). Because of their scope of influence, power, and authority over all youth in the United States, the systematic decisions and practices endorsed within these institutions in response to Black youth’s use of cannabis can often lead to deleterious and enduring consequences that can adversely impact their mental health. Professional counselors who work with school-aged youth will likely be Black youth’s first encounter with the counseling profession. Therefore, these counselors’ engagement with Black youth will likely set the stage for their perception of behavioral health professionals. These counselors can assume a position of active, resolute defense and support of Black youth to bring an understanding to these systems about their ecology and rationale for cannabis use and foster proactive, helpful, and supportive strategies that nurture positive coping and healthy habits. Furthermore, these counselors can challenge the status quo and effect systematic change to combat the paradigms that stigmatize and pathologize Black youth who use cannabis.

Alternatively, even inadvertently, counselors working in these systems may impede the well-being of Black youth by becoming complicit in these systems and endorsing the pathologization of Black youth and the criminalization of their cannabis use. For instance, counselors may have inherent biases about Black youth, their community, and why they use cannabis. Furthermore, counselors may have views about substance use that prejudice their thinking and approach to working with this population. Even when counselors can bracket their biases (Kocet & Herlihy, 2014), they may fail to address the structural barriers or systems that maintain a posture of criminalizing and dehumanizing Black youth.

Therefore, the purpose of this article is to describe the ecological context of Black youth, particularly in low-SES communities; their reasons for using cannabis; and the response of the school and criminal justice systems to this use. This article also discusses how counselors working in these systems or with Black school-aged youth can be efficacious advocates, promote healthy coping habits, and address systemic barriers that are harmful to Black youth’s mental health. To illustrate these issues, I will begin by sharing an anecdote of one of my experiences as an early-career mental health counselor who was part of a multidisciplinary team primarily working with school-aged youth. I hope that this article will make counselors more aware of their biases, particularly regarding cannabis use among Black youth, and that they will work to minimize bias and meet this population’s needs effectively.

Personal Anecdote

Very early in my career as a mental health counselor, I had an epiphany about the profession and my unwitting complicity in pathologizing and criminalizing Black youth who used cannabis. I was part of an interagency collaborative team that included the public school system, a community mental health organization, a case management team, and the JJS. Our goal was to help so-called troubled teens make better choices and graduate from high school. Referrals to our team usually came from high school teachers, administrators, or the JJS. All the referred youth were enrolled in a public school system. We covered several counties whose demographics included mostly White, Black, and a few Hispanic students.

I was in the position for about 6 months when I noticed a behavior pattern. I must say before I describe this behavior that I had developed relationships with this interdisciplinary team, and they were good people who meant well. However, the approach the team took, including myself, with the White students was different than that used with the Black students. Most of the time, the youth were referred for the same reasons: They were caught smoking, possessing, or being under the influence of cannabis on school grounds. I remember the case of two youths specifically, whom I will refer to as Diondre and Johnny. Johnny was a White teen who lived in a town not too far from Diondre. This town is predominantly White, and Johnny’s family would be considered upper middle class. Diondre came from the other side of town, an area that is predominantly Black, which was considered “the ghetto.” Diondre’s family was considered working class.

As the team simultaneously worked with these two youths, a pattern emerged. The approach with Johnny was very restorative, and there was an inherent belief that Johnny was not “this kind of person,” that he was just going through a tough phase, and that we needed to help him bounce back. Team members would say of Johnny, “He’s a good kid,” “You know, ‘boys will be boys,’” and, “He’s just experimenting. . . . When I was his age, I did too. I just didn’t get caught.” Coming out of those meetings, Johnny might have thought of himself: “I’m a good kid. I’m just having a bad day, and this is not really me. I have worth, and people believe that I will eventually turn things around.”

In contrast, meetings with Diondre were very combative; there was always a more solemn tone, and sometimes even an aggressive one, used with him. Team members would say about Diondre, “He’s acting like a thug,” “I think he’s in a gang. Is there a father figure in the house?” “We need to get him some mentoring,” and “You know, his mom has never attended one of the intervention meetings; she probably doesn’t care—you know these parents.” At meetings, Diondre would hear statements such as “If you don’t stop doing this, you’re gonna be in juvie” and “Diondre, you need to shape up. Life is hard, but you gotta toughen up.” Coming out of those meetings, Diondre might have thought of himself: “I’m a bad seed, inherently flawed and destined to be locked up. I can’t have a bad day. It’s always like this. I don’t learn. My mom doesn’t care about me, and people don’t believe I’m worth the trouble.”

Because I was the only Black male on the team, I was assigned to “speak some sense” into him—“Have a man-to-man talk with him,” as one team member said. I recall during my first meeting with Diondre that he was slumping in the chair, and I caught his eyes—it is an image that is indelibly imprinted on my mind. Diondre sat in the chair defeated, exuding hopelessness and sadness. Looking over at me, before I could get a word out, Diondre mumbled with a sigh, “Man, you don’t even know me.” His facial expression, his dispirited disposition, and his words shocked me. Immediately, I recognized that yes, it was true: I did not know him. I did not care to know his story, his experience, or his world. I had made assumptions about him and his cannabis use, just like the others on my team.

I realized I had been complicit in the system by criminalizing a young man for his cannabis use and never once finding out what was underneath it. I had never given him the benefit of redemption as I did with Johnny. Now I had learned that, yes, Diondre was redeemable, and like Johnny, he could have bad days. I experienced his life changing as I worked through my biases about him, his community, and his cannabis use, which was something to which I could not relate. Although I had taken a course in multicultural counseling and addiction, I was so steeped in my biases and “cultural superiority” that it impaired my ability to effectively work with a population different from mine. I had become complicit with the system; until my epiphany, I did not advocate for change. I share this story and this article especially for new or emerging counselors who may work in programs or institutions that serve Black youth as a reality check and way of reassessing their roles and fiduciary duties to the clients they serve.

Cannabis Use and Mental Health Among Black Youth

Cannabis is the most frequently used illicit substance by adolescents in the United States (Miech et al., 2017). For instance, in 2019, 37% of U.S. high school students reported past cannabis use, and 22% reported use in the past 30 days (C. M. Jones et al., 2020). Moreover, teenage cannabis use is at its highest level in 30 years, and today’s teens are more likely to use cannabis than tobacco (C. M. Jones et al., 2020). Despite this rise in teen use and the laissez-faire, pro-recreational support of cannabis use by the majority of U.S. adults (Van Green, 2022), researchers have well elucidated the dangers of cannabis use on the developing brains of teenagers and youth.

Several studies have, for example, found that consistent or heavy use of cannabis is likely to have permanent effects on adolescents, including long-lasting impairment of cognition, brain structure, and brain function associated with a potentially irreversible decline in intelligence quotient (Batalla et al., 2013; Jackson et al., 2016; Szczepanski & Knight, 2014). Furthermore, long-term use of marijuana during adolescence is also associated with increased incidence and worsened course of psychotic, mood, anxiety, and substance use disorders (Levine et al., 2017). Additionally, the American Academy of Child and Adolescent Psychiatry (AACAP; 2023) asserted that short-term cannabis use can lead to, among other things, problems with memory and concentration, school difficulties, increased aggression, and worsening of underlying mental health conditions. Given these potential harms, it behooves parents and community and government leaders to develop programs and services that can discourage or otherwise lessen the use of cannabis among all youth.

Although many programs and services have been proffered and continue to be developed to address cannabis use among youth, punitive methods that disproportionately affect Black youth continue to be the most dominant approach (Volkow, 2021). Black youth tend to be penalized more frequently and to a greater degree when compared to their White counterparts (Ammerman et al., 2015). Instead of being assessed for treatment and support to help them manage stressors or cope with traumas or other emerging mental health challenges, Black youth disproportionately receive school disciplinary actions ranging from detention to suspension as well as referrals to the JJS (Sheehan et al., 2021), a process that has been aptly referred to as the school-to-prison pipeline (Bacher-Hicks et al., 2021; Blitzman, 2021).

Ecology of Black Youth
     Several studies that examined racial differences in motives for cannabis use have found that Black adolescents and emerging adults tend to use cannabis for three main reasons: coping, emotional enhancement, and social motives (Buckner et al., 2016; Patrick et al., 2011; Terry-McElrath et al., 2009). Therefore, counselors must seek to understand the environmental context of Black youth, particularly those who live in low-SES communities, to address their cannabis use competently and ethically. Bronfenbrenner’s (1995) ecological systems theory can help counselors understand the ecological context in which Black youth’s development occurs and, by extension, potentially why they use cannabis.

According to Bronfenbrenner (1995), complex interactions between individuals and their environments shape human development. Bronfenbrenner’s model consists of five interrelated systems: microsystem, mesosystem, ecosystem, macrosystem, and chronosystem. Examining these various systems will help counselors deal with their biases and increase their knowledge so they can forge culturally responsive approaches in managing cannabis use. Although numerous aspects are implicated in Black youth’s ecological systems, Black youth are frequently more vulnerable to socioeconomic and psychosocial factors that affect their mental health (American Psychological Association, 2017), often leading to maladaptive coping strategies such as cannabis use. A few of these factors are discussed below.

Black youth are more likely to live in impoverished neighborhoods with limited access to quality education, health care, and recreational resources (Sanders et al., 2023). Additionally, Black youth encounter higher rates of unemployment and underemployment compared to their White counterparts (Ren, 2022). These factors sustain their rationale for using cannabis to cope with stressors (Andrews et al., 2015; Mrug et al., 2016).

Black Youth and Mental Health
     Another important factor to consider in the ecology of Black youth is their poor mental health status resulting from their social context. Black youth are more likely than their White counterparts to be overrepresented in environments where adverse childhood experiences occur, such as low-income neighborhoods and the foster care system (Bernard et al., 2020). Black children are more likely than White children to be exposed to frightening or threatening experiences (Morsy & Rothstein, 2019). Twice as many Black children compared to White children have lost caregivers to COVID-19 (Treglia et al., 2023), and they have also experienced vicarious racism and trauma in witnessing the widely televised murders of Black people (J. C. Williams et al., 2019).

These environmental stressors, along with psychological factors, including depression, post-traumatic stress, suicide, racism, and substance-using peers, exacerbate Black youth’s vulnerability to worsened mental health problems, including depression and suicide. According to the AAKOMA Project, Black youth experience significant anxiety related to decision-making and worrying about bad events happening (Breland-Noble, 2023). King et al. (2022) explained that depression symptomatology can be one of the driving forces behind cannabis use for coping in Black youth and can thus result in more frequent cannabis use. Not only are Black youth experiencing severe challenges associated with SES, education, housing, and mental health, but suicide rates among Black youth have increased sharply (Lindsey et al., 2019; Stone et al., 2023).

Race-Based Trauma
     Black youth, particularly in urban environments, report high incidences of exposure to interpersonal trauma (Henderson, 2017). Relatedly, racial trauma due to systemic racism, including discriminatory practices, racial profiling, and unequal access to opportunities, is a critical factor that negatively affects Black youth’s mental well-being (J. C. Williams et al., 2019). Constant exposure to racial discrimination can lead to feelings of hopelessness, anxiety, and depression (Mouzon & McLean, 2017). Saleem et al. (2020) explained that racial trauma can significantly contribute to high rates of trauma among Black youth. Schools are often one of the first sites where Black youth experience racial trauma and its physical, psychological, and spiritual consequences (Marie & Watson, 2020).

     According to data from the CDC, from 2018 to 2021, the largest increase in suicides among people 10–24 years old was Black individuals, with an increase of 37%. This rise in suicide among Black youth has been increasing for over two decades (Stone et al., 2023). Furthermore, between 1991 and 2017, suicide attempts among Black adolescents increased by 73%, while attempts among White youth decreased, according to an analysis of more than 198,000 high school students nationwide (Lindsey et al., 2019).

Furthermore, according to AACAP, suicide rates among Black youth have risen faster than in any other racial/ethnic group over the past two decades, with suicide rates in Black males 10–19 years old increasing by 60% (AACAP, 2023). Additionally, early adolescent Black youth are twice as likely to die by suicide as compared to their White counterparts (AACAP, 2023). Even among the youngest children—ages 5–12—research has found that Black youth in this age category were approximately twice as likely to die by suicide than their White counterparts (Stone et al., 2023).

According to The Trevor Project (2020), 44% of Black LGBTQ youth seriously considered suicide in the past 12 months, including 59% of Black transgender and nonbinary youth. Furthermore, 17% of Black LGBTQ youth attempted suicide in the past 12 months, including more than one in four Black transgender and nonbinary youth. Nearly twice as many Black LGBTQ youth ages 13–17 attempted suicide in the past 12 months compared to Black LGBTQ youth ages 18–24 (The Trevor Project, 2020).

Despite these clear indicators of underlying issues, instead of being perceived as youth with potential cannabis use disorders trying to cope with a myriad of emotional, psychological, and socioeconomic challenges, Black youth who use cannabis are often perceived as pathologically deficient (McElrath et al., 2016) and deserving of punitive treatment approaches such as being referred to the criminal justice system. Hence, the JJS has become the de facto “drug treatment” system for Black youth with substance use disorders (SUDs) in the United States (M. E. Johnson et al., 2022).

Confronting Biases: My Journey of Self-Exploration
     Existing biases, stereotypes, and misinformation may lead counselors to assume that Black youth use cannabis more frequently than their White peers, which further justifies pathologization of their cannabis use, just as I did when working on the interdisciplinary team. My and the team’s prejudices against Diondre’s cannabis use caused us to see him and people in his community as pathological users of drugs, unlike Johnny, who was only experimenting and would get over it. These biases were likely, in part, informed by research, which continues to find that Black youth report a greater likelihood of cannabis use than their White counterparts (R. M. Johnson et al., 2019; Lanza et al., 2015; Wu et al., 2016).

As I embarked on a journey of deep self-reflection after my epiphanic moment with Diondre, one of the things I realized was that science and research have historically not only failed the Black community, but they have also been weaponized against it in all domains, especially behavioral health science (Scharff et al., 2010). I thus had to confront an epistemological assumption that helped me understand research differently. Although research articles were limited in describing the complexity of cannabis use within the Black community and Black youth, I came to understand the role of these and other research limitations in the perpetuation of bias and stereotypes.

As explained by Connelly (2013) and Puhan et al. (2012), despite the primary goal of presenting limitations being to provide meaningful information to the reader, too often, limitations in medical education articles are overlooked or reduced to simplistic and minimally relevant themes. Whether clearly communicated by researchers or neglected by practitioners, overlooking limitations and other aspects—such as sample size, population, and other methodological or analytic procedures—can reinforce very harmful beliefs that influence our practice of counseling. Research had informed me and others on the team that Black youth used cannabis more than White youth, but questioning research, particularly research limitations, had opened my eyes to a reality that contradicted what I believed.

I came to realize, as explained by Unger (2012), that much of the research on racial or cultural differences in cannabis use tends to categorize racial groups into broad umbrella designations (e.g., White, Hispanic, Black, Asian) without considering the extensive heterogeneity of people within these categories. Social, biological, cultural, and other factors may contribute to the heterogeneity of risk for substance use by non-racial characteristics, but these factors are not often examined (Unger, 2012).

Lee et al. (2021) examined the complexity of youth’s cannabis use across racial, ethnic, and cultural backgrounds. A total of 68,263 adolescents between the ages of 12 and 17 were divided into seven subgroups by race/ethnicity (White, Hispanic, Black, Asian, Native American, Native Hawaiian/Pacific Islander, and mixed race). Lee et al. then examined cannabis-specific risk and protective factors, including perceived availability of cannabis, adolescents’ perceived risk of cannabis use, and perceived disapproval of parents, peers, and close friends. Past-month, past-year, and lifetime cannabis use were used as cannabis use outcomes to examine the associations with risk and protective factors as well as with race/ethnicity.

Lee et al.’s (2021) study found that 1) the perceived availability of cannabis was associated with higher use, 2) lower disapproval of cannabis use perceptions and lower cannabis risk perceptions were also associated with greater cannabis use, and 3) disapproval of one’s parent(s)/peer(s)/friend(s) was inversely related to past-month, past-year, and lifetime cannabis use. These findings suggest there is substantial heterogeneity of cannabis risk, protective factors, and cannabis use across race and ethnicity among U.S. adolescents when other sociological and cultural factors are considered, as Unger (2012) previously emphasized. So, it is not that Black youth use cannabis more than White youth, but rather that Black youth, particularly in low-SES communities, may experience more risk factors that better account for or motivate cannabis use than their race.

Black Youth, the War on Drugs, and Cannabis Use

The American JJS is characterized by an overrepresentation of Black youth, including Black children at young ages (e.g., Abrams et al., 2021; Puzzanchera, 2021; Puzzanchera et al., 2022). Although Black Americans make up only 15% of all youth, 41% of youth in custody in the United States are Black (Puzzanchera, 2021). Furthermore, according to the Sentencing Project, Black youth are more likely to be in custody than White youth in every state but Hawaii (Rovner, 2023).

In 2017, the Sentencing Project reported that Black youth in the United States disproportionately enter the JJS at significantly higher rates than their White peers. Black youth are more than four times as likely to be detained or committed to juvenile facilities as their White peers (Rovner, 2023). This influx of Black youth in the criminal justice system has been called the school-to-prison pipeline, a phenomenon wherein students are pushed out of public schools and into the JJS, often causing irreparable harm (Hemez et al., 2020).

The school-to-prison pipeline often includes policies such as zero-tolerance discipline, school-based arrests, disciplinary alternative schools, and secured detention (Hemez et al., 2020; Welsh & Little, 2018). Black students are often subject to harsher disciplinary actions at school than White students are, and those punishments can damage students’ perceptions of their school and negatively affect their academic success years later (Del Toro & Wang, 2023). Although Black students make up 16% of public school enrollment, they account for 42% of all students who have been suspended multiple times. Black males have led the country in suspensions, expulsions, and school arrests (Green et al., 2020), while Black students with disabilities are the most likely to receive out-of-school suspensions (Harper, 2021).

The JJS is ill equipped to provide support for Black youth who use cannabis for coping. Research indicates that youth in the JJS are grossly under-assessed for SUDs, and many are never referred for SUD treatment, even when current substance use and associated problems are reported (M. E. Johnson et al., 2022). Black youth are sometimes assessed as having behavioral problems rather than having a mental health or substance use issue (AACAP, 2022). Black youth who do receive diagnoses are often misdiagnosed or are over-diagnosed, including with very severe disorders that exaggerate legitimate mental health symptoms (Rutgers University, 2019; Schwartz & Blankenship, 2014).

Given this complexity of their ecological developmental context, it is incumbent upon counselors who work with Black youth, especially in collaboration with or within the JJS, to engage with them ethically, competently, and empathetically instead of becoming complicit with systems that perpetuate racialized systematic barriers that can lead to disastrous outcomes for Black youth. Having a correct understanding of the origin and intent of drug laws in America can help counselors dismantle their prejudices, biases, and assumptions against Black youth.

As mentioned in the anecdote, although I am a Black man, I did not grow up in the United States and therefore lacked significant understanding of certain aspects of U.S. history, which impacted my working with Diondre. For instance, I was aware of slavery, Jim Crow, and racism toward Black people, but was very much ignorant of the composite of laws embodied in the war on drugs and how it originated as a way to demonize Black and Brown people. My journey in understanding Diondre’s context led me to the realization that from their inception, most drug laws in the United States were aimed at demonizing Blacks for the purpose of incarceration.

According to Baum (2016), President Nixon’s domestic policy advisor John Ehrlichman revealed this very motive in a 1994 interview, in which he stated that the war on drugs had begun as a racially motivated crusade to criminalize Black Americans and the antiwar left:

The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. . . . You understand what I’m saying? We knew we couldn’t make it illegal to be either against the war or blacks, but by getting the public to associate the hippies with marijuana and blacks with heroin. And then criminalizing them both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night in the evening news. Did we know we were lying about the drugs? Of course we did. (LoBianco, 2016, paras. 2–3)

Understanding that policies enshrined in the war on drugs originated with a malicious animus against Black bodies made me realize that a system was in place that continued to propagate the dehumanization of Black people through unwitting yet complicit participants, including me. This knowledge increased my awareness of what I was doing and laid bare my biases and how they influenced my work with Diondre.

Counseling Implications

Although counselors can impede and be complicit in perpetuating systems that are deleterious for Black youth who use cannabis, they can also be crucial allies in supporting their needs. First, counselors need to educate themselves about how addiction occurs. Some counselors may hold on to debunked theories about addiction, such as the choice theory, which erroneously posits that addiction is a choice (Heyman, 2009), or the moral theory, which posits that addiction entails a moral failing (Kennett & McConnell, 2013; Pickard, 2017). Both of these views blame the person with an addiction for their problems, justifying judgmental behaviors toward them, such as my initial approach to working with Diondre. But these views are not consistent with current research and best practices.

Many researchers and government agencies have increasingly come to understand addiction as a brain disease that affects every demographic and that treatment rather than punishment is a much more effective approach in helping people with SUDs (CDC, 2023; Goldstein & Volkow, 2011; R. Johnson, 2021; National Institute on Drug Abuse [NIDA], 2020). Counselors who understand addiction as a disease can provide insight and understanding about the plight of Black youth who use cannabis to cope and can create an environment of empathy, healing, and capacity rather than punishment.

Second, counselors need to understand that many of the drug laws in the United States were not developed based on sound scientific research and a clear understanding of how addiction happens. Rather, they were built on racist ideologies that demonized Black Americans and other racial and ethnic minorities (Flowe, 2021; Hickman, 2000; Waxman, 2019; E. H. Williams, 1914). Combined with flawed addiction theories (e.g., the aforementioned moral model and choice theory), drug laws were designed to penalize instead of treat people battling addiction, especially racial and cultural minorities (Flowe, 2021; Kennett & McConnell, 2013; Pickard, 2017; University of Georgia School of Law, 2022). Counselors should reflect upon what they learned about drugs and both the historic and present regulation of drugs in the United States.

Third, counselors need to increase their level of self-awareness. As Ratts et al. (2015) explained in the Multicultural and Social Justice Counseling Competencies (MSJCC), “Privileged and marginalized counselors develop self-awareness, so that they may explore their attitudes and beliefs, develop knowledge, skills, and actions relative to their self-awareness and worldview” (p. 5). Developing self-awareness is very hard, because it requires a level of vulnerability and honest self-reflection that can often be brutal. Doing the work reflects a deep exploration of one’s self, values, beliefs, and assumptions and can bring out a lot of shame, causing one to be trepid and shrink from vital acts of self-exploration. Nevertheless, this work is essential if we are to be honest with ourselves and develop cultural humility.

Moreover, doing the work in my experience has resulted in such an unparalleled and profound groundedness that I have no regrets doing it. This practice of self-exploration has not always been easy, but it has truly transformed my existence as a human being, making me a better person. After my epiphany with Diondre, I explored my isms. I remember that one of my aha moments was realizing that, although I was a Black man working with Black youth, I was both a victim and a perpetrator of internalized racism (Hall, 2010). Scholars have referred to this phenomenon of Black-on-Black racism in many ways, such as colorism (Clark, 2007; Fears, 1998; M. M. Williams, 2011), internalized racism (Hall, 2010), and double consciousness (Du Bois, 1897). Deep reflection caused me to realize that, even as a Black man in the United States, I had adopted negative messages about individuals in my own race, and these influenced my understanding of my clients’ issues and my provision of clinical services.

Both Johnny and Diondre were caught using cannabis, but my and my team’s disposition toward them differed. The assumption was that Diondre’s use was pathological somehow and required a heavy hand, while Johnny’s use was exploratory and required a gentle nudge in the right direction. Race was the delineating factor, and me being Black did not ensure support for Diondre because of my negative internalizations. Although all forms of racism are harmful, internalized racism is especially toxic, as it is a rejection of self and a tacit acceptance of oppression. Self-exploration as a result of my experience with Diondre not only benefited him, but it helped me grow in my acceptance of my humanity in areas I was unaware that I was neglecting.

This allowed me to be more open to other perspectives and human experiences. I became genuinely interested in Diondre as a person. I visited his community, his church, and his home; I spent time with him and his friends at the park. I met his pastor, who had known him since he was an infant. I saw him playing the drums at his church. I met his uncle, who affirmed that “he gon’ be a good quarterback.” I met his father, who, although he did not live in the same home with Diondre and his mother, was nonetheless invested in his son’s life. I met his cousins who introduced him to cannabis and experienced the verbal chastising of them by their aunt, Diondre’s mom. I listened to her talk about her aspirations for her firstborn child and only son. He was a person who was loved. He had challenges, but he also had numerous resources of which I was not aware.

More than 15 years later, I continue to do the work. I assume that I have isms that might interfere with the therapeutic process. With my person-centered orientation, I explore elements of culture and identity of my clients; I open a door to explore our differences. The cultural formulation adopted by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, (5th ed., text rev.; 2022) is helpful in achieving this. I do it with everyone, even if they appear to be similar to me. Even with clients with whom I only have a few sessions, I find a way to bring up or broach apparent and hidden cultural differences. Broaching is the process by which counselors bring up cultural characteristics of the client and the counselor and invite clients to explore the relevance of those characteristics (Day-Vines et al., 2007). Broaching is very important because it preemptively communicates to the client that their whole person is welcomed into the therapeutic space.

We may only have a few minutes in session to do this work, so I would start by saying something like, “Hey, I know that we are both males, but, for instance, I identify as a cisgendered male. What about you? How do you identify? And what concerns do you have about our similarities or differences?” Doing this allows the client to be seen and sets a tone for our interactions. Even when clients brush this off during our initial session, I have experienced instances in which they bring up things later and were thankful for me broaching; they had made note of it, and it made them feel safe with me. I remember exploring cultural differences with Diondre and, through that process, exploring what it meant to be a Black male in his community. We had profound conversations about identifying as a thug or nerd, which his cousins teased him about. Diondre even opened up and began to explore his sexual orientation, something he did not feel safe doing with anyone in his community for fear of being judged. I continue to practice broaching and highly recommend it.

The fourth action counselors can take to be allies for Black youth who use cannabis calls for moving beyond self-exploration and understanding Black youth’s culture to a commitment to dismantle systemic barriers. The fourth developmental domain of the MSJCC specifies that social action should be employed in six areas, which include, among others, institutional, community, and public-policy levels, to build multicultural counseling competency (Ratts et al., 2015). Structural racism includes the ways in which societal structures and institutions establish and perpetuate policies, practices, and social norms that reify racial hierarchies, including differential access to material conditions and opportunities based on race (Gee & Ford, 2011). Alvarez et al. (2022) emphasized that system transformations can occur at the client level, at the provider level, and at the organizational and community levels. Getting to know myself and my isms and gaining an in-depth perspective of Diondre, his family, and his community allowed me to gain insight into their ecological context and the systems they had to deal with, including the multidisciplinary team I was working with. I was not always successful, but I was very committed to pushing for equitable policies. Counselors within schools, the mental health industry at large, and the JJS have an opportunity to advocate for equitable treatment so that clients such as Diondre can have the same expectations for restoration and redemption despite their ecological contexts.


Over the past 15 years of experience as a professional counselor, I have come to value the experiences that have shaped me into the person I am today. Not that I am free from defects as a person and as a clinician, but I am becoming. Becoming a multiculturally competent counselor requires that we constantly look at ourselves and the systems within which we are employed. As our country becomes more polarized and people retreat into silos of ideology, political dogma, religiosity, and otherizing, as counselors we must resist. I am convinced more than ever that we need to maintain a stance that consistently heralds a message of love, compassion, empathy, and humanization.

To do this, we must commit to doing the work—the ongoing and at times painful, awkward, and vulnerable work of intentional self-reflection, advocacy, and action. Black youth, like other marginalized youth and adults, have suffered much and for a long time. In us they should find refuge, warmth, and a safe space to cry, to laugh, and to question themselves, their cultural identity, their gender identity, their faith, and more. Through us, they can learn to develop ways to cope with all that they experience without causing deleterious consequences to themselves. By doing the work, we can realize that, just like Johnny, Diondre can have bad days, and with a little help and support, maybe his bad days or maladaptive coping will not lead to life-altering punitive consequences.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.


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Rommel Johnson, PhD, NCC, LPC, CRC, CAADC, is an assistant professor at The University of Texas Rio Grande Valley. Correspondence may be addressed to Rommel Johnson, 1201 W University School of Rehabilitation Services and Counseling, Edinburg, TX 78539,

Utilizing Collective Wisdom: Ceremony-Assisted Treatment for Native and Non-Native Clients

Julie Smith-Yliniemi, Krista M. Malott, JoAnne Riegert, Susan F. Branco

Faith and Indigenous healing ceremonies offer spiritually oriented interventions that maintain client wellness or mitigate client existential, biopsychosocial, or spiritual distress. Mental health practitioners of all identities may ethically apply ceremony-assisted treatments with Native and non-Native populations. Three such interventions are described in this article, drawn from Indigenous traditions as practiced personally and professionally by the first and third authors. Directives for use, including populations appropriate for application, adaptations, ethical considerations, and culturally responsive competency considerations, are included.

Keywords: Indigenous, healing ceremonies, ceremony-assisted treatments, Native, culturally responsive

Across time and cultures, humans have engaged in rituals as a means for fostering healing, resilience, grounding, and connection to something larger than oneself, to ultimately create and sustain meaning and health in life (Dallas et al., 2020; Ingerman, 2018). A ritual or ceremony entails enacting a sequence of behaviors or ideas relating to symbols and meanings (La Fontaine, 1985). Healing ceremonies are spiritually oriented rituals that seek to return a person to wellness or to maintain one’s physical, spiritual, or emotional health, particularly in the face of perceived threats or losses (Crouch, 2016; Kumar et al., 2023). Such traditions often stem from religious, cultural, or ethnic roots and are commonly performed to signify celebrations or other important events (Kumar et al., 2023). These acts also offer spiritual coping as a means to address difficult existential, biopsychosocial, or spiritual situations (Crouch, 2016; Mathew, 2021); to elicit healing narratives or conversations regarding trauma; and to honor feelings of frustration, fear, anxiety, and guilt (Crouch, 2016).

Indigenous healing and ceremonial practices are part of community wellness and healing traditions for Native tribes across the North American continent (Causadias et al., 2022; Saiz et al., 2021). Such practices are passed down by the generations, despite having been forced underground for a period when the U.S. government outlawed Native American cultural practices (Irwin, 1997). Indeed, colonizers have sought to suppress and erase the Indigenous knowledge and practices of colonized communities around the world throughout history.

Scholars have recently recognized the efforts of Indigenous communities across North America to reclaim the many traditional practices to which they had been denied access because of the violence of colonization (McCormick, 2021). This healing movement is embodied in the United Nations Declaration on the Rights of Indigenous Peoples (United Nations, 2008), emphasizing the rights of Indigenous people to maintain their cultural, spiritual, and health traditions and practices (Kumar et al., 2023; McCormick, 2021). In turn, ceremony-assisted treatments can be used by and with persons of all Indigenous roots to enact healing and sustain wellness and survivance (e.g., resistance and thriving in the face of oppression; Vizenor, 1993).

Because of the efficacious nature of healing rituals, mental health practitioners of all identities have sought to apply traditional practices with Indigenous clientele and in addressing a variety of symptoms of client distress (McCormick, 2021). Non-Native American mental health practitioners have drawn upon Indigenous rituals such as smudging and drumming to address myriad forms of presenting distress across tribal groups (Blackett & Payne, 2005). Examples of issues addressed through such rituals include chronic pain (Greensky et al., 2014), distress from discrimination and colonization (Lu & Yuen, 2012; West-Olatunji et al., 2008), and substance use (Spillane et al., 2021).

In light of the universal practice around making meaning through ritual, certain Indigenous interventions may also be considered for adaptation with non-Native clientele, albeit with caution and an ethical mindset (Rathod et al., 2019). Currently, however, there are limited guidelines around the ethical implementation of ceremony-assisted interventions for non-Native practitioners, particularly for work with non-Native clientele. Such guidelines are essential to mitigate harmful acts of appropriation born from colonization and the continued exploitation of Indigenous communities and their practices on the North American continent (Meade et al., 2022).

Consequently, considering the importance and power of ritual and ceremony as a healing and wellness practice, we offer recommendations for non-Native and Native practitioners to ethically explore and incorporate ceremony-assisted interventions into practice with Native and non-Native clientele. We provide an overview of relevant provisions of the American Counseling Association’s ACA Code of Ethics (ACA; 2014) and, through examples, outline how practitioners can implement ceremony-assisted treatments while avoiding cultural appropriation.

Next, we present three ceremony-assisted treatments, including smudging, drumming, and a letting-go ceremony. Such traditions stem from Indigenous origins and are applied by authors Smith-Yliniemi and Riegert in both professional and personal settings. Suggestions for use, including appropriate populations and areas of distress, are included. We address ethical considerations in promoting respectful and culturally sensitive use of each practice, to share traditions with broader populations while seeking to maintain the cultural integrity of said practices.

Regarding language use in this article, we will interchangeably apply the terms Native, Native American, Indian, and Indigenous to refer to persons who are indigenous to Turtle Island (i.e., the lands recognized by the dominant normative population as North America). Reference will be made to Creator, to indicate a universal reference by Indigenous communities of a spiritual presence greater than oneself. In addition, drawing from the preferred naming conventions of tribal communities, the terms Ojibwe and Anishinaabe will be used interchangeably in referring to Smith-Yliniemi’s and Riegert’s origins. However, we recognize that Indigenous people on Turtle Island are a diverse group of tribes or nations with their own languages, traditions, cultures, and naming conventions (National Museum of the American Indian, n.d.). Consequently, different tribes or Indigenous communities may choose different terminologies and for unique reasons, and many will likely take differing stances from those put forth in this article.

Practitioner Positionality
     As the authors, we collectively identify as counselor educators. We each approach the directives in this article with multiple intersecting identities and critical lenses with which we seek to understand and make meaning of the world and our work. We attempt to embody cultural humility, responsiveness, and antiracist and decolonizing frameworks. We recognize that counseling as a practice has historically applied a pathologizing and therefore harmful lens toward clientele and, in particular, toward communities whose identities have been minoritized by dominant normative systems (Malott et al., 2023). Hence, to counter this deficit-based narrative, we ascribe to a strengths-based perspective and recommend practitioners do likewise (White et al., 2020). We encourage Native American practitioners seeking to “remember what they already know” about Indigenous practices as they return to their ancestral roots. In light of these points, we will transparently and authentically share the identities and frameworks we bring to this work.

Julie Smith-Yliniemi identifies as an Anishinaabe ikwe, an Indigenous woman, who grew up on a Native American reservation in the Midwest. Additional heritage includes Scandinavian descent. Intersectionalities include being a mother, wife, daughter, cisgender, temporarily able-bodied, and a person who engages in her traditional Native American ceremonial practices. Her personal and professional lens is grounded in humanistic and relational–cultural theories.

Krista M. Malott identifies with multiple intersecting identities that profoundly shape her lens, some of which include being White, U.S.–born, cisgender, female, temporarily able-bodied, spiritually agnostic, and a member of a transracially adoptive family. She principally assumes humanist, systemic, antiracist, and intersectional lenses, which shape her worldviews and her approach to her work.

JoAnne Riegert identifies as an Anishinaabe ikwe who lives and works on a Native American Indian reservation in a rural community. Her ancestral heritage also includes French Canadian and German descent. Her familial roles include being a grandmother, mother, sister, daughter, niece, and aunt. She is steeped in the Native American community and her worldview originates from this perspective. Her theoretical foundation incorporates restorative justice practices and relational-cultural theory.

Susan F. Branco identifies as a Latina, South American–born, transracial adoptee, cisgender female, able-bodied, descendent of the Guahibo tribe, and connected to the Anishinaabe culture through marriage. She is an active member of the adoptee community and is working to reculturate and reclaim her lost cultural and Indigenous heritage. Her clinical and scholarly work revolve around relational-cultural and liberation theories.

Ethical Application and Considerations

For the purpose of this article, we approach the concept of adaptation with a collectivist perspective, whereby we eschew an ownership concept of healing practices by any one cultural group. Consequently, as counselor educators and mental health practitioners, we collectively suggest that some Indigenous ritual or ceremonial healing practices may also be adapted for clients of non-Native identities, and by practitioners of all cultural identities, albeit while keeping certain points in mind—for example, if undertaken with respect and sensitivity, awareness, and guidance, and with the understanding that every person has origins to some tract of land and a spiritual connection to earth and self. This perspective is not true, of course, for all Native interventions, and not all Indigenous people will adhere to this stance. Attending to ethical guidelines can reduce the risk of appropriation, whereby cultural knowledge is used without proper and respectful acknowledgement to the cultural creators (Lalonde, 2021). Ethical guidelines may also increase cultural appreciation, adaptation, and acknowledgement, along with respectful attribution to the creators of certain interventions without stereotyping (Han, 2019; Hiratsuka et al., 2018; Meade et al., 2022).

To further attend to issues of ethics and harm in drawing on Indigenous healing ceremonies, non-Native counselors may refer to Meade et al.’s Checklist for Counselor Practitioners (2022). Meade and colleagues (2022) cited the need for practitioners to acquire cultural knowledge to more ethically implement ceremony-assisted practices, beginning with researching the “origins of the clinical intervention” (p. 103). We encourage practitioners to consider relevant ethical standards (ACA, 2014) as a starting point in the journey to Indigenous practice implementation and adaptation. We will denote suggested ethical standards after each ceremony-assisted treatment description.

Ceremony-Assisted Treatments

In the following sections we describe three specific healing rituals premised on Indigenous ceremonial treatments as means for supporting clients in healing or in sustaining wellness in a private (i.e., individual client) setting: smudging, drumming, and a letting-go ceremony. We detail when and how (and with whom) such practices could optimally be applied. A case example is used to illustrate application of each ritual with clients, with directives for the cultural adaptation of each. Considering the right and essential need for Indigenous peoples to protect their lands, traditions, and ceremonies (Drissi, 2023; United Nations, 2008), each ritual includes directives according to ethical use of its application, including consideration around appropriation and reverence for land and material use, when applicable.

     Smudging is an act of burning a traditional medicinal plant with the purpose of cleansing the body, mind, or spirit; renewing energy within and around individuals in a particular space or with a certain object; or calling for help in opening oneself to a new experience (Borden & Coyote, 1991). Some people incorporate smudging into their daily lives, while others apply it as needed. For instance, if a person is in the presence of someone who is giving off negativity or energy that is not welcoming, they may leave and smudge themselves to cleanse themselves of the negativity. At other times, if a person receives a gift or buys something new, they smudge that object in order to cleanse it. Cleansing a space to bring positive energy is also a common use of smudging. Hence, if someone moves into a new or different home, or is using a specific space for a ceremony, they might walk around the space, smudging it.

Smudging may invoke positive energy for a specific event. For instance, both in-person or virtual meetings can be started with a smudge. Smith-Yliniemi smudges each morning as a way to start her day positively. A counselor could begin sessions with a smudge, if the client desires to do so, along with personalizing or adapting the ceremony according to the client’s expressed needs or wants.

Smudging is a ceremonial process with a purpose, a beginning, and an end, with different teachings according to different tribal or community norms. Examples of smudging materials include cedar, sage, and sweetgrass. Those materials can be purchased or found in nature. In Smith-Yliniemi’s Anishinaabe community, sage is used, and it is gathered within a natural setting, with the act of gathering as part of the ceremonial process. Grown in the wild, sage differs according to the ecosystem in which it resides. Smith-Yliniemi’s community typically picks sage annually during the summer months when it is grown and ready, typically found in ditches and usually in patches. The person picking the sage will offer tobacco to Mother Earth and to the sage plant prior to picking it, to give thanks.

Traditional tobacco has been used for spiritual and medicinal purposes within communities for generations. It is central to culture, spirituality, and healing (National Native Network, n.d.). To offer tobacco, a person takes a pinch of loose-leaf tobacco from a bag or jar and places it in the palm of their left hand. The left hand is typically used because it is closest to our hearts. One then closes their hand with the tobacco secured in the fist and prays to Mother Earth and gives gratitude for the healing medicine offered by sage; they also ask the sage to help all who smudge with it. After the prayer, the tobacco in the left hand is gently placed next to the sage plants intended for harvest.

One of the Anishinaabe Original Instructions from Creator is to take only what one needs, so that there is enough for others. Individuals typically pick enough sage for those who are unable to do so, such as elders or those affected by an impairment. The sage is cut or picked from the stem of the plant, leaving the root intact; in this way the sage is able to regrow each year. Once picked, the sage is hung upside down to dry, a process that can take several weeks depending on the heat and humidity. It is then bundled and stored in a dry place to be used throughout the year.

Although smudging can be used at any time of the day, it is often done in the morning. To smudge, a small amount of sage is taken off the bundle and rolled into a small ball. It is usually placed in a shell or a special bowl and then lit with matches. The teaching Smith-Yliniemi received is that, when smudging, the smoke from the burning sage is initially taken into the hands and placed over the heart while asking Creator to open one’s heart to the experience they are about to have, as a new beginning. That beginning may entail the opening of the day, a counseling session, an event related to a life transition, or something else. In this way, a person asks for help to open their heart to a new experience.

Next, the smoke from the sage is smudged (fanned or wafted) toward the throat area while asking Creator to help with one’s words—to formulate loving and respectful words and thoughts and to know when to use them thoughtfully. Hence, one smudges the throat to reduce impulsivity and increase thoughtfulness and deliberation in speaking. Next, the ears are smudged while asking Creator to help the person hear what they are meant to hear, as so much of what one hears can cause undue worry. Hence, smudging the ears allows others’ words not meant to be heard to dissipate. In this way, Creator helps people to better hear only that which promotes learning and growth or the calming of our minds.

Next, the eyes are smudged while asking Creator to help one see what they are meant to see, including the best in others—knowing that all persons have flaws and wounds from living in a world full of chaos and worry. Additionally, the person asks to look beyond the physical, to use a lens that Creator intends. Seeing in this way allows one to live in a more peaceful manner. The person then smudges their head while asking Creator to help them with healthy thoughts and the ability to welcome a positive mindset. Consequently, through this ceremony, a person seeks spiritual and physical healing through the cleansing of any negative feelings, thoughts, or energies. They ask Creator to help them to be present and open to a more positive, healthy, and compassionate way of being toward themselves and others.

Counselors or clients of any identity can smudge if it is something they feel called to do and it makes them (or their clients) feel better. As the process is used by Indigenous communities around the world, anyone can have their own smudging routine. Some groups use smudging in association with ceremonies, as a means to feel connected to something they have lost, such as their culture and ways of being, or to address loss from war, genocide, intergenerational trauma, or colonialism. Smudging can be used as a precursor to a “welcome home” ceremony for Native American clients who were adopted and do not know their culture well or urban Indians lacking direct connection to their reservation or tribe. The ritual serves as an opening process that clears the space of any negative energy before enacting that ceremony. Smudging in this way brings in positive energy and allows attendees to be fully present and with open spirits, hearts, and minds. In turn, the welcome home ceremony acts as a coming-together process that helps individuals feel a part of their cultural community, as a symbolic rebirth of their connection to their culture.

Smudging can cleanse one’s mind, body, and spirit, bringing the person to the here and now, and therefore it can help with depression, trauma, anxiety, or substance abuse. In turn, researchers have cited smudging to have significant meaning for individuals in regard to myriad issues, from physical health issues (Greensky et al., 2014) to mental health recovery (Spillane et al., 2021) to connecting employees to one another and to their work setting through the ritual itself (McPhee et al., 2017).

Ethical Considerations
     In considering the ethics of applying smudging with clients, there are several points to keep in mind. First, for non-Indigenous practitioners, it is essential that ethical standard C.2.a. Boundaries of Competence (ACA, 2014) is considered. This states that practitioners, at minimum, read about and, ideally, receive training or experience with the practice of smudging. Such services could be advertised as one intervention available to specific populations, similar to the way other modalities are advertised (e.g., via the practitioner’s website, written materials, and verbally). Mentions of smudging should include its traditional origins and meaning, in order to educate potential clients about the nature of the intervention. Potential areas of learning include understanding the historical roots and practices of smudging, recognizing the impact of colonialism and contemporary culture on the practice (McCormick, 2021), and attending to personal bias and values per standard A.4.b. Personal Values (ACA, 2014).

In addressing issues of cultural appropriation, practitioners should avoid use of the intervention solely for profit, aligned with standard A.4.a. Avoiding Harm (ACA, 2014). When using the intervention, they should clearly credit the source and origins of the practice for their clients. Regarding materials, they should also be mindful to avoid taking more sage than necessary, to allow others access to the plant. Ideally, counselors would consult, learn, and draw from local cultural protocol and original persons/elders/tribes of their area. They would also keep in mind that what is acceptable in one community is not the same in others, and that although some Indigenous persons believe that Indigenous medicines are there to help people of any and all identities, others believe such practices should be maintained as sacred and exclusive to their community. Hence, one should seek out protocols and perspectives in their local community, aligned with ethical standard C.2.e. Consultations on Ethical Obligations (ACA, 2014).

Finally, if smudging with clients whose ancestors may have used the practice, such as African Americans, it is important to gauge their cultural awareness regarding their identities. Perhaps encourage research around ancestral African ceremonial practices or research such histories collaboratively. Explore their perspectives and emotions around what is discovered; what has been lost to colonialism, enslavement, genocide, and other historical traumas; and how they wish to proceed with smudging as a practice in collaboration with the counselor. A decolonizing counseling framework could be drawn upon for processing deep-seated trauma and corresponding emotions stemming from colonization impacts (Millner et al., 2021). In so doing, counselors will attend to ethical standard A.2.c. Developmental and Cultural Sensitivity (ACA, 2014).

Adaptation Possibilities
     As an intervention, smudging is suitable for adaptation. If not using sage, counselors can still engage in the act of cleansing a space. Some clients may be interested in burning a different herbal medicine that is meaningful to them. Some may be interested in using incense or oils to cleanse themselves or the space they are in. Adaptations, in turn, can be made in collaboration with each client, to honor their own cultural norms and practices.

Smudging: A Case Example
     Kiah, a 15-year-old Indigenous youth, sought out her school counselor, who was non-Indigenous. The client had been struggling with identity issues since hearing that there was going to be a school-sponsored powwow at the end of the school year. Some of her friends asked her if she would be dancing, as they knew she was Native American. However, she moved from the reservation to the city over 10 years ago and didn’t know much about her culture or dancing. As a result, she was feeling disconnected and anxious about who she was as a Native American.

In an effort to support Kiah, the school counselor researched and read articles regarding Native American identity and also reached out to the school district’s Native American education director in order to glean ideas on how to effectively work with the student. The director advised the counselor to engage Kiah in an activity that included her memories of living on the reservation while asking her what she may want to reconnect to.

During this activity, Kiah remembered her grandmother having a shell on her kitchen table, a distinct smell, and feelings of calmness in her home. Working collaboratively, the student and counselor recalled that her grandmother would engage in the ceremonial practice of smudging each day, and Kiah realized this was something she would like to do in reconnecting to her culture. The Native American education director shared the smudging teaching with the student and helped procure sage from a local Native American–owned shop. The student relearned this ceremonial practice and planned to regularly practice the new ritual as a way to stay grounded in and connected to her identity.

     The goals of drumming are to find rhythm in one’s life again; to help people celebrate, grieve, and heal; and to feel connected to Mother Earth as one was once connected to their mother’s womb (Rojiani et al., 2022). Many Indigenous people believe that drumming represents the heartbeat of Mother Earth. The act of drumming connects the drummer with the earth. It is a practice that is both intimate and ceremonial. Drumming has been shown to enact multiple positive outcomes in clients, with examples including positive identity development (Rojiani et al., 2022); stress reduction and empowerment (Maschi et al., 2013); coping with societal oppression (McKinley, 2023); and anxiety reduction, decreased self-stigma, and the improvement of mood (Mungas & Silverman, 2014; Rowe et al., 2023).

Drums can be made from different animal hides; in the Midwest region, they are often made with deer hides. Drums can be made or bought, with kits accessible online. Drumming music can come from any origin. Oftentimes, Indigenous songs originate from someone’s dream and then are gifted to a person or group. One example is that of an elder who once dreamt a specific song for a women’s ceremony, and then gifted the song to Smith-Yliniemi and Riegert. The elder sang the song to them, and it was their responsibility to learn the song and sing it at that certain monthly ceremony from then on, which has been done for the past decade. The drum is considered a sacred living object, as an animal gave their life so that humans could benefit and heal. Consequently, caring for a drum should occur regularly and is considered a ritualistic ceremonial experience, whereby the keeper has the responsibility to acknowledge its life and treat it with great respect and honor.

The act of drumming includes tapping the instrument with a drumstick or hand. One or multiple individuals can drum. Drumming can be used in ceremonies. In some communities, behavioral health departments offer ceremonies to community members as a way to heal and connect with their Indigenous roots. As an example of the use of drumming in counseling, when Smith-Yliniemi engaged in group trauma therapy with adolescents, she would use drumming as a way to connect members. They would begin with a smudge and then one person would choose a song and either drum and sing individually or ask the group to join if they happen to know the song.

Individuals of all identities can drum, as the practice is not exclusively Indigenous (e.g., there are music therapy degrees that incorporate drumming for all). Anyone can drum, as it comes from within; one doesn’t have to be a musician or take lessons. Drumming can be used with myriad client issues, including depression, oppression, anxiety, affect regulation, substance use, and identity strengthening. As noted in the prior paragraph, drumming can connect members of a group to enhance social interest (Sperry et al., 2021) or create a sense of belonging and humanization (Craddock et al., 2022).

Ethical Considerations
     In considering the ethics of applying drumming with clients, there are several points to keep in mind. First, like the above directives with smudging, for non-Indigenous practitioners, it is essential that practitioners adhere to standard C.2.a. Boundaries of Competence (ACA, 2014) and read about, research, and study—and ideally receive training or experience with—the practice of drumming. Potential areas of learning include understanding the historical roots and practices of drumming, recognizing the impact of colonialism and contemporary culture on the practice (Quarshie, 2023), and use of drumming in contemporary healing practices (Rojiani et al., 2022; Rowe et al., 2023), all of which support adherence to standard C.2.b. New Specialty Areas of Practice (ACA, 2014). In addition, counselors can describe the practice, meaning, and impacts of drumming both in advertising and verbally with clients.

Adaptation Possibilities
     When drumming with clients whose ancestors may have used the practice, such as African Americans, similar to the suggestions for smudging, it is important to explore their awareness of their identities and roots, encourage research around their ancestors’ ceremonial practices, or research such histories collaboratively. Explore their perspectives and emotions around what is discovered; what has been lost to colonialism, enslavement, genocide, and other historical traumas; and how they wish to proceed with drumming as a practice in collaboration with the counselor.

Drumming: A Case Example
     Zane, a non-Indigenous, African American client sought counseling because of feeling depressed following several failed romantic relationships. Zane explained to the counselor that he had a recent “aha” moment when he realized he kept breaking up with his partners because he didn’t know who he was. His insight came after watching a movie on African American history and realizing he wasn’t sure of who he was, where he was from, or any cultural practices of his African American ancestors. Zane asked, “How am I supposed to know what I want in others when I don’t even know myself”?

The counselor explored with Zane what parts of the movie called him to his “aha” moment. He explained that it was a part in which African ceremonies were taking place and that the drumming had immediately brought him to tears. Throughout the next few sessions Zane and his counselor explored his African roots, and he ordered a drum kit so that he could make his own drum. Zane also reached out to a local African organization and began attending a bimonthly community event that promotes African culture and song. Over time and across the counseling sessions, Zane’s mood appeared to significantly improve. He began to discuss additional ways of researching his identity and to also consider the implication of these explorations on his dating choices going forward.

Letting-Go Ceremony
     A letting-go ceremony is a ritual that allows a person to process and/or release thoughts, emotions, or memories around beliefs or experiences in order to bring about healing and a sense of peace and to make room for new ways of being or engaging in the world (McCormick, 2021). It is often believed that one cannot simply talk their way through a trauma, but that they must spiritually and physically release it as well. Using tobacco ties is one traditional way to release a trauma, as a symbol of letting go, freeing oneself from the human experience, and returning the trauma back into the earth. It is a metaphor for no longer having to carry a certain burden.

Tobacco is considered a sacred medicine that represents the earth and is used for myriad purposes in Indigenous communities (National Native Network, n.d.). A tobacco tie can be created by placing a small amount of tobacco on a cloth and folding or tying the corners to create a small ball or sachet. It can be connected to a chain of ties, as well. The ties are released or given to the earth or sky, through laying them near the roots of a tree or placing them in a fire.

The process itself can be ceremonial, implemented with fasting or praying. The idea is an offering to the spirit world meant to impact the here and now in the physical world and to release some of the pain associated with an event (Wilson & Restoule, 2010). When the client and counselor practice the ceremony together, both are able to let go of part of the pain. The collective connection of healing helps to ease some of the traumatic experience.

In an example of using tobacco ties in group counseling, Smith-Yliniemi would often invite a medicine person to be part of the closure process for trauma groups. The medicine person would instruct group members to make a tobacco tie for each trauma they wanted to release from their bodies and their lives. These ties would then be used in a sweat lodge ceremony in the final session of a 10–12 week group.

The idea of symbolically “giving over/letting go” or releasing something as a means for healing is a universal act and therefore can be drawn upon and applied by counselors and clients of any identity. However, the ceremony would look different according to the client’s identity and wishes. Letting go allows one to release thoughts or beliefs that keep them held to the past—hence, it allows people to stay more focused in the present moment, which could apply to many topics. Common letting-go issues include grief, traumas, and depression, as well as negative and harmful thoughts, feelings, habits, and experiences. Ultimately, we could not think of any issue that necessarily would not benefit from a spiritual and/or physical ceremonial process of “letting go.” The client, of course, must be amenable to the idea of letting go; hence, the counselor should collaboratively determine client readiness for letting go and explore client reluctance, if it does arise, as a natural part of the process.

Ethical Considerations
     Individuals of any identity can engage in letting-go ceremonies, and likely the best practice is to initially draw upon clients’ own cultural practices specific to letting go in line with standard E.5.b. Cultural Sensitivity (ACA, 2014). However, if they are unaware of any such practice in their own community, counselors may adapt a letting-go ceremony as described here to meet the client’s need. Because letting-go ceremonies can be particularly emotionally laden for both the client and counselor, we encourage counselors to monitor their own wellness and to be mindful of counselor impairment, as noted in ACA ethical standard C.2.g. Impairment (2014).

Adaptation Possibilities
     If a person does not use tobacco as part of the letting-go ceremony, other elements of nature can be used instead. For example, a person can use a stone. A stone/rock is known as a “grandfather” in many Indigenous cultures. They have been on the earth the longest and have helped humans for many generations, carrying wisdom and strength. As a symbol of letting go, a person could find and hold a grandfather (rock) in their hand, releasing their pain from the human experience back into the earth through the rock, symbolizing that we do not have to carry the pain within us, but that we can release it to Mother Nature, who serves as a caregiver to us all.

Letting-Go Ceremony: A Case Example
     Lisa, a non-Indigenous client, came to counseling to address the trauma of losing an unborn child. During the sessions, the counselor and Lisa explored the impact of this trauma. Together, they decided to engage in a letting-go ceremony as a means for healing. As a first step, the counselor gave credit to the origins of the letting-go ceremony and explained to the client how and from whom the intervention was learned.

In preparation for the ceremony, the counselor obtained the necessary items, while also tending to their own emotions to ensure that the ceremony was delivered in a healthy and therapeutic way. The counselor prepared the meeting space to ensure that it was free of distractions. A blanket was laid on the floor with a sacred altar or centerpiece, on which both the counselor and Lisa placed items that were meaningful to them. Elements of the natural world were also part of the altar—examples of potential elements include a stone, tree leaves, a small dish of water, and even an electric candle to represent fire.

In addition, objects that represented other important people in the client’s life could be present, such as a small picture or an item that belongs to a significant person. That object signifies that one does not carry the challenges in their lives alone, that there are other humans who helped to guide one along the way. In this case, the centerpiece objects were selected collaboratively by the counselor and Lisa with the intention of providing support during the letting-go ceremony.

Next, the counselor offered a small piece of cloth (4” by 4” square) to Lisa, while keeping a piece of the material for themself. In this cloth, Lisa and the counselor placed dried herbs and natural earth medicines brought specifically for the ceremony. They then tied their individual bundles of herbs with a small string and held them in their left hands, which are closest to the human heart. Importantly, only a small amount of dried medicine (one teaspoon) was used for the cloth tie.

Next, a song was played. (Other options include reading a poem or offering several moments of silence.) The counselor explained to Lisa that the particular moment was spent intentionally in sending any energy from the traumatic experience into the tied cloth. After some time passed and the client signaled that they felt ready, the counselor brought the session to a close. The altar was disassembled while both participants continued to hold their ties.

At the end of the session, the counselor explained that the cloth tie that held the medicine and the energy from the ceremony can be placed on the earth, left at the base of a tree, placed in the woods, or even put near a body of water. The implication and healing properties of the ceremony were that the energy and emotions from the loss are now part of the tie and part of the earth, so that Lisa did not have to carry them all individually. The counselor also explained that a letting-go ceremony was not a one-time practice, and that throughout Lisa’s life, she now had the knowledge to practice letting go as needed.

Competency and Cultural Responsivity Considerations

We have identified methods by which practicing counselors can begin to implement ceremony-assisted treatments. Suggestions for obtaining more information about ceremony-assisted experiences include reaching out to and collaborating with one’s local Indigenous community and seeking out a knowledge expert. It is important to offer a gift to the person who is sharing their knowledge. Gift giving in this way aligns with the spirit of the 2014 ACA Code of Ethics preamble, which asserts the importance of honoring and “embracing a multicultural approach in support of the worth, dignity, potential and uniqueness of people within their social and cultural contexts” (p. 2). ACA ethical standard A.10.f. Receiving Gifts may also be relevant for giving gifts to those from whom one learns. Making a gift to recognize the importance of honoring cultural norms around gifting is certainly in keeping with the reasons and values behind this standard. Gift giving in this instance could entail any tangible item given with thoughtful consideration from one’s heart to the heart of the person from whom they seek wisdom. Examples include plants from the earth (dried or fresh), an object with a meaningful phrase, something useful (such as towels/blankets), or a handmade item. The gift item itself is not as important as the intention behind it—as an expression of love and respect and the sharing of gratitude for the opportunity to be open and learn from wisdom keepers. The experience of earnestly seeking, listening, and developing deeper understanding creates an opportunity for the growth of cultural humility (Tham & Solomon, 2023). Additionally, practitioners are building cultural responsivity as they adopt customs and traditions with awareness of the cultural origins.

Once knowledge of the healing ceremony is learned, practitioners should also offer the earth a gift of natural essence (a stone, small berry, dried herb, or small amount of water), as the counselor now holds this wisdom and has a responsibility to honor the earth and the person who gifted it to them. This connection and reciprocity between the natural and human world are a continual exchange of gratitude. It is essential that practitioners give due credit to the contributors of newly learned practices and traditions (Meade et al., 2022). In service delivery, sincerity is honored while using our own language and understanding.

In considering competency, ethical standard C.2.b. New Specialty Areas of Practice cites the need for counselors to take steps to ensure competence in applying new techniques, and always with the lens of “protecting others from possible harm” (p. 8). Additionally, counselor commitment to ongoing learning is emphasized in ethical standard C.2.f. Continuing Education (ACA, 2014). Hence, learning should not be considered as a singular universal practice; rather, practitioners should seek to learn in the moment from the knowledge keeper and engage in ongoing consultation, learning, and interaction with the wisdom holders. Continual practitioner reflection and the eliciting of client feedback—to determine the meaningfulness and impact of such interventions—is also essential to determining counselor effectiveness. These steps align with ethical standard C.2.d. Monitor Effectiveness (ACA, 2014), stating the importance of counselor action in monitoring the effectiveness of the work they do.


Ceremony-assisted treatments are powerful sources of healing and health for clientele. Ritual is essential for all humans, as a means for healing and for the maintenance of one’s physical, spiritual, and emotional health (Hewson et al., 2014)—albeit in ways that are uniquely shaped by personal culture and experiences (McCormick, 2021). We hope that the interventions included in this article can be used to enhance client mental health and health care needs.

Essential directives noted in this article include the importance of consulting with Indigenous healers within (or in approximation to) readers’ own contexts, to consider the ethical application of Indigenous-origin healing practices. We suggest seeking out and receiving education around such interventions, their histories, and the communities from which they originate to gain further understanding and respect for the practices. Those working in school systems may want to work collaboratively with an Indigenous education director in the ethical provision of ceremony-based interventions in their setting or to advocate for hiring such professionals for settings that lack an expert. Readers can also refer to the Association for Multicultural Counseling and Development’s Native American Concerns Group as a resource for Native counselors as well as for professionals counseling Native populations.

We reiterate that the perspectives around the use of and appropriation of Indigenous practices differ within and across Indigenous communities. Meade et al.’s (2022) Checklist for Counselor Practitioners reminds practitioners to remain vigilant to their own intersecting identities and to adhere to ethical practices in order to avoid harmful cultural appropriation. We attend to several of these recommendations by acknowledging and sharing our intersecting identities and offering guidance on ethically adapting the interventions to all clients.

Finally, going forward, when sharing these healing teachings, we encourage readers to maintain an awareness of the deep roots of these practices—stretching back and beyond seven generations—as a way to honor the ancestors who came before us and who have persisted in the face of great tragedy. We recognize the oral traditions that have allowed these teachings to be passed across the generations and ask readers to mindfully and respectfully pass on such teachings (orally or in writing) for seven generations more. In this way, future communities will know the healing practices that have aided Indigenous people for thousands of years, and they can adapt such practices in ways that heal and bring balance and wholeness to each unique community. Ultimately, we hope that counselor awareness of such factors will ensure that these teachings are shared in a mindful, loving, and honorable way.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Julie Smith-Yliniemi, PhD, NCC, LPCC, is an assistant professor and Director of Community Engaged Research at the University of North Dakota. Krista M. Malott, PhD, LPC, is a full professor at Villanova University. JoAnne Riegert, PhD, LPCC, is a mental health professional from the White Earth Indian Reservation. Susan F. Branco, PhD, NCC, BC-TMH, LPC, LCPC, ACE, is an associate professor at Palo Alto University. Correspondence may be addressed to Julie Smith-Yliniemi, 1301 N Columbia Rd, Suite E-2, Grand Forks, ND 58202,