Mar 9, 2020 | Volume 10 - Issue 1
Szu-Yu Chen, Dareen Basma, Jennie Ju, Kok-Mun Ng
Distance counselor education has expanded educational opportunities for diverse groups of students. To effectively train and support global students in counseling programs, the authors explore some unique challenges and opportunities that counselor educators may encounter when integrating technology in the multicultural counseling curriculum. The authors discuss pedagogical strategies that can enhance distance learners’ multicultural and social justice counseling competencies. Through an intersectional, social construction pedagogy, counselor educators can decolonize traditional multicultural counseling curricula and foster an international distance learning environment. Additional innovative approaches and resources, such as online multiculturally oriented student services, online student-centered multiculturally based organizations and workshops, and office hours for mentoring online international students and supporting distance learners’ needs, are described.
Keywords: distance counselor education, multicultural, international, online education, social justice
The growth in distance learning has led to an integration of technology in the curriculum over the past two decades (Allen et al., 2016). Counselor educators now can deliver distance learning courses internationally via videoconference systems, such as two-way audio and video software programs, for students to attend classes either synchronously or asynchronously (Snow et al., 2018), and many programs are moving toward distance education (Benshoff & Gibbons, 2011; Reicherzer et al., 2009). This shift in educational platforms allows both domestic and international students to receive counselor education and training remotely without having to commute or leave their home countries. For example, the counselor education program at the institution of the first three authors currently has over 300 students from the five most populous continents in various stages of counselor preparation. Distance education has expanded educational opportunities, targeted underserved groups of students, and given space for the formation of a more globally diverse student body (Columbaro, 2009; Gillies, 2008).
With the dramatic increase of diversity and attention to racism and other forms of human oppression in the United States, by the early 2000s, the issues of multiculturalism and social justice had come to the center of the counseling profession (Arredondo, 1999) and were recognized as two sides of the same coin (Ratts, 2011). As a result, multicultural education in the profession has been aimed at enhancing students’ awareness of cultural diversity and social justice in counseling relationships and implementation of advocacy competencies as they grapple with power, privilege, and oppression at the individual and systemic levels (Ratts et al., 2015). More recently, the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2015) has integrated a social justice and advocacy component into the framework of multicultural counseling competencies developed in 1992 by Sue, Arredondo, and McDavis, and highlighted the intersection of identities and the role power, privilege, and oppression play in the counseling relationship. The American Counseling Association (ACA; 2014) has also asserted that “counselor educators actively infuse multicultural/diversity competency in their training and supervision practices. They actively train students to gain awareness, knowledge, and skills in the competencies of multicultural practice” (F.11.c). Yet there seems to be a lack of attention in the literature to how online training programs can address global students’ multicultural and social justice counseling competencies given their non-traditional modes of learning delivery. With the emphasis on the helping relationship in the counseling profession, instructors who teach online face additional challenges because of a lack of in-person contact with students and may feel skeptical about the effectiveness of creating a safe and interactive space virtually, especially in relation to addressing challenging and complex topics (Hall et al., 2010).
It is worth noting that many counselor educators have not received formal pedagogical education and training on integrating technology into their curriculum and developing effective online courses (Cicco, 2012). This impacts educators’ feelings of discomfort or lack of preparedness when developing and delivering an online international multicultural counseling course, as well as facilitating discussions about multicultural issues and developing global students’ multicultural and social justice counseling training and competencies through an online medium. Consequently, when considering the development of an online multicultural counseling course, educators have to not only grapple with the complexity of designing a nuanced curriculum, but also negotiate delivery of a curriculum on an evolving learning platform in which international students who do not reside in the United States are integrated into the learning experience. As such, there are several opportunities and challenges to consider when facilitating multicultural and social justice counseling training on an online platform.
To effectively retain and support global students with diverse backgrounds and learning styles in distance counseling programs, herein we explore challenges and opportunities that counselor educators encounter when integrating technology in the multicultural and social justice counseling curriculum. Specifically, we want to discuss pedagogical strategies that we have found valuable to enhancing global learners’ multicultural and social justice counseling competencies. With the movement toward internationalizing the counseling profession, we believe that counselor educators can decolonize the traditional multicultural counseling curriculum and promote global students’ multicultural and social justice advocacy competencies through an intersectional and social construction online pedagogy and further cultivate an inclusive global learning environment. Additionally, we want to share innovative approaches counselor educators can use to support global students’ needs and enhance student retention in online counseling programs.
Internationalization of Multicultural Counseling Education in the Virtual Classroom
In international distance education, each student may differ in experiences of culture, cultural identities, and developmental level of multicultural counseling and social justice competencies. To address the increase in a globally diverse student body, the counseling profession is transforming from a Western-based to a global-based practice (Lorelle et al., 2012). Historically, textbooks and journal articles in the United States regarding diversity are typically monoculture in nature, focusing primarily on social identities such as race, ethnicity, gender, and social class that are commonly found in U.S.-based diversity discourse (Case, 2017). Students who live abroad may find these materials and foci disconnected from their contexts and not applicable to their practice. Consequently, these students can become less engaged in the learning experience.
The movement toward internationalizing the counseling profession over the past two decades has highlighted the need to extend multicultural competencies in ways that are relevant to mental health services beyond U.S. borders. Relatedly, Harley and Stansbury (2011) asserted that the multicultural movement needs to take place at two levels. On the first level, it requires our diligence to recognize, learn about, and appreciate the cultural diversity that exists on U.S. soil. The second level requires us to develop a global perspective that recognizes other cultures and sociopolitical forces that impact the lived experiences of people in other countries. Other scholars (e.g., Bhat & McMahon, 2016; Knight, 2004; Ng et al., 2012) also acknowledge these two dimensions in efforts to internationalize the counseling profession and emphasize the need to address the underdevelopment of cross-national multicultural competencies.
To date, systematic discourse related to international students’ learning experiences and perspectives in online training programs remains limited. To respond to this shift in distance counselor education, we propose adding a third dimension—the internationalization of counselor education—to the two levels of multicultural education proposed by Harley and Stansbury (2011). This third multicultural dimension requires a conceptualization of cultures and ways of being into a counseling curriculum that maintains a global and international perspective. Thus, learning is comprised of training activities and programs designed to prepare students to provide culturally responsive counseling services and advocacy that are simultaneously informed by both a local and global perspective.
Counselor educators are aware of the enormity of some of the challenges associated with the movement toward internationalizing counselor education. There have been encouraging but limited developments by the National Board for Certified Counselors (NBCC), ACA, and the Association for Counselor Education and Supervision (ACES) toward this cause. For example, to advance global mental health training and services, NBCC trains and collaborates with international counseling organizations to promote counselor professionalism as they develop their training requirements to the needs of their specific populations. ACA and ACES offer international counseling students and faculty interest networks in which counselors and counselor educators have space to facilitate discussions about challenges and solutions when providing global counseling services and preparing culturally responsive training curricula for students. However, the effect of these advocacies on internationalizing counselor education has not been widely evaluated yet. It appears that the counseling profession recognizes the benefits of this endeavor but is sorting out opportunities as well as resources necessary for implementation. We view contributing to the dialogue on internationalizing multicultural counseling training through an intersectional and social construction online pedagogy as a privilege.
Intersectional and Social Construction Online Pedagogy
An area of dissonance for international counseling students involves differences in cultural worldview. Marsella and Pederson (2004) posited that “Western psychology is rooted in an ideology of individualism, rationality, and empiricism that has little resonance in many of the more than 5,000 cultures found in today’s world” (p. 414). Ng and Smith’s study (2009) highlighted that international students, particularly those from non-Western nations, may struggle with integrating Eurocentric theories and concepts into the world they know. Their findings indicated that international trainees tend to experience more difficulties in areas related to clinical training and worldview conflicts in understanding mental health treatment compared to their domestic peers. International students can find that materials learned in Western-based counselor education have little relevance and applicability to the local demographics in which they work (Ng et al., 2012).
Ng and colleagues (2012) indicated that the goals of internationalizing counseling preparation curricula are to better equip students with required knowledge, awareness, skills, beliefs, and attitudes and to train students to become social change agents who actively resolve global mental health issues and inequalities. Herein lies the opportunity for counselor educators to intentionally search for appropriate pedagogies and to critically present readings and other media that help inculcate a multicultural perspective (Goodman et al., 2015) that is relevant to local contexts while appreciating a global perspective of lived experience and civilization. Social constructionism demands that we take a critical stance toward ways of understanding the world (Burr, 2015). It emphasizes the need to acknowledge the context and extent of subjectivity infused into what we know and invites us to critically examine the knowledge we have gained based on the culture and society surrounding the time period in which we exist. This lens helps us recognize that our knowledge is rooted in historical and cultural relativity and is socially created (Young & Collin, 2004). We need to be mindful that the knowledge created in the classroom has a social, cultural, and political impact on society. Thus, to internationalize distance counselor education, we consider it crucial for academics to recognize the social construction of the knowledge they carry and communicate in the virtual classroom setting, including the construction of their teaching methods for delivering knowledge (hooks, 1994).
Over 30 years ago, Crenshaw (1989) and hooks (1984) postulated that individuals hold a set of multiple and simultaneous identities. Crenshaw introduced the term intersectionality to describe individuals’ complex identities as opposed to categorical generalizations. Traditionally, multicultural courses tend to focus on one aspect of social identity and related oppressions separately from other social identities. The intersecting complexities among social identities and structural oppressions and privileges are often neglected. Collins (2000) provided a pedagogic conceptual framework to include both advantaged and disadvantaged identities. Although the intersectionality theory has been integrated within multiple disciplines, such as women’s studies, sociology, psychology, and law, instructors often do not incorporate intersectionality into diversity courses (Dill, 2009). Scholars, therefore, have called for an intersectional approach to transform higher education (Berger & Guidroz, 2009) and move beyond single-axis models.
To move beyond the individual and monocultural level, Case (2017) proposed that educators and students can address issues of culture, diversity, and advocacy in a diverse classroom through an intersectional pedagogy. Case emphasized an effective intersectional pedagogy that includes the following main tenets: Instructors (a) conceptualize intersectionality as a complex analysis of privileged and oppressed social identities; (b) teach intersectionality across a wide range of institutional oppression; (c) aim to explore invisible intersections; (d) include aspects of privilege and analyze power when teaching about intersectionality theory; (e) encourage students reflection about their own intersecting identities; (f) reflect the impact of educators’ social identities, biases, and assumptions on the learning community; (g) promote social action; (h) value the voice of marginalized students; and (i) infuse intersectional studies across the curriculum.
We believe that using an intersectional perspective that couples with a social construction perspective in multicultural education curriculum development can be valuable in the context of distance international counselor education, particularly in multicultural and international online education that contains a globally diverse student body. By implementing an intersectional and social construction pedagogical design in multicultural and social justice online counseling courses, instructors focus on examinations of social locations concerning privilege and oppression (Cole, 2009) and avoid overemphasizing any single characteristic of individual identities (Dill & Zambrana, 2009). This approach also provides instructors and worldwide students with a critical framework for analyzing structural power and oppression, examining the complexity of identities, and discussing action plans for empowerment and advocacy (Dill & Zambrana, 2009; Rios et al., 2017). Chan et al. (2018) also supported embodying an intersectional framework in developing multicultural and social justice courses within the counselor education curriculum. Counselor educators who teach beyond multicultural counseling knowledge and skills can enhance students’ critical thinking, case conceptualization skills (Chan et al., 2018), and cultural empathy (Davis, 2014) toward marginalized groups. Moreover, students are likely to see beyond the prescriptive counseling approach that addresses a limited set of cultural values (Chan et al., 2018). This perspective also can engage students in analyzing issues of privilege, power, and global oppression, and systematically reflecting on their own experiences.
Wise and Case (2013) noted that intersectional pedagogy is an inclusive approach that helps students reduce resistance when engaging in examining privileged and oppressed identities. This approach validates worldwide students’ various experiences and includes exploration of invisible interactions when discussing personal privilege. Considering that issues related to multiculturalism can evoke various emotions in the classroom, such as frustration, shame, guilt, and defensiveness, intersectional pedagogy provides an outlet to engage all students in this learning process (Banks et al., 2013; Wise & Case, 2013). Creating a safe space for learners in virtual classrooms to bravely experience and address these challenges requires thoughtful learning strategies. Accordingly, we illustrate intersectional and social construction pedagogy and strategies that counselor educators can consider integrating into online curricula to facilitate and assess global students’ multicultural and social justice counseling competencies, as well as provide supports for students in a diverse online learning environment.
Internationalizing an Online Multicultural Counseling Course
The master’s counseling program at the first three authors’ institution offers online or residential format options. The online counseling program provides domestic students and international students who live abroad opportunities to receive counselor education and training. Given the high ratio of international students and students with diverse backgrounds at the authors’ institutions, we believe that structuring the virtual multicultural counseling course from a global perspective and grounding it in a socially constructed, intersectional framework can facilitate student understanding and appreciation of multiculturalism, diversity, and social justice. Additionally, a successful integration of technology entails careful consideration of course content, the instructor’s role in the teaching and learning process, and students’ access to and comfort with the technology (Zhu et al., 2011). The following is an example of how an online master’s-level multicultural counseling course is delivered through an intersectional and social construction pedagogy that includes an international perspective, and how global students’ multicultural and social justice counseling competencies are assessed.
Our online multicultural counseling course focuses on creating a critical space where students can actively and transparently deconstruct their socially constructed knowledge, beliefs, and biases about differences and others. Rather than focusing on attending to specific cultural groups, which historically has been the norm for multicultural counseling classes, we focus on internationalizing the counseling profession and emphasize the need to address cross-national multicultural competencies. This course aims to develop students’ consciousness about the system of oppression that significantly impacts both dominant and marginalized groups’ well-being. Thus, the intersectional and MSJCC frameworks are used to structure our online multicultural counseling course in that knowledge, awareness, skills, and advocacy are at the core of each of the assignments, readings, and synchronized and asynchronized discussions.
Readings assigned for the class include both a clinical counseling textbook that attends to assessment, counseling, and diagnosis from a multicultural lens, and supplementary readings from the fields of multicultural and social justice education. Instructors use a learning management system to facilitate asynchronized online discussion board activities and readings and provide written, audio, or video feedback on students’ assignments. In addition to asynchronized learning, instructors and students meet in an interactive synchronized virtual classroom weekly for 1.5 hours over an 11-week course. Research shows that online models can be effective, with synchronous online programs being the most promising (Siemens et al., 2015). Students also have opportunities to do live multicultural role-plays in which instructors provide immediate feedback.
Instructors can face unique challenges in teaching and discussing some sensitive and controversial issues with students, which is an inherent part of multicultural and social justice advocacy training. It is recommended that educators foster positive relationships with students and establish a safe and trusting learning environment to engage students in constructive conversations and self-reflection (Brooks et al., 2017). Yet teaching a multicultural counseling class in a virtual setting can add additional barriers to fostering a safe learning environment. For example, in a virtual classroom, instructors are only able to see a student’s face amidst many other digital faces. As a result, some of the challenges of teaching this course virtually include effectively noting students’ nonverbal communications, sensing their emotive responses or reactions to the discussion content, and attending to topics that students may be having a difficult time speaking about in front of a large group. Moreover, many videoconferencing platforms allow students to engage in both private and public conversations with other students via chat boxes. Consequently, establishing virtual classroom ground rules is essential. Examples of ground rules and strategies that ensure a safe and respectful online learning environment may include: (a) turning on the camera to allow instructors and classmates to observe others’ nonverbal communication and address immediacy, (b) using headphones to respect classmates’ sharing, (c) turning off the private chat setting to avoid side conversations among students, and (d) providing options for students to share their thoughts and feelings in the chat box. It also is important to facilitate a discussion with students about ways to share their airtime with classmates in a virtual classroom and provide their classmates with understanding and support by observing virtual verbal and nonverbal communication.
To assess global students’ cross-national multicultural and social justice counseling competencies, we developed three major assignments and assessments for this class. Virtual classroom discussion is an essential assessment. To socially construct students’ knowledge of power, privilege, and oppression and reflect students’ learning experience, students are encouraged to actively share their reactions to the learning materials and how these materials are related to personal experience and counseling implications in their countries. Students’ level of participation and self- and other-awareness can be assessed in breakout rooms as well as in a large discussion group. However, considering students may have various ways to engage with the materials, instructors encourage students who struggle with verbally participating in the virtual classroom to collaboratively identify alternative concrete methods to evidence participation with instructors, such as reflective journals.
The second assignment is a group presentation that attends to manifestations of oppression within systems. The purpose of this assignment is to increase global students’ knowledge and understanding of how racism and oppression are produced and reproduced across generations, institutions, and countries. Although oppression impacts all institutions, this project encourages student groups to focus on dynamics in eight mutually reinforcing areas: housing, education, immigration, the labor market, the criminal justice system, the media, politics, and health care. Students are also asked to create a vignette based on the presented topic and facilitate role-plays. This experiential activity facilitates students’ understanding of intersecting identities in the counseling relationship and enhances cross-national cultural empathy by attending to clients’ experience. This assignment increases global students’ awareness of the complexity of mental health issues and transgenerational trauma that can ensue as a result of systematic oppression. It also challenges unconscious biases and beliefs that students may have around marginalized populations being impacted by these systems in their countries.
The last major assignment, the resistance project, is a quarter-long individual project and targets an increase in awareness of self. For counselors, awareness of self in the context of culture is one of the more challenging parts of our work and is a process that is ongoing and constant. This assignment focuses on attending to both conscious and unconscious biases to groups of people. Initially, students are asked to identify three specific cultural groups to which they identify resistance in their countries. Students can express significant struggles around this part of the assignment indicating feelings of guilt, shame, judgment of self, denial of bias, and confusion around their biases. Normalizing and validating these feelings is crucial in fostering a space for critical reflection, as well as providing non-judgmental feedback regarding their initial explorations. The next part of our resistance project asks students to select one of the three identified groups to explore in greater detail throughout the quarter. Students are asked to begin looking for numerous academic sources, social media sources, and immersion experiences that they can engage in throughout the quarter that would encourage them to very directly examine their biases. Significant levels of discomfort appear here among students, particularly regarding individual and group experiences they have engaged in. Students are asked to reflect on and lean into that discomfort in order to better understand it. In addition, they are asked to critically examine their internal process and connect their reactions back to their identified resistance.
Supporting Globally Diverse Students Outside of the Virtual Classroom
As counselor education focuses on further developing multicultural online pedagogy, there is a need to evaluate programmatic effectiveness in demonstrating sensitivity to the concerns of globally diverse student populations. Just as it is critical for instructors to attend to creating culturally relevant curricula, program administrators need an understanding of the challenges that characterize distance students from global communities and be intentional about addressing some of those challenges. This section discusses ways that institutions can walk the walk in their application of the principles espoused in curricular pedagogy by creating an environment in which worldwide students feel welcomed and supported.
According to the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2016), approximately 32% of students enrolled in counseling programs are from racially diverse heritages. Kung (2017) reported that “in the 2015–2016 academic year, over 1 million international students were reported as studying at U.S. colleges and universities” (p. 479). Currently, there are no official statistics on the number of students enrolled in distance counselor education programs by race, ethnicity, or country of residence. Although specific data is lacking, the statistics above provide an indication of the potentially significant presence of an international student population in distance learning programs. It is critical to examine the criteria for determining a university’s effectiveness in supporting worldwide students outside the virtual classroom. “Exemplary institutions” in recruiting and retaining minority students of color have the characteristic of being successful in increasing enrollment of minority students of color and retaining students through to graduation (Rogers & Molina, 2006). While an institution’s effectiveness in providing needed support does not necessarily equate to its ability to retain students and achieve high graduation rates, one can surmise that some unsupported individuals will choose to drop out. Although there are numerous ways that an institution can provide a sustainable environment for global students outside of the virtual classroom, we will focus on six key approaches, namely technology, field experience, multiculturally oriented student support services, mentorship, student-centered multiculturally based organizations, and multiculturally based events and workshops.
Technology
In an online education format, access to reliable technology is imperative to students’ success in the program. Level of access to proper computing devices or to the internet by various social identity groups can create a digital divide, which disadvantages one group over another (Bolt & Crawford, 2000; Clark & Gorski, 2001). International students from developing and underdeveloped nations experience frequent disruption when accessing virtual class meetings and course contents because of political causes or technological deficiency in their regions. For example, a student from the Central African Republic is sometimes unable to log in to class meetings when she is unable to turn on generators in a remote village for fear that this could alert guerilla gangs and prompt additional warfare. A student in Peru who does her internship in rural areas is unable to submit her assignments on time because of a lack of internet access. Students in Beijing experience tight internet firewalls preventing them from accessing sites such as Google, Gmail, and YouTube; this problem intensifies during the week of the governmental National People’s Congress annual meetings. Therefore, Clark and Gorski (2001) urged educators to critically analyze the use of the internet as an educational medium and examine ways technology “serves to further identify social, cultural, educational ‘haves’ and ‘have-nots’” in educational settings (p. 39).
As a partial solution to the problem of Chinese students’ difficulty in accessing web-based course content, our institution has purchased a VPN with a reliable server based in Hong Kong. Given that there are approximately 30-plus China-based students in matriculation at our institution each year, this becomes an institutional business decision. Additionally, academic advisors encourage Chinese students to approach their instructors at the beginning of each term to discuss a plan for accessing course material and timely submission of assignments. Instructors and administrators also have a responsibility to be proactive in collaborating with these students in finding alternatives by inquiring and learning about students’ potential challenges regarding technology. Educators need to discuss a plan to accommodate students’ needs within reason.
Field Experience
Issues with cultural worldviews and contextual differences become prominent during students’ process of searching for practicum opportunities and experiences of participating in clinical training in their home countries. Specifically, students and educators have encountered these obstacles in three aspects. First, the philosophical understanding of the purpose of internship and supervision of interns are different. Next, the integration of Eurocentric theories and implications with their clients’ cases might not be applicable. Last, there is a lack of regulatory infrastructure to guide and oversee the helping profession. A case example is students in China, where many native organizations expect to benefit financially from placement of interns. They do not seem to consider that student interns are capable of counseling clients under proper supervision. Thus, many mental health agencies do not permit trainees to provide counseling before graduation. Supervision is considered more of a business arrangement than a supervisory and mentoring relationship.
The first three authors’ institution offers an online practicum course each academic term for students residing and doing an internship overseas. This strategy aims to provide a weekly forum where students receive additional support in applying counseling concepts and approaches to their cultural context. This also serves as a supportive distance environment in which instructors and students collaboratively conceptualize and explore treatment approaches that are culturally and contextually relevant to their client populations. The second purpose for the dedicated practicum course is to navigate students’ dual legal and ethical milieus. A lack of regulatory oversight for the counseling profession in China and other countries has created legal and ethical challenges for intern placements. This reality has added confusion and inconsistencies in what is permissible based on U.S. regulatory and accreditation boards, as well as common practices in students’ home countries.
Multiculturally Oriented Student Support Services
Student services offices in institutions generally provide a wide range of services. To meet distance learners’ needs, it is necessary to implement some student services via an online format. First, institutions provide tutoring services to help improve the English writing skills of speakers of other languages. Students from immigrant and refugee communities as well as some international students fall into this category. Students from non–English-speaking countries enrolled in counseling and related disciplines tend to experience challenges related to English proficiency (Ng, 2006). As such, one-on-one tutoring is available at our institution for students who struggle with editing and American Psychological Association (APA) style writing. This service is critical because many foreign countries do not utilize APA format, and therefore international students do not have familiarity with this style of writing.
Second, tutors at the first three authors’ institution are doctoral students from the psychology department who have opportunities to provide services for students from marginalized communities. Through collaboration between the office of student services and the counseling department, this strategy serves as an excellent service learning experience in working with individuals from globally diverse communities. With an intentional design, the writing skills tutoring service complements classroom pedagogy on multiculturalism by presenting experience with real-world problems, providing opportunities for students to grapple with their beliefs and biases and involve action-oriented solutions.
Mentorship
Mentorship is a substantive resource for supporting worldwide students from diverse communities. Rogers and Molina’s (2006) study found that nine of the 11 psychology programs and departments that were successful at recruiting and retaining students of color had established mentoring programs. In general, ethnic minority students tend to prefer and report more satisfaction with mentors who share a similar racial background (Chan et al., 2015). Figueroa and Rodriguez (2015) posited that mentoring is social justice work that “is a racially and culturally mediated experience instead of a race-neutral, objective interaction” (p. 23). It is an unfortunate reality of counselor education that there exists a significant underrepresentation of minority faculty. The disparity is prominent among Hispanic/Latinx demographics, where student enrollment (8.5%) is almost double the number of faculty (4.7%) from Hispanic/Latinx heritage among CACREP-accredited programs (CACREP, 2016). Black student enrollment is 18.3% and only 12.7% of the total faculty members in CACREP-accredited programs are Black. Chan and colleagues (2015) suggested that in the absence of same-race mentors, the presence of cross-cultural support in the form of multiculturally sensitive mentoring can be beneficial and even critical to the success of international students from diverse ethnic backgrounds.
To support the unique needs of international students in the residential and online cohort, the first author designed weekly office hours for online international students to provide advising and mentorship. The virtual office hours aim to provide a space where students and their peers can not only share challenges, struggles, and concerns about their learning experiences in the program, but also support each other. Additionally, the third author and a colleague have served as international and distance directors of clinical training, which can provide specific mentorship regarding practicum experiences for international students.
Student-Centered Multiculturally Based Organizations
The presence of student-centered organizations is another effective way to provide a sense of belonging and an environment that facilitates peer support among those with shared interests on campus (Rogers & Molina, 2006). Some culturally and social justice–based organizations active at the first three authors’ institution serve this purpose well. One of the university-wide organizations, Diaspora, serves students, staff, and faculty in the community who are interested in learning about and advocating for mental health issues relevant to the Black diaspora. Members of Diaspora aim to raise the community’s awareness of psychosocial and environmental factors that impact the Black community’s well-being. Another organization at our institution, the Latinx Task Force, was formed with a Unity grant award from our university president’s office for faculty, students, and staff to join forces across programs to implement projects that serve the Latinx/Hispanic community on and off campus (Latinx Task Force, n.d.). Furthermore, the Latinx Task Force initiated a Spanish clinician course that introduces students to essential clinical vocabulary, clinical skills, and cultural considerations required to work with Spanish-speaking clients. The Latinx Task Force also conducts a mentorship series that brings Latinx professionals in the field to offer career mentoring support to students.
Multiculturally Based Events and Workshops
Delivery of multicultural education and inclusion of diverse students should not be limited to the virtual classroom. Institutions can be intentional in hosting events and workshops that complement and reinforce classroom pedagogy on multiculturalism while actively supporting individuals from various communities. In recent years, the first three authors’ institution has hosted a rich array of workshops with topics such as “LGBT Psychology,” “Asian Americans and Suicide,” and “Risk and Resiliency Among Newcomer Immigrant Adolescents.” In addition, a “Women of Color Leaders in Psychology” event celebrates the contributions of women of color in psychology and social justice. When the workshops occur in our physical venue, they are often made accessible via videoconferencing platforms and are recorded for later viewing at a convenient time or by those in a different time zone.
Multicultural counseling education and support of the globally diverse student population are ongoing, interrelated endeavors that extend beyond the virtual classroom walls. Intentionality in hosting extracurricular events and creating a supportive environment are ways an institution makes multicultural pedagogical concepts come alive for students. They also are a way of sustaining worldwide students to graduate with a strong foundation from which to launch their counseling careers.
Discussion and Future Direction for Research
The multicultural counseling course in counselor education programs is one of the critical spaces where global students actively engage with the core components of the MSJCC. Given the complexity of teaching this course in a distance learning format, it is crucial for educators to thoroughly think through the varying foundational components, including structure, content, pedagogy, and the various challenges that can arise in virtual classrooms.
We have used our experiences in integrating technology into the multicultural counseling curriculum to discuss online pedagogical framework and virtual course development while exploring unique opportunities, challenges, and solutions. Given the movement of internationalizing the counseling profession, we postulate that multicultural counseling distance education must extend beyond U.S. borders, class meetings, and the curriculum. It is critical that counselor educators provide multicultural and social justice counseling training through systemic modeling by internationalizing the curriculum and training environment and collaborating with training programs and institutions to advocate for, attend to, and support the needs of globally diverse students in distance education.
Currently, the literature on training and online delivery of international multicultural counseling education remains limited. To explore the best online pedagogy for internationalizing multicultural counseling education, more research is needed. As such, future research could focus on examining the outcome of incorporating intersectional and social construction approaches in online counseling curricula, including global students’ multicultural and social justice counseling competencies in their home countries. Future studies also might investigate different course structures and online pedagogy to understand the best methods for multicultural distance counselor education. There is a need to explore counselor educators’ experiences of conducting online multicultural counseling education with globally diverse student populations and their perspectives on receiving multicultural counseling distance education. Supports needed for global students in the online environment may differ from traditional students. Therefore, research on how the academic support of counseling programs and institutions impacts global students’ counseling practice and retention in distance counselor education can be valuable.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Allen, I. E., Seaman, J., Poulin, R., & Straut, T. T. (2016). Online report card: Tracking online education in the United
States. https://onlinelearningsurvey.com/reports/onlinereportcard.pdf
American Counseling Association. (2014). 2014 ACA code of ethics.
Arredondo, P. (1999). Multicultural counseling competencies as tools to address oppression and racism. Journal of
Counseling & Development, 77, 102–108. https://doi.org/10.1002/j.1556-6676.1999.tb02427.x
Banks, C. A., Pliner, S. M., & Hopkins, M. B. (2013). Intersectionality and paradigms of privilege: Teaching for social
change. In K. A. Case (Ed.), Deconstructing privilege: Teaching and learning as allies in the classroom (pp. 102–
114). Routledge.
Berger, M. T., & Guidroz, K. (Eds.). (2009). The intersectional approach: Transforming the academy through race, class,
and gender. University of North Carolina Press.
Benshoff, J. M., & Gibbons, M. M. (2011). Bringing life to e-learning: Incorporating a synchronous approach to online teaching in counselor education. The Professional Counselor, 1, 21–28. https://doi.org/10.15241/jmb.1.1.21
Bhat, C. S., & McMahon, M. (2016). Internationalization at home for counseling students: Utilizing technology to expand
global and multicultural horizons. International Journal for the Advancement of Counselling, 38, 319–329.
https://doi.org/10.1007/s10447-016-9274-7
Bolt, D. B., & Crawford, R. A. K. (2000). Digital divide: Computers and our children’s future. Bantam.
Brooks, M., Alston, G. D., Townsend, C. B., & Bryan, M. (2017). Creating a healthy classroom environment in
multicultural counseling courses. Journal of Human Services: Training, Research, and Practice, 2, 1–24.
Burr, V. (2015). Social constructionism. In J. Wright (Ed.), International encyclopedia of the social & behavioral sciences (2nd ed., pp. 222–227). Elsevier. https://doi.org/10.1016/B978-0-08-097086-8.24049-X
Case, K. A. (2017). Toward an intersectional pedagogy model: Engaged learning for social justice. In K. A. Case (Ed.), Intersectional pedagogy: Complicating identity and social justice (pp. 1–24). Routledge.
Chan, A. W., Yeh, C. J., & Krumboltz, J. D. (2015). Mentoring ethnic minority counseling and clinical psychology students: A multicultural, ecological, and relational model. Journal of Counseling Psychology, 62, 592–607. https://doi.org/10.1037/cou0000079
Chan, C. D., Cor, D. N., & Band, M. P. (2018). Privilege and oppression in counselor education: An intersectionality framework. Journal of Multicultural Counseling and Development, 46, 58–73. https://doi.org/10.1002/jmcd.12092
Cicco, G. (2012). Counseling instruction in the online classroom: A survey of student and faculty perceptions. i- manager’s Journal on School Educational Technology, 8(2), 1–10. https://doi.org/10.26634/jsch.8.2.2022
Clark, C., & Gorski, P. (2001). Multicultural education and the digital divide: Focus on race, language, socioeconomic class, sex, and disability. Multicultural Perspectives, 3(3), 39–44. https://doi.org/10.1207/S15327892MCP0303_7
Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64, 170–180. http://doi.org/10.1037/a0014564
Collins, P. H. (2000). Black feminist thought: Knowledge, consciousness, and the politics of empowerment (1st ed.).
Routledge.
Columbaro, N. L. (2009). E-mentoring possibilities for online doctoral students: A literature review. Adult Learning, 20(3–4), 9–15. https://doi.org/10.1177/104515950902000305
Council for Accreditation of Counseling and Related Educational Programs. (2016). CACREP annual report 2015. http://www.cacrep.org/wp-content/uploads/2019/05/CACREP-2015-Annual-Report.pdf
Crenshaw, K. W. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics. University of Chicago Legal Forum, 1989, 139–168. https://chicagounbound.uchicago.edu/cgi/viewcontent.cgi?article=1052&context=uclf
Davis, D. N. (2014). Complexity overlooked: Enhancing cultural competency in the White lesbian counseling trainee through education and supervision. Journal of Lesbian Studies, 18, 192–201. https://doi.org/10.1080/10894160.2014.849166
Dill, B. T. (2009). Intersections, identities, and inequalities in higher education. In B. T. Dill & R. E. Zambrana (Eds.), Emerging intersections: Race, class, and gender in theory, policy, and practice (pp. 229–252). Rutgers University Press.
Dill, B. T., & Zambrana, R. E. (2009). Critical thinking about inequality: An emerging lens. In B. T. Dill & R. E. Zambrana (Eds.), Emerging intersections: Race, class, and gender in theory, policy, and practice (pp. 1–21). Rutgers University Press.
Figueroa, J. L., & Rodriguez, G. M. (2015). Critical mentoring practices to support diverse students in higher education: Chicana/Latina faculty perspectives. New Directions for Higher Education, 171, 23–33. https://doi.org/10.1002/he.20139
Gillies, D. (2008). Student perspectives on videoconferencing in teacher education at a distance. Distance Education, 29, 107–118. https://doi.org/10.1080/01587910802004878
Goodman R. D., Williams, J. M., Chung, R. C.-Y., Talleyrand, R. M., Douglass, A. M., McMahon, H. G., & Bemak, F. (2015). Decolonizing traditional pedagogies and practices in counseling and psychology education: A move towards social justice and action. In R. D. Goodman & P. C. Gorski (Eds.), Decolonizing “multicultural” counseling through social justice (pp. 147–164). Springer.
Hall, B. S., Nielsen, R. C., Nelson, J. R., & Buchholz, C. E. (2010). A humanistic framework for distance education. Journal of Humanistic Counseling, Education and Development, 49, 45–57. https://doi.org/10.1002/j.2161-1939.2010.tb00086.x
Harley, D. A., & Stansbury, K. L. (2011). Diversity counseling with African Americans. In E. Mpofu (Ed.), Counseling people of African ancestry (pp. 193–208). Cambridge University Press.
hooks, b. (1984). Feminist theory: From margin to center. South End Press.
hooks, b. (1994). Teaching to transgress: Education as the practice of freedom. Routledge.
Knight, J. (2004). Internationalization remodeled: Definition, approaches, and rationales. Journal of Studies in International Education, 8, 5–31. https://doi.org/10.1177/1028315303260832
Kung, M. (2017). Methods and strategies for working with international students learning online in the U.S. TechTrends: Linking Research and Practice to Improve Learning, 61, 479–485.
Latinx Task Force. (n.d.). Welcome to Palo Alto University Latinx task force. https://www.ltf.paloaltou.edu
Lorelle, S., Byrd, R. J., & Crockett, S. (2012). Globalization and counseling: Professional issues for counselors. The Professional Counselor, 2, 115–123. https://doi.org/10.15241/sll.2.2.115
Marsella, A. J., & Pedersen, P. (2004). Internationalizing the counseling psychology curriculum: Toward new values, competencies, and directions. Counselling Psychology Quarterly, 17, 413–423. https://doi.org/10.1080.09515070412331331246
Ng, K.-M. (2006). Counselor educators’ perceptions of and experiences with international students. International Journal for the Advancement of Counselling, 28, 1–19. https://doi.org/10.1007/s10447-005-8492-1
Ng, K.-M., Choudhuri, D. D., Noonan, B. M., & Ceballos, P. (2012). An internationalization competency checklist for American counseling training programs. International Journal for the Advancement of Counselling, 34, 19–38. https://doi.org/10.1007/s10447-011-9141-5
Ng, K.-M., & Smith, S. D. (2009). Perceptions and experiences of international trainees in counseling and related programs. International Journal for the Advancement of Counselling, 31, 57–70.
https://doi.org/10.1007/s10447-008-9068-7
Ratts, M. J. (2011). Multiculturalism and social justice: Two sides of the same coin. Journal of Multicultural Counseling and Development, 39, 24–37. https://doi.org/10.1002/j.2161-1912.2011.tb00137.x
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2015). Multicultural and social justice counseling competencies. https://www.counseling.org/docs/default-source/competencies/multicultural-and-social-justice-counseling-competencies.pdf?sfvrsn=20
Reicherzer, S., Dixon-Saxon, S., & Trippany, R. (2009). Quality counselor training in a distance environment. Counseling Today, 51(12), 46–47.
Rios, D., Bowling, M., & Harris, J. (2017). Decentering student “uniqueness” in lessons about intersectionality. In K. A. Case (Ed.), Intersectionality pedagogy: Complicating identity and social justice (pp. 194–213). Routledge.
Rogers, M. R., & Molina, L. E. (2006). Exemplary efforts in psychology to recruit and retain graduate students of color. American Psychologist, 61, 143–156.https://doi.org/10.1037/0003-066X.61.2.143
Siemens, G., Gašević, D., & Dawson, S. (2015). Preparing for the digital university: A review of the history and current state of distance, blended, and online learning. Massive Open Online Course Research Initiative.
Snow, W. H., Lamar, M. R., Hinkle, J. S., & Speciale, M. (2018). Current practices in online counselor education. The Professional Counselor, 8, 131–145. https://doi.org/10.15241/whs.8.2.131
Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(2), 64–88. https://doi.org/10.1002/j.2161-1912.1992.tb00563.x
Wise, T., Case, K. A. (2013). Pedagogy for the privileged: Addressing inequality and injustice without shame or blame. In K. A. Case (Ed.), Deconstructing privilege: Teaching and learning as allies in the classroom (pp. 17–33). Routledge.
Young, R., & Collin, A. (2004). Introduction: Constructivism and social constructionism in the career field. Journal of Vocational Behavior, 64, 373–388. https://doi.org/10.1016/j.jvb.2003.12.005
Zhu, E., Kaplan, M., & Dershimer, C. (2011). Engaging faculty in effective use of instructional technology. In C. E. Cook
& M. Kaplan (Eds.), Advancing the culture of teaching on campus: How a teaching center can make a difference (pp. 151–166). Stylus Publishing.
Szu-Yu Chen, PhD, NCC, LPC, RPT, is an assistant professor at Palo Alto University. Dareen Basma, PhD, LPC-MHSP, is a core faculty member at Palo Alto University. Jennie Ju, PhD, LPC, is a core faculty member at Palo Alto University. Kok-Mun Ng, PhD, NCC, ACS, LPC, is a professor at Oregon State University. Correspondence can be mailed to Szu-Yu Chen, 1791 Arastradero Drive, Palo Alto, CA 94304, dchen@paloaltou.edu.
Mar 26, 2019 | Volume 9 - Issue 1
Loni Crumb, Natoya Haskins, Shanita Brown
This phenomenological study explored the experiences of 15 professional counselors who work with clients living in impoverished communities in rural America. Researchers used individual semi-structured interviews to gather data and identified four themes that represented the counselors’ experiences using the Multicultural and Social Justice Counseling Competencies as the conceptual framework to identify the incorporation of social justice and advocacy-oriented counseling practices. The themes representing the counselors’ experiences were: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The counselors’ experiences convey the need to alter traditional counseling session delivery formats, practices, and roles to account for clients’ life experiences and contextual factors that influence mental health care in rural, impoverished communities. Approaches that counselors use to engage in social justice advocacy with and on behalf of rural, impoverished clients are discussed.
Keywords: rural, impoverished communities, advocacy, social justice, multicultural
Approximately 41.3 million Americans live in poverty (Semega, Fontenot, & Kollar, 2017) and consistently face multiple chronic stressors (e.g., food and housing insecurities, social isolation, inability to access adequate physical and mental health care) that impact their quality of life (Fifield & Oliver, 2016; Hill, Cantrell, Edwards, & Dalton, 2016). Nevertheless, the scope of mental health concerns of individuals and families residing in persistently poor, rural communities remains under-researched and overlooked by the public, scholars, and policymakers (Tickamyer, Sherman, & Warlick, 2017). Furthermore, advocacy efforts that foster social and economic justice and support the mental health of persons living in rural poverty warrant further advancement.
Scarce availability of mental health care services, ineffective modes of treatment and interventions, and mistrust of mental health care professionals contribute to the low utilization of mental health care services among persons living in rural poverty (Fifield & Oliver, 2016; Imig, 2014). Consequently, there are few evidence-supported culturally relevant mental health interventions tailored to address the specific needs of people living in rural poverty, particularly with a focus on social justice advocacy (Bradley, Werth, Hastings, & Pierce, 2012; Imig, 2014). Counselors practicing in rural, impoverished areas must be prepared to address systems of oppression, discrimination, marginalized statuses, and the impact these factors have on counseling services and clients’ well-being (Grimes, Haskins, & Paisley, 2013; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016). Moreover, according to the 2016 Code of Ethics from the National Board for Certified Counselors (NBCC) and the 2014 ACA Code of Ethics from the American Counseling Association, counselors are expected to take actions to prevent harm and help eradicate the social structures and processes that reproduce mental health disparities in vulnerable communities (ACA, 2014; NBCC, 2016). In recognition of this expectation, the Multicultural and Social Justice Counseling Competencies (MSJCCs) were developed to guide mental health counselors toward practicing culturally responsive counseling and incorporating social justice advocacy initiatives into the process (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015). Thus, the MSJCCs’ framework undergirds our examination of counselors’ experiences and clinical practices that support the mental health and well-being of clients living in poverty in rural America.
Understanding Rural Poverty and Mental Health Care
When discussing literature pertaining to rural poverty, it is important to first define relevant terms. The U.S. Department of Agriculture’s Economic Research Service (USDA; 2017) defines poverty as having an income below the federally determined poverty threshold. For example, the 2017 poverty threshold for an individual under 65 years of age was $12,752, and the poverty threshold was $16,895 for a household with two adults under age 65, with one child under 18 years of age (USDA, 2017). Persistently poor areas are defined as communities in which 20% or more of the population has lived below the poverty threshold over the last 30 years with low populations (fewer than 2,500 people; USDA, 2017). The majority of persistently poor communities are located in rural Southern regions of the United States (USDA, 2017). Rural communities that experience persistent poverty have had little diversification of employment, are underserved by mental health care providers, and lack affordable housing and economic development (Tickamyer et al., 2017). For the purposes of this study, the definitions described above were used to define and understand rurality and poverty.
Mental Health Care in Rural, Impoverished America
An abundance of literature exists that identifies concerns related to mental health care for people who live in rural poverty (Reed & Smith, 2014; Tickamyer et al., 2017). For example, Snell-Rood and colleagues (2017) conducted a qualitative study that explored the sociocultural factors that influence treatment-seeking behavior among rural, low-income women. Participants reported that the quality of counseling in their rural settings was unsatisfactory because of counselors recommending coping strategies that were “inconsistent” with daily routines and beliefs (Snell-Rood et al., 2017). Alang (2015) conducted a quantitative study that investigated the sociodemographic disparities of unmet health care needs and found that men in rural areas were more likely to forgo mental health treatment because of gender stereotypes. Specifically, Alang found that men were encouraged to ignore mental health concerns and avoid help-seeking behaviors. Furthermore, children living in rural poverty have fewer protective resources and less access to services that can address their needs and are subsequently exposed to increased violence, hunger, and poor health (Curtin, Schweitzer, Tuxbury, & D’Aoust, 2016).
Adults and children living in rural poverty often have lower mental health literacy (i.e., the ability to recognize a mental health concern when it arises and how to cope with one when it occurs; Rural Health Information Hub, 2017). For example, researchers (Pillay, Gibson, Lu, & Fulton, 2018) examined the experiences of the rural Appalachian clients who utilized mental health services and found that clients were ambivalent about diagnoses and suspicious when providers suggested psychotropic medications to support treatment. Likewise, Haynes et al. (2017) conducted focus group interviews that included persons living with a mental illness, health care providers, and clergy living in rural, impoverished communities in the Southern United States, and reported a general lack of awareness about mental illness. The researchers suggested that individuals have less knowledge of what mental illness looks like, how to recognize it, and how to identify warning signs of crises in Southern rural, impoverished communities (Haynes et al., 2017). As a result of less mental health literacy, people in rural low-income communities may delay seeking counseling treatment until symptoms have intensified and face a greater likelihood of hospitalization related to mental health challenges (Neese, Abraham, & Buckwalter, 1999; Stewart, Jameson, & Curtin, 2015).
Counselor Competence and Poverty Beliefs
Researchers have indicated that mental health professionals practicing in rural, economically deprived areas are not properly trained to address the multiple needs of this population (Bradley et al., 2012; Fifield & Oliver, 2016; Grimes, Haskins, Bergin, & Tribble, 2015). Fifield and Oliver (2016) surveyed 107 rural clinicians, exploring their perceived training-related needs and the pros and cons of rural counseling practice. The researchers found that many counselors did not receive adequate training to work with the population they served, and the counselors did not feel properly prepared to address the host of issues that may arise in their rural practice.
Moreover, mental health professionals continue to hold negative poverty beliefs and social class biases (Bray & Schommer-Aikins, 2015; Grimes et al., 2015; Smith, Li, Dykema, Hamlet, & Shellman, 2013) that negatively impact the quality of services provided. Researchers have shown that some counselors are less willing to work with clients of lower socioeconomic statuses because of communication barriers, having less knowledge of and exposure to the poverty culture, and possessing negative stereotypes about poor, rural populations (e.g., uneducated, dirty, violent, lazy; Bray & Schommer-Aikins, 2015; Smith et al., 2013). Consequently, clients from lower socioeconomic statuses receive more serious mental health diagnoses or are often misdiagnosed, which may be attributed to the professional’s negative biases, as well as lack of adequate multicultural training (Clark, Moe, & Hays, 2017).
Multicultural Counseling Competence
Increased training in multicultural counseling competence has a significant impact on counselors’ poverty beliefs (Clark et al., 2017; Toporek & Pope-Davis, 2005). In a quantitative study examining the relationship between multicultural counseling competence and poverty beliefs using a sample of 251 counselors, Clark et al. (2017) identified that higher levels of multicultural competence and training decreased poverty biases and helped counselors to understand the structural causes of poverty. Similarly, Bray and Schommer-Aikins’ (2015) survey of 513 school counselors found that counselors with training through multicultural courses recognized the external factors that contribute to poverty; however, the study did not focus on effective interventions that counselors utilized with this population.
Although these studies identified that multicultural knowledge and awareness increased counselors’ understanding of the culture of poverty, more research is necessary to explore how this information is applied to provide counseling professionals with evidence-based illustrations of social justice advocacy in practice (Ratts & Greenleaf, 2018). Accordingly, the purpose of this study was to (1) develop an understanding of the experiences of mental health counselors who work in rural, persistently poor communities and (2) identify ways that counselors incorporate social justice advocacy into counseling using the lens of the MSJCCs. The research question guiding this study was: What are the lived experiences of mental health counselors working in rural, persistently poor communities?
Conceptual Framework
The MSJCCs, a revision of the Multicultural Counseling Competencies (Sue, Arredondo, & McDavis, 1992), offer a framework to incorporate culturally responsive counseling and social justice advocacy initiatives into counseling practices, research, and curricula (Ratts et al., 2015). Established in a socioecological framework, the MSJCCs help counselors examine personal biases, skills, and the dynamics of marginalized and privileged identities in relation to multiculturalism and social justice counseling competence and advocacy. Additionally, the MSJCCs assist counselors in acknowledging clients’ intersecting identities, which bestow various aspects of power, privilege, and oppression that may impact their growth and development.
The developmental domains of the MSJCCs—(a) counselor self-awareness, (b) client worldview,
(c) counseling relationship, and (d) counseling and advocacy interventions—help counselors understand social inequalities that are perpetuated by institutional oppression in order to better serve historically marginalized clients (Ratts et al., 2015). Likewise, aspirational competencies espoused in the MSJCCs—namely (a) attitudes and beliefs, (b) knowledge, (c) skills, and (d) action—serve as objectives for multicultural, social justice competence and advocacy interventions (Ratts et al., 2015, 2016). Although the MSJCCs have been identified as goals for all counselors, limited research exists that illuminates the MSJCCs as a framework for understanding social justice applications within rural, high-poverty areas. Therefore, in considering the four distinct developmental domains and aspirational competencies, the authors utilized the MSJCCs as a basis to understand counselors’ experiences in rural, high-poverty communities. For the purposes of this study, social justice advocacy is understood as interventions and skills that counselors utilize to address inequitable social, political, or economic conditions that impede the personal and social development of individuals, families, and communities (Lewis, Ratts, Paladino,
& Toporek, 2011).
Method
University institutional review board approval was granted for this study. We used a descriptive phenomenological qualitative research design, which is suitable for scholars to examine the lived experiences of individuals within their sociocultural context (Creswell & Creswell, 2018; Giorgi, 2009). In descriptive phenomenological studies, researchers use participants’ responses to describe common experiences that capture the “intentionality” (perception, thought, memory, imagination, and emotion) related to the phenomenon under study (Giorgi, 2009). Furthermore, using qualitative research methods allows researchers to provide an in-depth exploration of lived experiences and helps multiculturally competent counselor–researchers highlight gaps in counseling literature and inequities in counseling practices in order to advocate for systemic changes in the counseling profession (Hays & Singh, 2012; Ratts et al., 2015).
Role of the Researchers
We recognize the possibility of bias in empirical research and acknowledge our social locations, identities, and professional experiences in relation to the current research study. All three authors identify as African American women from low socioeconomic backgrounds. We identify as counselor–advocate–scholars (Ratts & Greenleaf, 2018) and incorporate advocacy for underserved populations into our counseling practices, research, supervision, and teaching (Ratts et al., 2015). We bracketed personal thoughts and feelings and discussed biases that may possibly influence the data throughout the study. For example, the frequent criminalization of poverty was a difficult finding to discuss with the participants and we met to express our thoughts regarding this finding. A graduate research assistant (middle class, European American female) was selected to assist in data collection and analysis to increase objectivity in the research process, as she was less familiar with underserved populations, but trained extensively in qualitative research techniques. We acknowledge that we used the developmental domains and aspirational competencies espoused in the MSJCCs to conceptualize this research study, analyze the data, and present the findings and implications to foster positive changes in mental health care for people living in rural, poor communities. Furthermore, it is our view that the data did not emerge independently, but that as researchers we used a rigorous process such as the use of thick descriptions to analyze and identify nuances and commonalities in the data while also accounting for our assumptions and biases (Hays & Singh, 2012; Lincoln & Guba, 1986). Our position as counselor–advocate–scholars helps to bring expertise to our scholarship and practices (Hays & Singh, 2012; Ratts & Greenleaf, 2018).
Participants
Fifteen participants (N = 15; 13 women, two men) were selected for the study using purposeful criterion sampling (Patton, 2014). Participants’ ages ranged from 28 to 67 years (M = 40). Twelve participants identified as European American and three as African American. Twelve participants were licensed professional counselors and three were licensed professional counselor associates. Two participants had doctoral degrees in counseling. Participants practiced counseling in various settings such as private practices, colleges, secondary schools, and community counseling centers. Participants also had additional credentials: three were licensed professional counselor supervisors, seven were licensed clinical addiction specialists, one was a certified clinical trauma professional, and one was a registered play therapist. Years of work experience as a professional counselor ranged from 2 to 20 (M = 6.7).
Data Collection and Analysis
Recruitment solicitation flyers were distributed to various mental health agencies located in rural counties designated as persistently poor (USDA, 2017) in one state in the Southeastern United States. The mental health agencies were identified by searching public information websites for counseling and psychological support resources within these counties. Potential participants completed a telephone eligibility screening and a demographic questionnaire. The demographic questionnaire included questions asking potential participants to identify a pseudonym, their age, ethnicity, employment status and location, and professional credentials. Participants who met inclusion criteria (i.e., licensed mental health clinicians currently employed in persistently poor rural locales) were selected to participate in the study. There is no required sample size for phenomenological studies; rather, authors (Creswell & Creswell, 2018; Hays & Singh, 2012) recommended researchers consider the purpose of the research and depth of the data. We continued to recruit participants until saturation was achieved by seeing a recurrence in the data (Creswell & Creswell, 2018; Hays & Singh, 2012). After completing Interview 15, we did not identify novel data and agreed that a sufficient amount of data was collected to provide a comprehensive understanding of the phenomenon under investigation.
The researcher is the key instrument for data collection in qualitative research (Creswell & Creswell, 2018). A graduate assistant and the first author collected all study data by the use of qualitative interviews using an open-ended, semi-structured interview protocol (Hays & Singh, 2012). Each participant completed individual, one-phase, open-ended, semi-structured, face-to-face or live video interviews, lasting approximately 60–90 minutes. We audio-recorded all interviews, and they were transcribed by a professional transcription service.
The 12 interview questions that guided the study were framed by the MSJCCs’ constructs in extant literature related to the experiences of mental health counselors and clients in rural, poor communities (Bradley et al., 2012; Clark et al., 2017; Grimes et al., 2015; Grimes et al., 2013; Kim & Cardemil, 2012) and specific multicultural and social justice counseling constructs espoused in the MSJCCs (Ratts et al., 2015; Ratts et al., 2016). Six questions focused on understanding the participants’ knowledge of rural, poor communities and their experiences. Examples of these questions were: “Can you tell me the influence that persistent poverty has on the services you provide in a rural setting? What personal and client factors or experiences are influential to your work?” and “What is needed for you to competently provide counseling services to this population, if anything?” An additional six questions, also informed by the MSJCCs, sought to further explore the participant’s beliefs, skills, and actions related to multicultural competence, social justice advocacy, and counseling, such as “Can you share with me your definition and understanding of social justice advocacy in counseling? Can you share ways (if any) you incorporate social justice advocacy into your work as a counselor in a rural, economically deprived area?” and “Please share any perceived barriers to engaging in social justice advocacy and counseling in rural, economically deprived areas.”
Analysis of the data was informed by Giorgi’s (2009) and Giorgi, Giorgi, and Morley’s (2017) process for descriptive phenomenological data analysis. Specifically, we adhered to five steps in the data analysis process. First, we assumed a phenomenological attitude, in which we bracketed suppositions that could potentially influence the data and research process, such as our frustrations with perpetual deficit ideology in research related to marginalized populations. Second, after each interview was completed, we individually read each transcript to get a sense of the whole experience (i.e., native descriptions) and wrote brief notes in the margins to pinpoint any significant descriptive statements and expressions (Hays & Singh, 2012). For instance, we notated participants describing specific counseling practices that they believed were related to social justice advocacy as significant descriptive statements. We sent participants a copy of their transcript for member checking. Third, we re-read transcripts to demarcate data into multiple meaning units by clustering the invariant descriptions of participants’ experiences.
Initially, we also used a priori codes based on the MSJCCs to begin to identify units of meaning. For example, codes such as systems, advocacy, self-awareness, community, and collaboration helped us to infuse the MSJCCs’ framework and focus the findings toward understanding social justice experiences. As an example, the recognition and appreciation of a client’s ability to ascertain needed resources despite having less access and the participants’ willingness to assist in resource allocation were two invariant descriptions of experiences. The analysis process yielded 46 initial units of meaning. Participants’ quotes and definitions related to meaning units were contained in a research notebook to manage data and establish consensus coding (Hays & Singh, 2012). We held multiple meetings to discuss if and how these meaning units related to the developmental domains of the MSJCCs. For example, we discussed how one meaning unit, idiosyncrasies in the support system, closely related to the MSJCCs’ client worldview domain and reached a consensus in understanding that the participants’ ability to recognize that their clients had often strained their natural support systems exemplified that the counselor possessed knowledge of how their clients’ economic status and limited support systems shaped their attitudes and engagement in mental health treatment. In our fourth step, we reviewed the data to transform the meaning units into sensitive descriptive expressions that highlighted the psychological meaning of participants’ descriptions. We used free imaginative variation to determine the essence of the phenomenal structures of the participants’ experiences (Giorgi, 2009; Giorgi et al., 2017). We discussed any differences in understanding participants’ invariant experiences. For example, we discussed if the participants’ recognition of their need for a professional consultation to address underdeveloped counseling skills and biases related to the MSJCCs’ counselor self-awareness domain. Finally, we negotiated the interconnections and essential meanings of the meaning units, coalesced the data, and identified four essential structures that represented the descriptions of participants’ experiences and assigned them a descriptive thematic label.
Strategies for Trustworthiness
It is vital that researchers establish criteria for trustworthiness in qualitative research studies (Morrow, 2005). We demonstrated credibility through the use of bracketing, triangulation of the data sources, member checking, and peer debriefing (Morrow, 2005). Participants were provided with a copy of their transcriptions and case displays to review for member checking. We employed triangulation of data by crosschecking data (Hays & Singh, 2012) with the existing empirical studies related to rural poverty and mental health counseling. Data collection and analysis occurred concurrently in order to triangulate findings (Hays & Singh, 2012).
Findings
Using an MSJCCs lens, we identified four themes that represented the experiences of counselors who work with clients in rural poverty: (1) appreciating clients’ worldviews and life experiences, (2) counseling relationships influencing service delivery, (3) engaging in individual and systems advocacy, and (4) utilizing professional support. The findings are explicated using participants’ quotes to illustrate the meaning of each theme.
Appreciating Clients’ Worldviews and Life Experiences
Participants in the study described how they developed an appreciation for their clients’ worldviews and life experiences, even if they were different from their own. For example, Jade shared how she gained insight into and showed an appreciation for her clients’ worldviews by “showing empathy, being curious, and asking questions about what it was like for them in certain situations.” Jade expressed that seeking to understand clients’ worldviews was vital when working with African Americans living in rural poverty because she did not have the same experiences. Shelly also conveyed an appreciation for her clients’ worldviews and experiences and the impact on her clinical skills, sharing that she acquired a “different perspective” in her approach by gaining knowledge of her clients’ family structures and listening to their history.
Nine participants described that working in rural, impoverished communities entailed understanding the impact that limited resources have on providing adequate mental health services and recognizing the idiosyncrasies in clients’ support systems. Three participants described how their clients had often “burned” or “exhausted” their natural support system (i.e., personal relationships with other people that enhance the quality of one’s life), which made it difficult for participants to identify persons who would be supportive of their clients in the mental health treatment process. Addie described her counseling experiences in rural, poor communities, stating, “People have so little to fall back on, if they’re chronically mentally ill or they have a family member who is, they’re just out of resources, and they’ve maybe even burned their natural supports.” Addie further elaborated on her experiences, explaining that family members would often not return her phone calls after a client was admitted for inpatient mental health treatment.
Five participants expressed the importance of considering how low mental health literacy and mental illness stigma influenced clients’ knowledge, attitudes, and beliefs toward mental health treatment. Lola explained that she observed low mental health literacy in rural, poor communities: “There is a very low level of understanding with regard to symptoms associated with mental illness.” Lola discussed the prevalence of stigma toward clients with diagnosed mental health disorders as well as toward clients that had not been formally diagnosed because of the limited understanding of mental illness. Likewise Julian, a school-based counselor, expressed the impact of low mental health literacy in rural, high-poverty communities. Julian shared that the majority of her youth clientele were being raised by their grandparents, who had less knowledge of mental health symptoms and treatment; therefore, grandparents were often hesitant to seek mental health treatment services for their grandchildren.
Many (n = 11) of the participants indicated that in understanding the clients’ experiences and worldviews they were able to see how clients managed to be resourceful and resilient when faced with hardships. In illustration, Lola stated, “They are some of the most resourceful and resilient people that I’ve ever met; they have a knack for finding ways to achieve what needs to happen despite not having the typical resources . . . that’s very admirable.” Sue and Brenda expressed similar sentiments, also describing their clients as “resourceful.” In essence, participants explicated their attitudes and dispositions (e.g., recognizing and appreciating clients’ resourcefulness, possessing curiosity, learning about family structure and support systems) in working with clients in rural, impoverished communities. In accordance with the MSJCCs, participants expressed the importance of recognizing how the worldviews and life experiences of their marginalized clients are influenced by the context of rural poverty, such as how low mental health literacy and stigma impact the utilization of mental health treatment for this population.
Counseling Relationships Influencing Service Delivery
Participants (n = 10) described the importance of having a strong counseling relationship when working with marginalized individuals and families living in rural poverty. This solid relationship motivated participants to alter the mode of service delivery or intentionally focus more on client-centered services. Reflecting on her experiences providing home-based counseling services, Sue expressed the importance of building trust and empowerment in counseling relationships, especially when clients were involved with professionals from other agencies (e.g., probation officers) who also visited their homes. Sue described how she reinforced trust and empowerment by telling her clients, “This is about you and I’m walking alongside this path with you, I’m not going to make decisions for you.” Sue expressed that reinforcing empowerment was an essential part of counseling in rural, poor communities because clients often felt as if their power has been taken away.
Other participants shared that many of their clients came to counseling sessions without their basic needs met (e.g., food, housing, and safety) and that a solid counseling relationship allowed for more trust and openness. In return, participants expressed that clients were more willing to express their need for basic necessities without feeling ashamed, and that they often altered their services to assist clients in ascertaining immediate resources. For example, Heather noted that the poverty level was so low in her community that many of her youth clients’ basic needs were not being met and they would ask her to stop and purchase them meals. Heather disclosed that she often responded by stating, “Okay, we’re going to have to change where we’re providing therapy today, or maybe how therapy’s going to look today” to accommodate their needs. Similarly, Sadie shared, “It’s hard to see your clients going without things that you would consider basic.” Sadie described circumstances in which she arranged for food to be dropped off to the school and picked up by her clients.
Che and eight other participants acknowledged that having strong counseling relationships with clients living in rural poverty increased their willingness to extend their services beyond traditional counseling roles and settings. The participants described various cases in which they assisted clients in securing food or housing, or navigating Medicaid and other entities. For example, Che shared that she attended a mental health disability hearing with her client in which she was allowed to speak on the behalf of a client who experienced severe social anxiety. Additional participants described ways they broadened their roles to include consulting and case management and provided examples of ways they altered counseling sessions (e.g., including children because clients had no childcare) or offered incentives for attendance (e.g., bus passes and toiletries) to support clients’ continuity in treatment as well as using these as a means to help meet clients’ imminent needs. Overall, participants conveyed that their counseling relationships allowed for trust and flexibility that enabled them to use ancillary skills and knowledge when working in rural, persistently poor communities, such as skills in crisis management or intentionally building resource networks with medical professionals, churches, social service providers, law enforcement, and community organizations to help meet clients’ basic needs.
Engaging in Individual and Systems Advocacy
All participants reported engaging in various individual and systems advocacy interventions when working in rural, impoverished communities. Participants shared that engaging in advocacy was necessary, ranging from their initial sessions with their clients until termination and follow-up. George shared that he started advocacy initiatives in the initial assessment by “not jumping to assumptions” and spending more time observing clients and exploring their history. He stated that he acknowledged if clients were already taking steps toward positive change to encourage self-advocacy. George explained, “I think the most direct thing that I can do is to empower people to recognize their strengths and their rights.” Similarly, Jade shared, “I use motivational interviewing with clients to help them become better advocates for themselves.” Other participants expressed that promoting self-advocacy was vital for this specific population because of the high probability that a client would not return to counseling because of barriers related to transportation, finances, and stigma. Seven participants shared that it is important to have personal knowledge of systems that affect the client in order to inform advocacy interventions. Renee mentioned, “With all the Medicaid changes . . . I’ve got to take every client into a financial conversation. . . . So keeping myself educated . . . I can be a voice of support to them and have an understanding if they come to me.”
Additionally, participants reported various situations in which they engaged in advocacy interventions outside of the office setting. Two participants shared that they engaged in advocacy with and on behalf of clients to help them navigate the criminal justice system. For example, Jade advocated on behalf of a teenage client to law enforcement officials to request the removal of her client’s ankle monitor, which she believed was not necessary. Heather shared that she wrote letters to the courts on behalf of her clients.
Participants also discussed their involvement with helping clients sustain housing. Che shared, “I’ve spoken up for my clients against landlords who were trying to railroad several of my clients with their rent, and one in particular was trying to charge my client double the rent.” Similarly, Jade shared, “I was able to advocate to my supervisors to get funds to help pay the past bills so [clients] could move into a new location and not lose housing.”
Four participants conducted trainings in schools and within the community to inform others of culturally responsive practices with people living in rural poverty. Sadie shared that she provided educational workshops to school counselors, administrators, and teachers to help them understand the life experiences of individuals and families living in rural poverty. Sadie explained that she educated her colleagues on the effects of generational poverty and helped them to explore ways they could use various educational strategies for clients in these circumstances. Overall, counselors recognized clients’ needs and engaged in an array of advocacy interventions individually with clients, as well as in the community to support clients’ continuation in treatment, link clients to services, or help clients allocate resources in rural, poor communities.
Utilizing Professional Support
Some participants (n = 6) were the only mental health providers in the communities in which they worked. Thus, they spoke of instances of feeling frustrated because of the lack of resources for clients, role overload, and inability to connect with other counselors. Participants expressed that support from other professionals in the behavioral health field was helpful to alleviate frustrations. With this awareness, participants shared that conversations, consultations, and formalized supervision sessions were useful to explore their biases and feelings of hopelessness, to address compassion fatigue, and to learn new clinical interventions. For example, Blaze shared that formalized supervision was beneficial to increase his knowledge and improve his attitude about working in rural, impoverished communities. He stated, “The people who have supervised me understand that I’m coming from a different area and this is all kind of a learning curve. They’ve been good about helping me acclimate to the area.” Similarly, eight participants shared that ongoing supervision was helpful to abate adopting negative stereotypes and to address de-sensitization to clients’ needs, particularly when seeing clients who perpetually faced hardships. Lola discussed the benefits of having a professional support system among her colleagues to manage the demands of counseling in rural poverty. She stated, “We support each other personally when professional issues begin to impact our personal lives.” Furthermore, Lola described that ongoing supervision was “very helpful and necessary” as it provided her the opportunity to “check in” with herself and assess how she was managing the demands of her work.
Seven participants shared that receiving professional support reinforced ongoing self-awareness. For example, Sadie stated, “I think [it’s important] being willing to recognize that I’m not perfect . . . being willing to say here’s a place where I need to improve.” Sadie also expressed that it was important for her to seek supervision or personal mental health services to not allow her personal frustrations to “bleed over” into her client sessions. Likewise, Jade explained that supervision and taking continuing education credits regarding cultural differences were optimal to her success. In alignment with the constructs in the MSJCCs, the participants acknowledged the importance of engaging in critical self-reflection to take an inventory of their skills, beliefs, and attitudes (Ratts et al., 2016) that impact the services they provided to marginalized clients living in rural poverty. Overall, seeking ongoing supervision and engaging in professional development activities were necessary to prevent adopting stereotypes and to continue advocacy efforts.
Using participants’ voices and the lens of the MSJCCs, we illuminated the essence of providing mental health counseling in rural, persistently poor communities. The participants described the importance of showing an appreciation for clients’ worldviews and life experiences and how their counseling services encompassed varied approaches to service delivery and non-traditional counseling methods to engage rural, impoverished clients in the treatment process. Participants frequently engaged in individual and systems advocacy with and on behalf of their clients and described how having professional support was necessary to provide culturally responsive mental health counseling in rural, persistently poor communities. The findings serve as the basis for the following discussion.
Discussion
This study explored the experiences of mental health counselors working in rural, impoverished communities and identified ways counselors incorporated social justice advocacy using the lens of the MSJCCs to identify advocacy skills and interventions. We found that counselors who work with clients in rural poverty appreciate their clients’ worldviews and life experiences, value their counseling relationships, alter service delivery formats, engage in advocacy, and seek ongoing professional support and development opportunities. Specifically, the first theme captured how counselors in the study expressed an appreciation for their clients’ worldviews and life experiences, as described in the MSJCCs’ client worldview domain. Counselors recognized that various contextual factors, such as family structure, nuances in the natural support systems, less access to resources, as well as how race and social class status shaped their clients’ worldviews, influenced their utilization of mental health treatment. This finding lends support to previous literature associated with examining how economic disadvantages and rurality influence mental health care services and literacy (Deen & Bridges, 2011; Kim & Cardemil, 2012). Consistent with the MSJCCs’ (Ratts et al., 2015) client worldview domain, the counselors explored and appreciated clients’ history and life experiences, and acknowledged the clients’ “resourcefulness” as a strength.
Furthermore, counselors in the study expressed a willingness to engage in their clients’ personal communities, which aligns with the suggestion in the client worldview domain that counselors should immerse themselves in the communities in which they work to learn from and about their clients (Ratts et al., 2015). The findings from the study correspond to previous research that examines how counselors with increased exposure to individuals living in poverty have enhanced multicultural competence and are able to critically examine systemic or structural factors that contribute to the underutilization of mental health services in high-poverty communities (Clark et al., 2017).
The second theme, counseling relationships influencing service delivery, reflected the MSJCCs’ counseling relationship domain. Participants recognized that their clients’ ability to engage in the traditional therapeutic process was often thwarted because many of their clients’ basic needs were not met. As implied in the counseling relationship domain, counselors are advised to utilize culturally competent assessment and analytical and cross-cultural communication skills that allow them to effectively determine clients’ needs and employ collaborative, action-oriented strategies to strengthen the counseling relationship (Ratts et al., 2015).
Reflective of this domain, counselors in the study often altered service delivery formats and assumed alternative roles to meet clients’ needs. The current findings offer support for research that advances increasing flexibility in counseling roles and culturally competent assessments when working in marginalized communities (Fifield & Oliver, 2016).
Another distinctive finding of this study was encompassed in the third theme, which captured the MSJCCs’ counseling and advocacy interventions domain, and illuminated the participants’ use of strategies to promote continuation of services (e.g., home-based counseling, group formats with the inclusion of childcare, and distributing incentives) as well as advocacy interventions to address clients’ imminent needs. Expanding previous research that illuminated the role of self-advocacy (Singh, Meng, & Hansen, 2013), the participants expressed the importance of engaging in intrapersonal, interpersonal, and institutional advocacy interventions with and on behalf of clients, such as assisting clients in securing or maintaining housing, acquiring supportive educational resources in school settings, rebuilding familial relationships, and preventing the criminalization of poverty. Although these findings are similar to previous researchers’ perspectives that suggest that counseling in rural poverty requires counselors to engage in various advocacy roles (Kim & Cardemil, 2012; Reed & Smith, 2014), this study answers the call to provide practical examples of incorporating social justice advocacy into counseling with historically marginalized populations (Ratts & Greenleaf, 2018).
The final theme identified in our study involved the participants’ use of professional support networks and seeking professional development opportunities to address areas of professional incompetence. Accordingly, this theme aligns with aspects in the MSJCCs’ self-awareness domain. As articulated in this domain, multiculturally competent counselors are expected to have an awareness of their social group statuses, power, privilege, and oppression, as well as acknowledge how their biases, attitudes, strengths, and limitations may influence clients’ well-being (Ratts et al., 2015). The counselors in our study engaged in both informal and formal action-oriented strategies, such as consultations and ongoing supervision with other mental health professionals, that helped them examine prejudicial beliefs, prevent the development of additional biases, and explore other areas of vulnerability and skills deficiencies as designated in the MSJCCs’ counselor self-awareness domain. This finding supports past research (Bowen & Caron, 2016; Reed & Smith, 2014) that indicated that because of the limited resources and remoteness in rural, impoverished areas, professional support is vital to assuage frustrations because of consistently seeing poor, rural clients navigate difficult life circumstances. However, this finding expands current understanding by focusing on the counselors’ ability to identify their own limitations and readily seek out additional supports.
Implications for Counseling Practice, Advocacy, and Training
Foremost, in order to offer culturally competent mental health counseling, it is important for counselors to appreciate their clients’ worldviews and life experiences and understand the unique oppressions that clients from rural, impoverished communities experience. For example, participants acknowledged that various contextual factors, such as family structure, mental illness stigma, and nuances in the natural support systems, shaped their clients’ worldviews and influenced their utilization of mental health treatment. Viewing clients’ concerns from a socioecological lens may strengthen the counselor–client relationship (Ratts et al., 2016) and decrease stigma related to mental health treatment (Stewart et al., 2015).
Counselors also must be flexible and recognize that altering the format of session delivery is often necessary to engage with clients in rural poverty. Individuals living in rural poverty face immense financial barriers that impede the utilization of mental health treatment (e.g., transportation issues), and there is a general lack of awareness about mental illness in rural, poor communities (Haynes et al., 2017). Thus, counseling in rural poverty should extend beyond office-bound interventions to include community-based interventions (Ratts & Greenleaf, 2018) and account for barriers that influence treatment utilization. For instance, the findings indicated that participants had a greater appreciation for clients’ worldviews and expanded their roles to include consulting, advocacy, and case management when they became more engaged in their clients’ personal environment and community.
Furthermore, counselors in this study collaborated with and on behalf of clients in advocacy efforts in various areas such as housing, criminal justice, social services, and school systems. Engaging in individual- and systems-level advocacy interventions (Ratts et al., 2016) when working in rural, impoverished communities is vital to promote equity and positive systemic changes (Reed & Smith, 2014). Given these findings, counselors should become comfortable with professionals in these areas as well as going into the respective environments. Thus, it warrants counselors to network with community partners, schools, faith communities, and law enforcement entities to establish relationships to enhance support networks. In addition, writing letters to federal and state legislators regarding national issues such as Medicaid funding is critical to address policies that benefit rural, impoverished communities.
Finally, multicultural and social justice competence is a developmental process, and professional counselors as well as counselors-in-training need opportunities for ongoing self-reflection to examine their personal assumptions and biases and enhance their skills when working with rural, impoverished communities. Clinical supervision grounded in a social justice framework can help counselors and supervisors process their biases and assumptions, develop a social justice lens of understanding clients from rural poverty, and cultivate advocacy skills (Smith et al., 2013). The MSJCCs should be facilitated throughout counseling program curricula versus one foundation course in multicultural counseling and development. Some possibilities for incorporating the MSJCCs into student learning across all courses include experiential activities, group work, and role-plays that cover topics such as worldviews, intersecting identities, power, privilege, and social class. For example, audiovisual materials found on the Rural Health Information Hub website (www.ruralhealthinfo.org) can help students visualize the experiences of rural and impoverished communities. Additionally, encouraging or requiring counselors-in-training to engage in rural, economically disadvantaged communities for their practicum and internship experiences can be incorporated into the clinical sequence in counselor preparation programs
Recommendations for Future Research
There are several pathways to advance research pertaining to mental health counseling and social justice advocacy in rural poverty. Rural, impoverished areas continue to experience low mental health literacy, which perpetuates stigma. Thus, investigations about stigma in rural poverty can provide insights into the underutilization of mental health treatment in rural communities. Research of various designs regarding the lived experiences of poor women, men, and children in rural communities can inform culturally responsive counseling practices. For example, empirical studies about the experiences of grandparents raising grandchildren in rural poverty can offer unique perspectives for ways to enhance mental health literacy and increase utilization of mental health services. Additional studies are also needed to explore social justice advocacy interventions that are necessary to test the efficacy of the MSJCCs.
Finally, a primary limitation of this study was that the participants had varied professional license levels, areas of specialization, years of professional experience, and provided counseling services to diverse clientele in various settings. The data in the current study did not allow us to assess if variances in the noted areas had a differential impact on the participants’ counseling experiences in rural poverty. Consequently, additional qualitative studies that allow researchers to examine these differences more pointedly are needed to fully understand the experiences of counselors from varied backgrounds and experience levels. Furthermore, readers should exercise caution when generalizing the experiences of the 15 participants in this sample to other counselors working in rural, impoverished communities. The experiences of participants in this sample may not capture the experiences of all counselors working in these communities; however, readers can make decisions regarding the degree to which the findings of the study are applicable to the settings in which they live and work (Hays & Singh, 2012).
Conclusion
Poverty significantly impacts the mental health of children and adults living in rural communities, resulting in having limited access to resources and services that can promote healthy development and well-being. Therefore, mental health counselors working in rural, poor communities must often incorporate social justice advocacy within the context of clients’ experiences of oppression in their counseling practices to provide culturally responsive services. The MSJCCs provided a lens to explore the knowledge, skills, beliefs, and overall practices of 15 professional counselors working in rural, impoverished communities. By examining the experiences of these counselors, we identified how counseling professionals working in rural, impoverished communities acknowledged and appreciated their clients’ worldviews and life experiences, created strong therapeutic alliances, altered counseling service delivery, engaged in advocacy, and sought professional support to sustain their ability to provide culturally responsive counseling services. Multiculturally competent counselors should continually explore ways to amend their current practices to address the various sociocultural barriers that impede the mental health and well-being of rural, poor children and adults. It is our hope that counselors will utilize the findings from this study to further the discourse on rural poverty and create positive change in these communities.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Alang, S. M. (2015). Sociodemographic disparities associated with perceived causes of unmet need for mental health care. Psychiatric Rehabilitation Journal, 38, 293–299. doi:10.1037/prj0000113
American Counseling Association. (2014). 2014 ACA code of ethics. Alexandria, VA: Author.
Bowen, J. M., & Caron, S. L. (2016). A qualitative analysis of home-based counselors’ experiences in a rural setting. Journal of Counseling & Development, 94, 129–140. doi:10.1002/jcad.12070
Bradley, J. M., Werth, J. L., Jr., Hastings, S. L., & Pierce, T. W. (2012). A qualitative study of rural mental health practitioners regarding the potential professional consequences of social justice advocacy. Professional Psychology: Research and Practice, 43, 356–363. doi:10.1037/a0027744
Bray, S. S., & Schommer-Aikins, M. (2015). School counselors’ ways of knowing and social orientation in relationship to poverty beliefs. Journal of Counseling & Development, 93, 312–320. doi:10.1002/jcad.12029
Clark, M., Moe, J., & Hays, D. G. (2017). The relationship between counselors’ multicultural counseling competence and poverty beliefs. Counselor Education and Supervision, 56, 259–273. doi:10.1002/ceas.12084
Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Thousand Oaks, CA: Sage.
Curtin, K. A., Schweitzer, A., Tuxbury, K., & D’Aoust, J. A. (2016). Investigating the factors of resiliency among exceptional youth living in rural underserved communities. Rural Special Education Quarterly, 35(2), 3–9. doi:10.1177/875687051603500202
Deen, T. L., & Bridges, A. J. (2011). Depression literacy: Rates and relation to perceived need and mental health service utilization in a rural American sample. Rural and Remote Health, 11(4), 1–13.
Fifield, A. O., & Oliver, K. J. (2016). Enhancing the perceived competence and training of rural mental health practitioners. Journal of Rural Mental Health, 40, 77–83. doi:10.1037/rmh0000040
Giorgi, A. (2009). The descriptive phenomenological method in psychology: A modified Husserlian approach. Pittsburgh, PA: Duquesne University Press.
Giorgi, A., Giorgi, B., & Morley, J. (2017). The descriptive phenomenological psychological method. In C. Willig & W. S. Rogers (Eds.), The SAGE handbook of qualitative research in psychology (2nd ed., pp.176–192). Thousand Oaks, CA: Sage.
Grimes, L. E., Haskins, N. H., Bergin, J., & Tribble, L. L. (2015). School counselor candidates’ shared beliefs and experiences regarding the rural setting. In Ideas and research you can use: VISTAS 2015. Retrieved from https://www.counseling.org/docs/default-source/vistas/school-counselor-candidates.pdf?sfvrsn=fedb432c_4
Grimes, L. E., Haskins, N. H., & Paisley, P. O. (2013). “So I went there”: A phenomenological study on the experiences of rural school counselor social justice advocates. Professional School Counseling, 17, 40–51. doi:10.5330/PSC.n.2013-17.40
Haynes, T. F., Cheney, A. M., Sullivan, J. G., Bryant, K., Curran, G. M., Olson, M., . . . Reaves, C. (2017).
Addressing mental health needs: Perspectives of African Americans living in the rural south. Psychiatric
Services, 68, 573–578. doi:10.1176/appi.ps.201600208
Hays, D. G., & Singh, A. A. (2012). Qualitative inquiry in clinical and educational settings. New York, NY: Guilford Press.
Hill, S. K., Cantrell, P., Edwards, J., & Dalton, W. (2016). Factors influencing mental health screening and treatment among women in a rural south central Appalachian primary care clinic. The Journal of Rural Health, 32, 82–91. doi:10.1111/jrh.12134
Imig, A. (2014). Small but mighty: Perspectives of rural mental health counselors. The Professional Counselor, 4, 404–412. doi:10.15241/aii.4.4.404
Kim, S., & Cardemil, E. (2012). Effective psychotherapy with low-income clients: The importance of attending to social class. Journal of Contemporary Psychotherapy, 42, 27–35. doi:10.1007/s10879-011-9194-0
Lewis, J. A., Ratts, M. J., Paladino, D. A., & Toporek, R. L. (2011). Social justice counseling and advocacy: Developing new leadership roles and competencies. Journal for Social Action in Counseling & Psychology, 3, 5–16.
Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous? Trustworthiness and authenticity in naturalistic
evaluation. New Directions for Program Evaluation, 1986(30), 73–84. doi:10.1002/ev.1427
Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52, 250–260. doi:10.1037/0022-0167.52.2.250
National Board for Certified Counselors. (2016). NBCC code of ethics. Greensboro, NC: Author.
Neese, J. B., Abraham, I. L., & Buckwalter, K. C. (1999). Utilization of mental health services among rural elderly. Archives of Psychiatric Nursing, 13, 30–40. doi:10.1016/S0883-9417(99)80015-6
Patton, M. Q. (2014). Qualitative research and evaluation methods (4th ed.). Thousand Oaks, CA: Sage.
Pillay, Y., Gibson, S., Lu, H. T., & Fulton, B. (2018). The experiences of north-central rural Appalachian clients
who utilize mental health services. Journal of Rural Mental Health, 42(3–4), 196–204.
doi:10.1037/rmh0000100
Ratts, M. J., & Greenleaf, A. T. (2018). Counselor–advocate–scholar model: Changing the dominant discourse in counseling. Journal of Multicultural Counseling and Development, 46(2), 78–96. doi:10.1002/jmcd.12094
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2015). Multicultural and
social justice counseling competencies. Retrieved from https://www.counseling.org/docs/default-source/competencies/multicultural-and-social-justice-counseling-competencies.pdf?sfvrsn=20
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44, 28–48. doi:10.1002/jmcd.12035
Reed, R., & Smith, L. (2014). A social justice perspective on counseling and poverty. In M. J. Ratts & P. Pedersen (Eds.), Counseling for multiculturalism and social justice: Integration, theory, and application (4th ed., pp. 259–273). Alexandria, VA: American Counseling Association.
Rural Health Information Hub. (2017, March 23). Rural mental health. Retrieved from https://www.ruralhealth info.org/topics/mental-health
Semega, J. L., Fontenot, K. R., & Kollar, M. A. (2017). Income and poverty in the United States: 2016: Current population reports (Report No. P60-256). Washington, DC: U.S. Census Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2017/demo/P60-259.pdf
Singh, A. A., Meng, S., & Hansen, A. (2013). “It’s already hard enough being a student”: Developing affirming college environments for trans youth. Journal of LGBT Youth, 10, 208–223.
doi:10.1080/19361653.2013.800770
Smith, L., Li, V., Dykema, S., Hamlet, D., & Shellman, A. (2013). “Honoring somebody that society doesn’t honor”: Therapists working in the context of poverty. Journal of Clinical Psychology, 69, 138–151. doi:10.1002/jclp.21953
Snell-Rood, C., Hauenstein, E., Leukefeld, C., Feltner, F., Marcum, A., & Schoenberg, N. (2017). Mental health treatment seeking patterns and preferences of Appalachian women with depression. American Journal of Orthopsychiatry, 87, 233–241. doi:10.1037/ort0000193
Stewart, H., Jameson, J. P., & Curtin, L. (2015). The relationship between stigma and self-reported willingness to use mental health services among rural and urban older adults. Psychological Services, 12, 141–148. doi:10.1037/a0038651
Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(2), 64–88. doi:10.1002/j.2161-1912.1992.tb00563.x
Tickamyer, A. R., Sherman, J., & Warlick, J. L. (2017). Rural poverty in the United States. New York, NY: Columbia University Press. doi:10.7312/tick17222
Toporek, R. L., & Pope-Davis, D. B. (2005). Exploring the relationships between multicultural training, racial attitudes, and attributions of poverty among graduate counseling trainees. Cultural Diversity and Ethnic Minority Psychology, 11, 259–271. doi:10.1037/1099-9809.11.3.259
U.S. Department of Agriculture, Economic Research Service. (2017). U.S. state fact sheets. ASI 1546-6. Retrieved from
https://www.ers.usda.gov/data-products/state-fact-sheets/
Loni Crumb is an assistant professor at East Carolina University. Natoya Haskins is an associate professor at the College of William and Mary. Shanita Brown is an instructor at East Carolina University. Correspondence can be addressed to Loni Crumb, 213B Ragsdale Hall, Mail Stop: 121, Greenville, NC 27858, crumbL15@ecu.edu.
Sep 28, 2018 | Volume 8 - Issue 3
M. Ann Shillingford, Seungbin Oh, Amanda DiLorenzo
Natural disasters over the past few decades have necessitated mass migration of Haitian immigrants to the United States. Haitians residing in the United States have experienced significant cultural and social challenges. Recent political deportation mandates have increased the systemic challenges that Haitian students and their families are currently facing in the United States. These systemic barriers have fostered an increase in stressors affecting the mental wellness of Haitian students and their families. This article introduces school counselors to the culturally focused, multiphase model of psychotherapy, counseling, human rights, and social justice as a framework to assist Haitian students and their families.
Keywords: Haiti, immigrant, school counseling, human rights, social justice
There has been a growing trend in the counseling profession to provide culturally relevant services to all clients. In fact, most recently, Ratts, Singh, Nassar-McMillan, Butler, and McCullough (2016) proposed the Multicultural and Social Justice Counseling Competencies to support the evolving need for multiculturally competent counselors to support today’s diverse populations and their varying mental health needs. One diverse group that has caught the attention of counseling professionals is the Haitian population. A long history of political unrest, coupled with grievous damage from natural disasters over the past few decades, has snowballed the migration of Haitian families into the United States. With mass migrations come challenges with cultural identity, social and academic obstacles, and psychological impairment. This article highlights the role of school counselors as social justice advocates and introduces the multiphase model of psychotherapy, school counseling, human rights, and social justice as a framework for offering services to Haitian students and their families. The authors present literature underlining the experiences of the Haitian population both within the context of their home country and also as immigrants in the United States.
Effects of Natural Disasters on Haitian Migration
Over the past few decades, the small nation of Haiti has suffered tremendously from natural disasters. In January 2010, a major 7.1-magnitude earthquake shook the island’s core, killing close to 300,000 men, women, and children. An equal number of individuals were injured and at least 1.5 million were displaced. Among the damage and destruction were almost 4,000 schools (CNN, 2017). Six years later, Hurricane Matthew swept through the south side of the island, killing over 900 citizens and leaving severe devastation in its tracks (BBC News, 2016). A year after that, Haiti, already crippled economically by previous natural disasters, was hit by Hurricane Irma, a Category 5 storm. Cook (2017) reported that homes, bridges, and housing already weakened by previous disasters were destroyed. Not only were homes destroyed, but the country’s ability to rebuild also was diminished.
Each natural disaster in Haiti has meant a struggle for regrowth. Between 2015 and 2016, it was reported that the economic growth in Haiti was down to a staggering 2% (U.S. Department of State, 2018). Damage from natural disasters, drought conditions, governmental unrest, and a significant decrease in the country’s currency were identified as contributors to the financial stagnation (U.S. Department of State, 2018). Migration trends portrayed a parallel between decreased stability in Haiti and increased migration to the United States and other more secure territories. In fact, over the years, the United States has been the recipient of thousands of immigrants seeking security and a better future for their families. Stepick and Stepick (2002) reported that in the 20th century, the number of Haitian immigrants to the United States reached an all-time high. By 2010, there were approximately 587,000 Haitians living in the United States, and that number rose to almost 700,000 by 2015 (Migration Policy Institute, 2017). The distribution of Haitian immigrants varies from state to state, with Florida having the largest population (46%), followed by New York (25%), New Jersey (8%), Massachusetts (7%), Georgia (2%), and Maryland (2%). These numbers may continue to rise as the outlook for the island of Haiti remains bleak.
Prior to the January 2010 earthquake, Haitian migration to the United States was considered high due to unemployment, low socioeconomic stability, poverty, violence, and political instability on the island (Cone, Buxton, Lee, & Mahotiere, 2014). Presently, Haiti is considered the economically poorest country in the Western hemisphere (Coupeau, 2008; Mendelson-Forman, 2006). Haiti also has been notorious for its high number of orphans, with at least 380,000 before the earthquake and a significantly increased number of displaced and homeless children after the earthquake (Little, 2010). Concern exists for the well-being of Haiti’s survivors of natural disasters, particularly the children. According to Potocky (1996), in the past years many Haitian children and their families who fled Haiti due to hardships and entered the United States as refugees often suffered from post-traumatic stress disorder (PTSD; Potocky, 1996).
The U.S. Department of State (2018) estimated that Haiti has received nearly $5.1 billion in aid from the United States since the earthquake. Assistance offered included increasing the number of officers on the police force to increase security, increasing basic health care through development of new clinics, construction of a mega power plant to provide electricity, and support for farmers to increase crop development. Even so, Haitians continue to struggle and have sought immigration support from the United States. Reports have suggested that as many as 55,000 Haitians applied and have been granted visas to the United States since the earthquake, and as many as 500 orphaned children have been allowed travel documents for adoption by U.S. families (Zissis, 2010).
To support Haiti over the past decade, U.S. Homeland Security has offered Temporary Protected Status (TPS) to large numbers of Haitians affected by the debilitating conditions caused by natural disasters as well as political unrest. TPS is offered to individuals from foreign countries where it may be unsafe or where resources are inadequate to support the citizens. TPS may be granted to individuals who are already in the United States or those still in their native country. TPS allows recipients to remain in the United States and secure travel and employment authorization (U.S. Department of State, 2018). As such, TPS has been granted to an estimated 60,000 Haitian citizens following the destruction from the 2010 earthquake. Outside of Haitians who have entered the United States through the TPS program, it has been reported that at least 40,000 more Haitians have entered the United States seeking refuge following Hurricane Matthew (Fifield, 2016). It appears that with each natural disaster the number of Haitian immigrants in the United States has increased.
Impact of Migration on Haitian Students and Families
Migration to a new country may come with difficulties for families, particularly children. Haitian children experience multiple layers of challenges in the American educational system and society at large. To better support Haitian students, counselors need to understand the impact of these hardships on various aspects of Haitian students’ lives and needs. The following sections provide a review on the complications facing these students and their unique needs.
Research suggests that traumatic events affect the physiological, psychological, and social welfare of immigrant students (Bean, Derluyn, Eurelings-Bontekoe, Broekaert, & Spinhoven, 2006). Haitian families may experience household stress due to separation of family members between the United States and their homeland (Desrosiers & St. Fleurose, 2002). Additional stressors include cultural misunderstanding and isolation in the school setting (Chhuon, Hudley, Brenner, & Macias, 2010); differences in educational policies, pedagogical practices, and teaching styles; and overall differences in school culture and climate (Cone et al., 2014). These challenges, particularly in the school setting, may be problematic for Haitian students and parents trying to acculturate to the American system.
Haitian students experience significant social difficulties. In a study exploring stressors experienced by immigrants to the United States, Haitian parents and children reported the highest number of stressors among immigrants from the Caribbean islands (Levitt, Lane, & Levitt, 2009). In addition, it has been reported that Haitian immigrants have a 20–30% higher chance of living in poverty-stricken conditions in the United States than people who are White (Hernandez, Denton, & Mcartney 2009). Douyon, Marcelin, Jean-Gilles, and Page (2005) indicated that students in highly populated Haitian communities—such as the Miami-Dade, Florida, area—may be surviving in not only poor health conditions, but also hostile territories where education appears to be futile and a life of crime is more appealing. Those social problems may add stress to the Haitian household, which may compound existing economic problems (Chierici, 2004). Indeed, migration disrupts the familial and social networks as well as the behavioral norms and cultural values of new immigrants. It places responsibility on counselors and other educators to meet the needs of these students academically, socially, and culturally (Asner-Self & Marotta, 2005). Thus, it is imperative for schools to help provide both supportive relationships to foster resiliency and additional resources for Haitian immigrant students.
Social and Cultural Needs
Haitian students face potential cultural difficulties, such as language barriers, cultural identity, and acculturation, particularly in the school setting. Haitian students and their families may primarily speak Haitian Creole, yet few interpreters are available to assist with standardized test explanations (Kretsedemas, 2005), student code of conduct reviews, and other pertinent information that may affect students’ academic functioning. In comparison to Spanish, which is taught in American schools, Haitian Creole is spoken only within the Haitian culture (Phelps & Johnson, 2004). Although Haitian Creole is based on the French language, it has syntactical influences from West African languages. It should be noted that it is not a dialect of French, but is its own independent language (Solano-Flores & Li, 2006).
Along with sensitivity to language barriers, Haitian students may encounter challenges in developing their cultural identity. As reported by Doucet (2005), Haitian students who may be struggling between their own cultural identity and the American culture might encounter school-related problems such as suspensions, truancy, academic failure, and eventual school dropout. Cone and colleagues (2014) reported the results of a qualitative study and emphasized the difficulty in identity formation that Haitian students experience in the United States. Identity formation was influenced by three factors: differences in pedagogical approaches to teaching between Haiti and the United States; differences in disciplinary approaches between teacher groups; and pressure from peers to become Americanized. To counter the stigma associated with being and looking different, Cone and colleagues noted that Haitian students may accede to their peers and hide any indication of their Haitian heritage. Consequently, these practices may foster added stress within the family network and community at large. Struggles with cultural identity formation can cause Haitian students to feel anxiety, confusion, fear, helplessness, and homesickness (Bachay, 1998), which may ultimately lead to increased risk of PTSD.
To further compound psychological distress experienced by Haitian families living in the United States, in November 2017, U.S. President Donald Trump declared an end to TPS for Haiti and several other countries (Park, 2018). This means that at least 60,000 Haitians currently residing legally in the United States through TPS can be deported by January 2019 (Daugherty, 2018). Additionally, deportation holds on Haitian citizens activated following the 2010 earthquake are being released, increasing the number of Haitians being deported. Deportation is destructive to family units, especially children. Children are affected by the knowledge of deportation of individuals within their community, even when that individual is unrelated to them. When a family member is deported, the rest of the family, including children, may suffer from poverty, reduced access to food and health care, and limited educational opportunities (Wiley, 2013). Thus, the already fragile academic, social, and cultural experiences of some Haitian students and families currently residing in the United States might be further aggravated by political mandates and changing policies. Therefore, culturally relevant support is warranted from those who serve this population, including school counselors and other stakeholders.
School Counselors’ Role in Supporting the Haitian Students
According to the American School Counselor Association (ASCA; 2012) National Model, professional school counselors are to develop a comprehensive school counseling program that addresses the social, personal, academic, and career needs of students. Several approaches have been introduced to provide school counselors a pathway to supporting immigrant students, including parenting workshops for Jamaican parents (Morrison, Smith, Bryan, & Steele, 2016); community outreach programs on college preparation for first-generation Latinx students, families, and friends (Tello & Lonn, 2017); and a comprehensive, multilevel system of support that includes school–family–community partnerships for adolescent immigrants (Suárez-Orozco, Onaga, & de Lardemelle, 2010). A thorough search of the literature, particularly school counseling literature, yielded a dearth of information on working with Haitian students and their families. In light of the numerous challenges that this population faces, the scarcity of research support is disappointing. Therefore, the authors provide a guideline for school counselors to support their Haitian clients by using the Multiphase Model of Psychotherapy, Counseling, Human Rights, and Social Justice (MPM; Chung & Bemak, 2012). The MPM was developed by counselor educators as a culturally responsive intervention to support individuals from marginalized groups. The MPM is psychoeducational in nature and consists of “affective, behavioral, and cognitive interventions and prevention strategies that are rooted in cultural foundations and relate to social and community process and change” (Chung & Bemak, 2012, p. 2).
Multiphase Model of Psychotherapy, Counseling, Human Rights, and Social Justice (MPM)
The MPM was developed by Chung and Bemak (2012), who expertly recognized the need for a culturally sensitive approach to supporting refugees globally. Chung and Bemak indicated that an effective counselor is one who understands the importance of refugees’ historical, sociopolitical, cultural, and psychological context when dealing with displacement, loss, and trauma. The MPM was constructed as a trauma-based model that integrates humanistic trauma therapy, exposure therapy, stress inoculation approach, and cognitive behavior therapy, and is framed by the multicultural counseling competencies (Arredondo et al. 1996). According to Chung and Bemak, the MPM includes five phases: (a) mental health education; (b) group, family, and individual psychotherapy; (c) cultural empowerment; (d) indigenous healing; and (e) social justice and human rights. Each phase can be used independently of the other and can be adjusted based on the needs of the client. The following section expands on the five phases and incorporates practical interventions for school counselors.
Phase One: Mental Health Education
Mental health education focuses on defining the counseling process for the client. Haitian immigrant students might not have had exposure to counseling in the past; therefore, it is important for school counselors to thoroughly explain what counseling is about, what the expectations are, and the expected outcomes of counseling. Chung and Bemak (2012) also noted the importance of discussing the meaning of confidentiality in both the context of the U.S. counseling community and in the client’s native community. Confidentiality is an ethical consideration supported by ASCA as an obligation for school counselors (ASCA, 2014). Lazovsky (2008) remarked on the fact that laws and regulations regarding confidentiality may differ internationally, so it is important for the counselor to explain the meaning and objectives of using confidentiality as it relates to family and school. During this phase, school counselors should pay close attention to the experiences of marginalization and trauma that these students and their families may have faced and the psychological distress related to potential deportation. Mistrust of Americans may be an essential part of the Haitian family’s survival mechanism (Stepick, Stepick, & Kretsedemas, 2018); therefore, school counselors should be cautious in this phase to be culturally sensitive to the fears and anxiety that the student and family may be experiencing.
Phase Two: Group, Family, and Individual Psychotherapy
The second phase is focused on providing culturally relevant counseling techniques and strategies. To do so, the school counselor needs to understand the contextual background of the student. What have their experiences been either while in Haiti or within the United States? How has that student and the family been affected by natural disasters and sociopolitical experiences? Based on this information, the school counselor needs to decide on the most appropriate culturally relevant interventions for the student. Surveys and questionnaires are an ideal format for gathering information about the experiences of Haitian students and their families (Ekstrom, Elmore, Schafer, Trotter, & Webster, 2004). However, school counselors should be mindful of language barriers and provide surveys that have been translated in both English and Haitian Creole. Additionally, individual and group counseling sessions need to be adapted to meet the cultural needs of the Haitian student. For instance, singing, dancing, and spiritual guidance are an integral part of the Haitian culture (Marcus, 2010). School counselors should consider the collectivist cultures of the Haitian population, which may influence their decision to engage the students in small groups as opposed to individual counseling. By utilizing culturally relevant counseling approaches, school counselors might find small group expressive techniques to be beneficial for developing trust, while assessing the psychological needs of the student.
Phase Three: Cultural Empowerment
Cultural empowerment extends support for client needs beyond the counseling setting to community resources. This phase incorporates collaborating with multiple agencies. Examples of such agencies include housing services, social services, and health services. The school counselor can choose to develop a team approach with the school’s social worker and other school stakeholders and serve as the facilitator of services. The objective during this phase is to serve as an advocate and guide for the student and their family to reduce their levels of stress and anxiety as well as meet their basic needs. In fact, Chung and Bemak (2012) surmised that cultural empowerment goes beyond in-office counseling to the greater community, with helpers rallying for services and resources to meet the families’ basic needs. Finally, cultural empowerment may mean providing adequate interpretation services for students and families (Kretsedemas, 2005) so that all stakeholders fully understand each other and the processes that are at work. In fact, school counselors and educators have a civic obligation to provide interpretive services to students and parents with limited English proficiency (Office for Civil Rights, 2015).
Phase Four: Indigenous Healing
From the American viewpoint, counseling, therapy, medicine, and health care are considered important aspects of holistic healing. However, within the Haitian culture, indigenous healing has been noted as a longstanding cultural practice. It is not uncommon for individuals from the Haitian population to seek help from spiritual healers, herbal specialists, and midwives rather than more formalized Westernized therapy. In fact, many Haitians hold extreme faith in natural healing and may be hesitant to pursue counseling in the context of the United States. Furthermore, Haitian individuals often believe that illness is caused by supernatural forces (Nicolas, DeSilva, Grey, & Gonzalez-Eastep, 2006); therefore, it is not unusual for families to pursue help from family healers, spiritual healers, or folk medicine in seeking the supernatural cause of illnesses. Nicolas and colleagues (2006) noted that common beliefs may attribute illnesses to evil spirits, a poor relationship with God, or offending the Lwa, a deity associated with the voodoo religion. Although not all Haitians hold these indigenous views, there may be a general mistrust of mental health services. Counselors working with Haitian clients should be cautious to embrace culturally sensitive practices that combine Westernized practices with indigenous healing. Seeking consultation from a Haitian spiritual healer might be a first step in formulating an effective counseling approach. Nicolas and colleagues (2006) suggested seeking these healers through Haitian community centers and through communication with family members of the clients. Counselors should avoid assumptions and initiate conversations with Haitian clients to understand their beliefs and practices.
Phase Five: Social Justice and Human Rights
The final phase of the multiphase model focuses on counselors advocating for the rights of their clients. Haitian immigrants in the United States experience political discrimination. For example, recent threats of deportation and the termination of TPS protection can be discriminatory. At this phase, it is vital that counselors examine their own worldviews, community relations, and the role of politics and political policies in counseling, as well as the impact of social injustices (e.g., discrimination, oppression, racism) on the well-being of their clients (Chung & Bemak, 2012). Griffin and Steen (2011) mentioned nine steps that school counselors can employ as social justice advocates: develop cultural competence; use data to support work, particularly educational inequalities; gain allies, recognizing that the work cannot be done alone; speak up at school, at town hall meetings, and at board meetings, and write to state legislators; educate and empower parents and families; stay politically engaged and know what is happening in the current political environment; be bold and confident in beliefs; be persistent, understanding that systemic barriers may stand in the way of progress; and conduct research to demonstrate the needs for justice, equity, equality, and fairness. School counselors are inundated with multiple roles and as such may not have the time and/or resources to cover all nine steps mentioned. However, knowledge of these practical strategies may be helpful in their ethical decision making and development of a culturally sensitive, comprehensive school counseling program. Essentially, school counselors should be leading agents of change, seeking to provide culturally relevant services to their immigrant students.
Summary
Haitian children face various systemic challenges adjusting to the U.S. educational system and society. Given their unique challenges and needs, Haitian children require specialized, culturally responsive school counseling programs. To provide such programs, school counselors need practical strategies on how to provide culturally appropriate interventions that address the multiple systemic challenges to Haitian students’ well-being. However, school counselors may find it difficult to find such information given the dearth of school counseling literature concerning Haitian students. Therefore, this article provides practical guidelines using the MPM that may strengthen school counselors’ approach to providing culturally responsive services to Haitian students and their families.
Using the MPM, school counselors will be in a better position to explore the benefits of counseling with their Haitian families. The model encourages school counselors to assess the unique needs of the children and families within a cultural context. Moreover, by using this model, school counselors are encouraged to actively engage in collaborative partnerships with multiple agencies and professionals to meet the practical needs of Haitian families. Lastly, school counselors need to work beyond the structure of the office setting and integrate social justice advocacy work for systemic changes to maximize therapeutic changes for Haitian students and their families. The authors hope that this guideline will help school counselors to better understand the multiple layers of challenges for Haitian students, as well as how to provide culturally relevant support.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
References
American School Counselor Association. (2012). The ASCA National Model: A framework for school counseling programs (2nd ed.). Alexandria, VA: Author.
American School Counselor Association. (2014). The school counselor and confidentiality. Retrieved from https://www.schoolcounselor.org/asca/media/asca/PositionStatements/PS_Confidentiality.pdf
Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalizing of the multicultural counseling competencies. Journal of Multicultural Counseling and Development, 24, 42–78.
Asner-Self, K. K., & Marotta, S. K. (2005). Development indices among Central American immigrants exposed to war-related trauma: Clinical implications for counselors. Journal of Counseling & Development, 83, 162–171. doi:10.1002/j.1556-6678.2005.tb00593.x
Bachay, J. (1998). Ethnic identity development and urban Haitian adolescents. Journal of Multicultural Counseling and Development, 26(2), 96–109. doi:10.1002/j.2161-1912.1998.tb00190.x
BBC News. (2016, October 8). Hurricane Matthew: Haiti south ‘90% destroyed.’ Retrieved from https://www.bbc.com/news/world-latin-america-37596222
Bean, T., Derluyn, I., Eurelings-Bontekoe, E., Broekaert, E., & Spinhoven, P. (2006). Validation of the multiple language versions of the reaction of adolescents to traumatic stress questionnaires. Journal of Traumatic Stress, 19, 241–255. doi:10.1002/jts.20093
Chhuon, V., Hudley, C., Brenner, M. E., & Macias, R. (2010). The multiple worlds of successful Cambodian American students. Urban Education, 45, 30–57. doi:10.1177/0042085909352583
Chierici, R. (2004). Caribbean migration in the age of globalization: Transnationalism, race, and ethnic identity. Reviews in Anthropology, 33, 43–59. doi:10.1080/713649339
Chung, R. C.-Y., & Bemak, F. P. (2012). Social justice counseling: The next steps beyond multiculturalism. Thousand
Oaks, CA: Sage.
CNN. (2017). Haiti earthquake fast facts. Retrieved from https://www.cnn.com/2013/12/12/world/haiti-earthquak
e-fast-facts/index.html
Cone, N., Buxton, C., Lee, O., & Mahotiere, M. (2014). Negotiating a sense of identity in a foreign land: Navigating public school structures and practices that often conflict with Haitian culture and values. Urban Education, 49, 263–296. doi:10.1177/0042085913478619
Cook, J. (2017). 7 years after Haiti’s earthquake, millions still need aid. Retrieved from Huffington Post, https://www.huffingtonpost.com/entry/haiti-earthquakeanniversary_us_5875108de4b02b5f858b3f9c
Coupeau, S. (2008). The history of Haiti. Westport, CT: Greenwood Press.
Daugherty, A. (2018). TPS solution for Haitians not a priority in high-stakes immigration debate. Retrieved from http://www.miamiherald.com/news/politics-government/article198879294.html
Desrosiers, A., & St. Fleurose, S. (2002). Treating Haitian patients: Key cultural aspects. American Journal of Psychotherapy, 56, 508–521.
Doucet, F. (2005). Divergent realities: The home and school lives of Haitian immigrant youth. Journal of Youth Ministries, 3(2), 37–65.
Douyon, R., Marcelin, L .H., Jean-Gilles, M., & Page, J. B. (2005). Response to trauma in Haitian youth at risk. Journal of Ethnicity in Substance Abuse, 4(2), 115–138. doi:10.1300/J233v04n02_06
Ekstrom, R. B., Elmore, P. B., Schafer, W. D., Trotter, T. V., & Webster, B. (2004). A survey of assessment and evaluation activities of school counselors. Professional School Counseling, 8, 24–30.
Fifield, J. (2016). After Hurricane Matthew, Haitians hope for change in US policy. Retrieved from The Pew Charitable Trusts: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/10/21/after-hurricane-matthew-haitians-hope-for-change-in-us-policy
Griffin, D., & Steen, S. (2011). A social justice approach to school counseling. Journal for Social Action in Counseling & Psychology, 3, 74–85.
Hernandez, D. J., Denton, N. A., & Mcartney, S. E. (2009). School-age children in immigrant families: Challenges and opportunities for America’s schools. Teachers College Record, 111, 616–658.
Kretsedemas, P. (2005). Language barriers and perceptions of bias: Ethnic differences in immigrant encounters with the welfare system. The Journal of Sociology & Social Welfare, 32(4), 109–123.
Lazovsky, R. (2008). Maintaining confidentiality with minors: Dilemmas of school counselors. Professional School Counseling, 11, 335–346.
Levitt, M. J., Lane, J. D., & Levitt, J. (2009). Immigration stress, social support, and adjustment in the first postmigration year: An intergenerational analysis. Research in Human Development, 2, 159–177.
Little, C. (2010). Immigration reform needed for U.S. economy and for Haiti. CNN Opinion. Retrieved from http://www.cnn.com/2010/OPINION/05/07/little.haiti.immigrants/index.html
Marcus, E. (2010). PTSD manifests differently in Haitian patients, says researcher. Retrieved from The Huffington Post: https://www.huffingtonpost.com/erin-marcus/ptsd-manifests-differentl_b_580825.html
Mendelson-Forman, J. (2006). Security sector reform in Haiti. International Peacekeeping, 13, 14–27. doi:10.1080/13533310500424629
Migration Policy Institute. (2017). Haitian immigrants in the United States. Retrieved from https://www.migration
policy.org/article/haitian-immigrants-united-states/
Morrison, S. S., Smith, D. E., Bryan, J. A., & Steele, J. M. (2016). An exploratory study of the child disciplinary practices of Jamaican immigrant parents in the United States: Implications for school counselors. Journal of School Counseling, 14(5). Retrieved from http://jsc.montana.edu/articles/v14n5.pdf
Nicolas, G., DeSilva, A. M., Grey, K. S., & Gonzalez-Eastep, D. (2006). Using a multicultural lens to understand illnesses among Haitians living in America. Professional Psychology: Research and Practice, 37, 702–707. doi:10.1037/0735-7028.37.6.702
Office for Civil Rights. (2015). Schools’ civil rights obligations to English learner students and limited English proficient parents. Retrieved from https://www2.ed.gov/about/offices/list/ocr/ellresources.html
Park, M. (2018). Trump administration ended protected status for 250,000 Salvadorans. These immigrants might be next. Retrieved from CNN Politics: https://www.cnn.com/2018/01/09/politics/temporary-protected-status-countries/index.html
Phelps, L. D., & Johnson, K. E. (2004). Developing local public health capacity in cultural competency: A case study with Haitians in a rural community. Journal of Community Health Nursing, 21, 203–215. doi:10.1207/s15327655jchn2104_1
Potocky, M. (1996). Refugee children: How are they faring economically as adults? Social Work, 41, 364–373.
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44, 28–48. doi:10.1002/jmcd.12035
Solano-Flores, G., & Li, M. (2006). The use of generalizability (G) theory in the testing of linguistic minorities. Educational Measurement: Issues and Practice, 25, 13–22. doi:10.1111/j.1745-3992.2006.00048.x
Stepick, A., & Stepick, C. D. (2002). Becoming American, constructing ethnicity: Immigrant youth and civic engagement. Applied Developmental Science, 6, 246–257. doi:10.1207/S1532480XADS0604_12
Stepick, A., Stepick, C. D., & Kretsedemas, P. (2018). Civic engagement of Haitian immigrants and Haitian Americans in Miami-Dade County. Retrieved from https://www.researchgate.net/publication/268441078_Civic_Engagement_of
_Haitian_Immigrants_and_Haitian_Americans_in_Miami-Dade_County
Suárez-Orozco, C., Onaga, M., & de Lardemelle, C. (2010). Promoting academic engagement among immigrant adolescents through school-family-community collaboration. Professional School Counseling, 14, 15–26.
Tello, A. M., & Lonn, M. R. (2017). The role of high school and college counselors in supporting the psychosocial and emotional needs of Latinx first-generation college students. The Professional Counselor, 7, 349–359. doi:10.15241/amt.7.4.349
U.S. Department of State. (2018). U.S. relations with Haiti. Retrieved from https://www.state.gov/r/pa/ei/bgn/198
2.htm
Wiley, D. (2013, June 13). New study findings on mixed-status immigrant families: Threat of family separation affects health of the children. Retrieved from https://ccf.georgetown.edu/2013/06/13/new-study-findings-on-mixed-status-immigrant-families-threat-of-family-separation-affects-health-of-the-children/
Zissis, C. (2010). The Haitian immigration debate. Council of the Americas. Retrieved from https://www.as-oa.org/
articles/haitian-migration-debate
- M. Ann Shillingford is an associate professor at the University of Central Florida. Seungbin Oh, NCC, is a doctoral candidate at the University of Central Florida. Amanda DiLorenzo is a doctoral student at the University of Central Florida. Correspondence can be addressed to M. Ann Shillingford, P.O. Box 161250, Orlando, FL 32816, Dr-S@ucf.edu.
Jun 28, 2018 | Volume 8 - Issue 2
Kristi A. Lee, Daniel J. Kelley-Petersen
The focus on human development is foundational to the field of counseling, with its importance codified in guiding documents and frameworks, such as the American Counseling Association’s Code of Ethics (2014). Many developmental theories have been established using single-gender or single-culture groups, yet they claim universal application to all humans. Although counseling students must learn these theories because of accreditation standards and licensure requirements, counselor educators need to prepare students for practice in a multicultural world. Counselors are now called to act as social justice advocates, and teaching strategies are needed to prepare students for this role. This study’s focus is on the use of service learning with community counseling students in a human development course. Results from a content analysis demonstrate how service learning enhances learning and broadens students’ perceptions of themselves, others, and social justice in counseling. Findings indicate a shift in participants’ perception of social justice in counseling.
Keywords: service learning, social justice, human development, developmental theories, content analysis
Distinct from the medical model that underlies psychology, the field of counseling has historically focused on developmental processes as the foundation to understanding what makes human life function well (Brady-Amoon, 2011; Kraus, 2008; Lewis, 2011; Stennbarger & LeClair, 1995). These processes of development are explained through theories about learning, normal personality development, and individual and family development, among others (Council for the Accreditation of Counseling & Related Educational Programs [CACREP], 2015). The American Counseling Association (ACA) identified “enhancing human development throughout the lifespan” as the first core value of the counseling profession (2014, p. 3). Further, human development has been established as one of eight knowledge areas by CACREP (2015), the national accrediting body for counselor education programs. Additionally, standardized tests, such as the National Counselor Examination for Licensure and Certification, require students to demonstrate mastery of studies that provide an understanding of the nature and needs of individuals at all developmental levels (National Board for Certified Counselors [NBCC], 2015).
Although understanding and promoting healthy human development across the lifespan are central themes in counselor education, there are critiques of the study of human development (Brady-Amoon, 2011). Many theories and models of human development reflect middle-class, Caucasian-American value systems and culture (Brady-Amoon, 2011; Broderick & Blewitt, 2015; Dixon, 2001; Henrich, Heine, & Norenzayan, 2010), and thus lack utility in developing both a robust and a nuanced understanding of groups who are outside of this demographic. Broderick and Blewitt (2015) stated that there is a “growing concern that traditional theories are insufficient to explain development because they are biased in favor of single-culture or single-gender models” (p. 351). The role of culture in human development is crucial to consider (Rogoff, 2003), yet many theories consider culture an extraneous variable. Systematic misapplication of theories designed for the dominant population may not adequately account for the accepted indicators of development for diverse cultural and societal contexts (Broderick & Blewitt, 2015;
Dixon, 2001; Kraus, 2008). Recognizing challenges in applying developmental theories to diverse populations is critical for counselors who promote social justice in counseling and in society (Kiselica & Robinson, 2001; MacLeod, 2013).
The Movement Toward a Social Justice Perspective in Counseling
Counselors have a unique position as frontline witnesses to how social inequities impact clients. Individual, couples, family, and group counseling are critical in helping clients in non-dominant groups navigate and survive systems of oppression and opportunity. However, these modalities of counseling may not be sufficient to prevent or meaningfully address mental health issues that have systemic causes (Toporek, Gerstein, Fouad, Roysircar, & Israel, 2006). The recognition for the need to adjust counseling approaches to work with issues of healthy human development in a pluralistic society has contributed to the growth of the social justice movement within the field of counseling (Ratts & Wood, 2011). At times identified as the “fifth force” (Ratts, 2009) in counseling, the social justice perspective not only addresses the individual needs of clients, but also seeks to change systems that inhibit human development for oppressed groups. Counselors are challenged to determine how to balance individual counseling interventions with advocacy interventions on local, state, or national levels. A social justice approach to counseling emphasizes the importance of healthy human development for individuals and social groups and necessitates a broader array of skills, knowledge, and perspectives, including advocacy skills (Bemak & Chung, 2011; Brady-Amoon, 2011; Lewis, 2011; Ratts, 2009).
Acceptance of the social justice counseling perspective is evidenced by its codification in important documents that guide many practitioners and educators in the field of counseling. In the preamble to the 2014 Code of Ethics, ACA identified “promoting social justice” (p. 3) as a core principle. Ethical counselors are called to “advocate at individual, group, institutional, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients” (2014, p. 5). In 2003, ACA endorsed the Advocacy Competencies (Lewis, Arnold, House, & Toporek, 2002), a document that describes skills and activities for counselor advocacy. Additionally, the 2016 CACREP standards call for preparation of counselors in “advocacy processes needed to address institutional and social barriers that impede access, equity, and success for clients” (2015, p. 10). These documents provide evidence that segments of the profession of counseling, particularly some counselor education programs, are embracing a social justice perspective that can be enacted through counselor advocacy.
Although many counselors may want to advocate for marginalized populations, they may not be comfortable doing so or they may not know how (West-Olatunji, 2010). Further, it is unclear whether counselor educators are adequately preparing students with the skills necessary to practice from a social justice perspective upon graduation (Bemak & Chung, 2011; Constantine, Hage, Kindaichi, & Bryant, 2007). Preparing counselors with effective and culturally relevant advocacy skills for work in today’s pluralistic society requires that counselor educators rethink historically used teaching methods (Brady-Amoon, Makhija, Dixit, & Dator, 2012; Burnett, Long, & Horne, 2005; Herlihy & Watson, 2007; Hoover & Morrow, 2016; Manis, 2012). Rethinking traditional teaching methods and curricula is particularly important for courses such as human development, which have traditionally focused on universalist theories established using single-gender or single-culture groups (Broderick & Blewitt, 2015). However, for the foreseeable future students will be required to demonstrate their mastery of these traditional theories on licensing exams (NBCC, 2015). To meet the dual challenge of preparing students for licensure and preparing them for practice in a pluralistic society, new teaching approaches are needed. The role of social justice advocacy has been conceptualized as central for counselors (Chang, Crethar, & Ratts, 2010; Lewis, Lewis, Daniels, & D’Andrea, 1998), yet few studies have demonstrated how to prepare students for this role.
Service Learning: A Pedagogy for Counselor Education
Defining Service Learning
Teaching that is active, experiential, and addresses real-world problems is needed to meet the call to prepare students as social justice advocates in the context of rapidly changing and diversifying demographics (Bemak, Chung, Talleyrand, Jones, & Daquin, 2011; Constantine et al., 2007; Manis, 2012). As an experiential teaching strategy that combines academic content learned in the classroom with activities in the community that address “human and community needs” (Jacoby, 2015, p. 6), service learning provides a potential avenue for more adequately preparing counseling students for work in today’s pluralistic society.
Although similar to experiential learning, service learning has a set of characteristics that make it distinct from internships and volunteerism (Furco, 2002). With an emphasis on collaboration with community partners (CPs) who represent historically marginalized communities, all participants enter the service-learning experience as learners and as contributors. Community members and students benefit from a collaborative learning partnership through which a solution to a community-articulated problem is developed (Warter & Grossman, 2002).
Service learning can take two forms: placement-based and project-based. Placement-based service learning usually involves a requirement for students to spend a set number of hours at a community organization where a student completes agreed-upon tasks (Parker-Gwin & Mabry, 1998). In project-based service learning, small student groups work with CP organizations on specific projects that help to meet a need or solve a community-articulated problem (Hugg & Wurdinger, 2007).
Service Learning in Counselor Education
A growing number of counselor educators have called for the use of service learning within counselor education to provide students with an avenue for understanding complex systemic social inequities (Bemak & Chung, 2011; Bemak et al., 2011; Constantine et al., 2007; Manis, 2012). Additionally, the use of service learning within counselor education has been the focus of a limited number of studies. A qualitative study by Jett and Delgado-Romero (2009) focused on the impact of using service learning with pre-practicum counseling students. Results showed that service learning “was perceived to facilitate student counselors’ professional development” (p. 116) through promoting a deeper understanding of counselors’ roles and contexts. Exposure to counseling environments promoted student counselors’ understanding of what counseling is, as opposed to what they imagined it to be (Jett & Delgado-Romero, 2009).
Service learning also has been found to increase multicultural competencies in counseling students. In utilizing service learning in a multicultural counseling class, Burnett, Hamel, and Long (2004) found that it provided “an opportunity to build community learning and cultural sensitivity” (p. 190). They found that service learning had merit in multicultural counseling competency training and in reducing a “missionary ideology” (p. 191) in students. These results suggest that service learning can be a useful strategy for helping students understand how to advocate with and on behalf of marginalized communities. In addition, service learning may give students the opportunity to practice advocacy skills in real-world contexts.
In order to explore the relationship between service learning and students’ understanding of the role of social justice advocacy in counseling, the present study documented and analyzed community counseling students’ experiences in project-based service learning in a human development course in a CACREP-accredited program. The study’s research question has four foci: In what ways does the use of service learning in a human development course impact students’ (a) understanding of course content; (b) understanding of development of people in non-dominant populations; (c) perceptions of themselves; and (d) understanding of a social justice perspective in counseling?
Method
Description of Participants and Sampling Procedures
The study included data from 40 participants. Seventy-six percent of participants identified as female, 24% identified as male, and no participant identified as “other,” an option allowing for non-binary gender identities. Participants’ age range was 22 to 56 with an average age of 31, and they identified with the following race or ethnic categories: Black, 5%; Hispanic, 22%; Native American, 2%; Two or More Races, 10%; White, 49%; and No Response, 12%.
To gain a broad understanding of students’ experiences, data from nearly all community counseling students (hereafter called participants) who participated in the course over four academic terms were included in the study. The data for one student was left out of the study because of participation in the research process. Each participant was in the first of a three-year community counseling program while enrolled in the course with service learning. The program was in its final cycle of CACREP
re-accreditation as a community counseling program at the time the data were collected. This study was approved by its host institution’s Internal Review Board.
Class as Context
Service learning is grounded in a specific “academic house” (Lee & McAdams, 2017) that informs the type of service activities. The academic house for the current research project was a course designed to meet the CACREP human growth and development curriculum requirement. Entitled Counseling Across the Lifespan, it was positioned as the first course in a three-year community counseling program located in a private, urban, medium-sized university in the northwest region of the United States. Taught over a 10-week academic term, the course utilized a text that covered theories and models of human development across the lifespan (i.e., theories of learning, personality development, cognitive development, ecological models). Course elements included reading, class lectures, small and large group discussions, papers, and quizzes. Many theories of development included in the course to help students meet the requirements of licensure were developed using a single-gender, monocultural group. To incorporate a social justice perspective, the course instructor (first author) believed it was essential for students to understand how Euro-Western theories of development may or may not apply to populations for whom they were not developed. To provide context for critical analysis of class content, students engaged in a major class project, the Developmental Service-Learning Project (DSLP).
Developmental service-learning projects. In keeping with high-quality service-learning pedagogy with a social justice focus, the DSLPs were designed in collaboration with CP organizations working with marginalized populations. The primary instructor worked with a center on campus that supported faculty in developing service-learning courses to identify potential partners whose organizations serve people across the lifespan. Project examples included needs assessments, resource manual development, and socio-emotional lesson plan development. All project ideas were suggested by CPs and planned collaboratively with the course instructor. CPs visited class to introduce their organizations and projects to students during the second class session. Students then selected a project and met with their CPs during class time to launch the collaborative project work.
The DSLP had several requirements. For students to gain an understanding of the organization and the population with whom they were working, students visited the site under the supervision of the CP. Each project included the development of a product that could go into immediate use at the CP organizations and that would continue to benefit the site after the project ended. Students also were required to read, analyze, and report how relevant scholarly literature informed their project work. A project proposal detailing what would be accomplished during the DSLP was submitted for approval to the CP and the course instructor. Upon approval, students carried out their projects while remaining in contact with their CPs. During the study’s time period, there were a total of 24 completed DSLP projects. In collaboration with CPs, students completed projects on curriculum development, program evaluations, needs assessments through focus groups and interviews, and intake process development, among others. CP organizations served individuals across the lifespan and in historically marginalized communities ranging from a program on kindergarten readiness with refugee families, to developing resources for housing for an older African immigrant community.
CPs attended the final class session for DSLP group presentations. Partners asked questions, gave verbal feedback, and completed formal written evaluations of the projects. Project groups wrote a final report for their CP detailing their work and product. Digital and physical copies of all products were given to CPs for their continued use. The last class session served to celebrate partnerships and accomplishments. After the term ended, the course instructor met with each CP to discuss the experience, solicit feedback, and plan future collaborations; several CPs collaborated on projects over multiple academic terms.
Data Collection and Analysis
Data were collected from three sources, each a required class assignment. The first two sources were reflection papers—one written by participants at midterm, and one at the end of the term. The third assignment was a self-evaluation completed by participants at the end of the DSLP experience. Participants responded to specific prompts such as “Did your experience with the Developmental Service-Learning Project impact your comprehension of the material from the text and lectures? If so, how?” and “Through the Developmental Service-Learning Project, what did you learn about: Yourself? Your community? Working with people who may have had a different developmental trajectory than you?”
Content analysis is a qualitative methodology that can be used for analyzing and drawing meaning from large amounts of textual data. It allows for the “subjective interpretation of the content of text or data through the systematic classification process of coding and identifying themes or patterns” (Hsieh & Shannon, 2005, p. 1278). This methodology has been widely used in counselor education research (Avent, Wahesh, Purgason, Borders, & Mobley, 2015; Burkholder, Hall, & Burkholder, 2014; Cook, Hayden, Gracia, & Tyrrell, 2015).
Using content analysis of secondary data, researchers analyzed existing textual data collected from study participants enrolled in the course over four academic terms, for a total of 120 documents (N = 40 students with three documents each). To maintain participants’ confidentiality and to minimize possible researcher bias, all identifying information was removed from the data sources by the first author prior to analysis. Each participant was assigned a numerical identifier linking them to the course section in which they participated. These identifiers were kept in an Excel file that was password protected and was kept away from the rest of the data in order to reduce bias.
Data were analyzed in two phases to identify central themes associated with the participants’ experiences and perceptions with DSLP. First, data corresponding to each of the four foci of the research question were grouped into the following a priori categories: (a) understanding of course content,
(b) understanding of human development in non-dominant groups, (c) perception of self, and (d) a social justice perspective in counseling. During the second phase of analysis, data within each category were coded by meaning units, which was defined as a collection of words, sentences, or paragraphs that referred to a discrete idea. Closely related codes were collapsed into themes. Researchers used NVivo 10 (QSR International, 2012) for the coding process and to calculate interrater reliability statistics.
Trustworthiness
During the study, the researchers engaged in several strategies to ensure the study’s trustworthiness. The research team consisted of the course instructor and a graduate student research assistant who was trained in the research procedures. Prior to the study’s design and again before data analysis, researchers examined their potential biases. As recommended by Rossman and Rallis (2003), researchers engaged in reflexivity through writing, discussing, and revising researcher-as-instrument statements throughout the process. This process was done to bracket the researchers’ beliefs and opinions to ensure that the participants’ voices could be heard fairly and clearly.
Data were collected from documents that participants completed at two different points during the academic term (midterm and end of term), providing the basis of a longitudinal analysis. At the beginning of data analysis, researchers spent several hours coding data together to support shared meaning of codes and ensure credibility of the analysis. Additionally, researchers engaged in peer debriefing of codes and the coding process at weekly research meetings. Within each phase of coding, the researchers calculated interrater reliability statistics in NVivo 10 (QSR International, 2012) to determine the credibility of the analysis. After each coding session, researchers documented their reflections, questions, and ideas in a reflexive journal designed to document decision making related to the analysis. An audit trail was kept ensuring confirmability of the study’s findings.
Interrater Reliability
During each phase of coding, researchers conducted interrater reliability testing using NVivo 10 (QSR International, 2012) to ensure credibility of the coding process. In the first phase of grouping data into four a priori categories for further coding, an interrater reliability test resulted in a kappa coefficient of .68. This outcome is considered a “substantial” benchmark for kappa coefficients by Landis and Koch (1977). During the second phase of coding into emergent categories, the kappa coefficient for data that was coded by both researchers was .96. This is an “almost perfect” benchmark for kappa coefficients (Landis & Koch, 1977). These results demonstrated that raters consistently coded the data in a similar matter and increased the data’s credibility.
Results
The study’s results indicated the level of impact the DSLP experience had on participants’ understanding of course content, understanding of people in non-dominant groups, perceptions of themselves, and what social justice in a counseling context meant to them. For participants, the DSLP experience became a lens to look at the world in a different way and was a primary frame of reference for the course. In this section, results for each of the four a priori categories is reported, including qualitative results from the content analysis, as well as a narrative description of the data’s emergent themes.
Understanding of Course Content
The first a priori category focused on the impact of the DSLP on participants’ understanding of content in the human development course. Content analysis resulted in 374 meaning units that coalesced into two themes: connecting class material and reflections on learning.
Participants articulated coming away with a more complex and nuanced understanding of seemingly straightforward developmental theories because of the DSLP experience. The messiness of lived experience became real in a way participants did not believe the theories always described. For example, one participant stated that the DSLP experience “muddied the overly clear waters of the text’s simplistic approach to the behavior of complex systems. The service-learning project was a much more realistic approach, introducing us to complex systems and their interactions.” The hands-on nature of the DSLP, as well as the real-world context it provided, facilitated learning that participants described as broader, deeper, and more relevant to their professional futures. Participants reported that the class content was more accessible, more understandable, and easier to absorb because of the DSLP experience. One participant stated that the service-learning experience “required me to broaden my scope of what we were learning in the class. The focus can often be narrow in the classroom setting, but we were able to consider the ‘big picture’ in a realistic way because of this project.”
Further, the context provided by the service-learning experience offered the opportunity for critical analysis of class content. Consistencies and inconsistencies between class content and the lives of the people at their DSLP sites became apparent to participants. Many times, students came away realizing the gaps between theoretical models and lived experiences, particularly for people in non-dominant groups. One participant stated that the experience “made me more critical of the dominant views of development presented in our text. . . . While I understand there are certain fundamental human needs, I really believe in thinking about context as much as content.”
Human Development in Non-Dominant Groups
The next a priori category focused on how the experience with the DSLP impacted participants’ understanding of development of people in non-dominant groups. As CP agencies worked with populations outside the dominant culture, the DSLP provided an opportunity for participants to learn about these groups. Data analysis resulted in 291 meaning units in five themes: access to resources, creating community, cultural awareness, cultural differences, and systems of oppression.
Because of the DSLP experience, participants noted better understanding of the challenges a person in a non-dominant group faces when creating or maintaining their identity. Several participants reported seeing community members’ struggles by incorporating a social construct or standard that did not fit with their own cultural experiences. One participant stated, “As an immigrant parent, the stress is likely increased because the ‘outside influences’ are coming from a culture that is at the very least unfamiliar, and at worst, in conflict with cultural values important to the parents.”
Participants observed a strong sense of resiliency in community members as they overcame obstacles to seek out support. Participants identified that engaging in wellness activities and having a sense of purpose and pride in their lives contributed to resiliency for community members. These wellness activities included groups offered at mental health agencies and informal gatherings where stories and experiences were shared. A participant stated that at her DSLP site she witnessed “strength and resiliency with which people can create meaning and community that is not based on dominant cultural values.”
Furthermore, participants witnessed that when faced with conflicts or challenges, community members found support by referring to their own cultural values and norms. A participant stated, “For an immigrant in a new country, believing that there are others around who not only speak the same language, but have the same values and interests can be powerful in promoting feelings of efficacy instead of helplessness.”
Perceptions of Self
The third a priori category focused on how the DSLP experience impacted participants’ perceptions of themselves. Content analysis resulted in 227 meaning units with three themes that focused on working with new populations, their personal role in social justice, and specific work-related skills.
As CP organizations worked with marginalized communities, such as the East African immigrant community and the youth of the Asian and Pacific Islander community, most participants interfaced with communities with whom they had not previously worked. These interactions spurred participant reflection on the similarities and differences between themselves and those with whom they were working. Participants expressed surprise in what they learned about communities new to them, expecting to find more similarities or more differences. One participant stated, “As a first-generation person, I assumed that I could relate to the issues that the families face. However, I learned that their experience here in (location) is much different than the one I had growing up.” Another participant stated, “Although the students that were in the (CP program) may have a different developmental trajectory than me, there were still many similarities between us. Their values and work ethic reflected the same as mine.”
The interaction with CPs and clients through the DSLP provided a lens for participants to see how structural inequities in society impact the health and development of people in marginalized groups. Because of this, participants were better able to see and understand their own privilege, whether that privilege was related to race, gender, socioeconomic status, or educational attainment. One participant stated, “To be able to briefly see through the eyes of another individual who does not have the same background or privilege as I do, I am better able to understand my own privilege.” Another participant stated, “We all have our own biases and stereotypes and maybe even racist ideologies that we need to get rid of.”
Many participants articulated their perspectives on what social justice meant to them personally and how to move social justice goals in society forward. These were general definitions of social justice not specific to how social justice related to counseling. One participant said, “I believe that being an advocate for social justice involves understanding that many factors in people’s lives influence their development, and that not everyone has equal opportunity to environments conducive to healthy development.” Another participant stated, “To me, social justice means recognizing human dignity across social categories and engaging in some way to distribute power more equitably among people.”
A Social Justice Perspective in Counseling
The final a priori category was focused on how engagement in the DSLP experience impacted participants’ understanding of a social justice perspective in counseling. Data analysis resulted in 416 meaning units with three themes: definitions of social justice in counseling, counselor social justice knowledge, and counselor action through advocacy.
Participants articulated what social justice in the counseling sphere meant to them. One participant stated, “In order to successfully incorporate a social justice approach to counseling, socioeconomic status, culture, academic proficiencies and group membership must be considered.” Empowerment was identified by multiple participants as key to social justice approaches to counseling. According to one participant, “Empowering individuals is at the heart of social justice.” Additionally, participants pointed to understanding each client as a whole individual, including their unique social location, as important in counseling from a social justice perspective.
Participants shared new knowledge of recognizing systems that impacted people in non-dominant groups and acknowledging that the external factors of barriers and injustices may play a role in the need for mental health services. One participant said, “A counselor can promote social justice by helping clients identify the foundation of their behavior and understand that their feelings of insecurity are valid.”
Participants identified that a social justice perspective in counseling included a call to advocate for clients. One participant defined advocacy as, “Part of being a therapist who believes in social justice is advocating for and empowering those individuals who feel they have no voice or feel their voice has been extinguished through societal or institutional oppression.” Participants stated that the goal of social justice counseling was, in fact, to strengthen and support the resiliency of their clients who experience challenges brought on by external factors. One person said, “Social justice advocacy seeks not only to fight oppression but to empower individuals and communities that have been historically oppressed to be self-determinant to live lives of meaning and hope through equitable redistribution of resources, power, and opportunities.”
Discussion
The results of this study offer insight about how using service learning in a human development course impacted community counseling students. Because these findings document a shift in understanding the nature of human development in a pluralistic society, they may be useful for counselor educators who teach human development and who strive to prepare counseling students with a social justice perspective.
The Teaching and Learning of Human Development
As a core curricular area of accredited programs, coursework in human development is required for all counseling students (CACREP, 2015). Students who seek to become licensed counselors must demonstrate their mastery of this content area on national exams (NBCC, 2015). Therefore, counselor educators have an obligation to prepare students with this knowledge base. However, universalist theories of human development may not sufficiently explain development of all groups in a society (Broderick & Blewitt, 2015; Henrich et al., 2010). There is growing acknowledgement that often embedded in models are the worldviews of those who developed them (Rogoff, 2003). Counselor educators are called to teach human developmental theory in such a way that students will be able to responsibly apply (or not apply) theories to clients from whom and for whom they were not developed.
This study’s findings demonstrate that service learning provides participants with a deeper and more nuanced understanding of human development course content through its application in real settings. Participants witnessed how theories did not always match the lives of people at their service-learning sites. Further, participants articulated witnessing how systems of oppression negatively impacted the development of marginalized people. These results build on the evidence that the use of service learning can promote multicultural competence (Burnett et al., 2004) and help students be more prepared to move into the professional role of counselor with a more realistic perspective of what the role means (Jett & Delgado-Romero, 2009).
Preparing Counseling Students as Social Justice Advocates
According to the Code of Ethics (ACA, 2014), counselors should be ready to advocate for removing barriers to healthy growth and development, yet specific strategies for preparing students to do so are lacking. Participation in collaborative service learning focused on important issues for marginalized populations facilitates new awareness of what social justice counseling means. The need for counselors to be aware of their own privilege was stated clearly by participants. In addition, being a counselor for social justice also meant advocating for clients at multiple levels. Working with CPs provided opportunities to witness important work in the community and to practice enacting social justice advocacy. The results demonstrate that service learning can be used as a teaching strategy to meet CACREP requirements and to meet the call for using new “structures, requirements, and goals” (Constantine et al., 2007, p. 27) to prepare students as social justice advocates.
Limitations and Future Research
This study’s findings demonstrated that service learning can be used to teach academic content as well as promote students’ understanding of social justice and advocacy. However, limitations are important to note. First, the primary researcher was the course instructor and the co-researcher participated in the class as a student, although data for the co-researcher was not included in the analysis. Although steps were taken to ensure trustworthiness and authenticity, future studies should include an outside researcher to strengthen the methodology. Second, data for the study was drawn from written text. As such, there were no opportunities to ask participants follow-up or clarifying questions. Although content analysis was chosen to examine the participants’ experiences of the DSLP while they were occurring, future studies using interviews or focus groups could provide more sources of data. Third, the current study focused only on the student experience in the DSLP. Although CPs were involved in every aspect of project creation, execution, and evaluation, they were not included in the systematic study of outcomes. Future studies should examine the impact of service learning on CPs, clients, and communities.
Conclusion
The demographics of the United States are rapidly changing, and soon there will be no one majority group (Cárdenas, Ajinkya, & Gibbs Léger, 2011). Continuing to teach monocultural theories is no longer sufficient; it risks further marginalizing non-dominant groups in society. If we were to better understand how different groups and cultures experience development through their own lenses and a shared pluralistic lens, the problem of applying theories to those from whom and for whom they were not developed would be eliminated. Counselor educators should work with CPs and community members to develop, research, and apply culturally appropriate theories of human development. Until that time, counselor educators must use effective teaching strategies that prepare students to work responsibly and competently in a multicultural world. Service learning, as an educational tool for social justice in counselor education, can contribute to meeting this need.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest or funding contributions for the development of this manuscript.
References
American Counseling Association. (2014). 2014 ACA code of ethics. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=4
Avent, J. R., Wahesh, E., Purgason, L. L., Borders, L. D., & Mobley, A. K. (2015). A content analysis of peer feedback in triadic supervision. Counselor Education and Supervision, 54, 68–80.
doi:10.1002/j.1556-6978.2015.00071.x
Bemak, F., & Chung, R. C. (2011). Application in social justice counselor training: Classroom without walls. The Journal of Humanistic Counseling, 50, 204–219. doi:10.1002/j.2161-1939.2011.tb00119.x
Bemak, F., Chung, R. C., Talleyrand, R. M., Jones, H., & Daquin, J. (2011). Implementing multicultural social justice strategies in counselor education training programs. Journal for Social Action in Counseling & Psychology, 3, 29–43.
Brady-Amoon, P. (2011). Humanism, feminism, and multiculturalism: Essential elements of social justice
in counseling, education, and advocacy. Journal of Humanistic Counseling, 50, 135–148. doi:10.1002/j.2161-1939.2011.tb00113.x
Brady-Amoon, P., Makhija, N., Dixit, V., & Dator, J. (2012). Social justice: Pushing past boundaries in graduate training. Journal for Social Action in Counseling & Psychology, 4, 85–98.
Broderick, P. C., & Blewitt, P. (2015). The life span: Human development for the helping professions (4th ed). Boston, MA: Pearson.
Burkholder, D., Hall, S. F., & Burkholder, J. (2014). Ward v. Wilbanks: Counselor educators respond. Counselor Education and Supervision, 53, 267–283. doi:10.1002/j.1556-6978.2014.00062.x
Burnett, J. A., Hamel, D., & Long, L. L. (2004). Service learning in graduate counselor education: Developing multicultural counseling competency. Journal of Multicultural Counseling and Development, 32, 180–191. doi:10.1002/j.2161-1912.2004.tb00370.x
Burnett, J. A., Long, L. L., & Horne, H. L. (2005). Service-learning for counselors: Integrating education, training, and the community. The Journal of Humanistic Counseling, Education, and Development, 44, 158–167. doi:10.1002/j.2164-490X.2005.tb00028.x
Cárdenas, V., Ajinkya, J., & Gibbs Léger, D. (2011). Progress 2050: New ideas for a diverse America. Retrieved from https://cdn.americanprogress.org/wp-content/uploads/issues/2011/10/pdf/progress_2050.pdf
Chang, C. Y., Crethar, H. C., & Ratts, M. J. (2010). Social justice: A national imperative for counselor education and supervision. Counselor Education and Supervision, 50(2), 82–87.
doi:10.1002/j.1556-6978.2010.tb00110.x
Constantine, M. G., Hage, S. M., Kindaichi, M. M., & Bryant, R. M. (2007). Social justice and multicultural issues: Implications for the practice and training of counselors and counseling psychologists. Journal of Counseling & Development, 85, 24–29. doi:10.1002/j.1556-6678.2007.tb00440.x
Cook, A. L., Hayden, L. A., Gracia, R., & Tyrrell, R. (2015). Exploring outcomes of a targeted supervisory training curriculum on developing multicultural competency and social justice advocacy. Outcome-Based Program Evaluation, 6(2), 126–140. doi:10.1177/2150137815594201
Council for the Accreditation of Counseling & Related Educational Programs. (2015). 2016 CACREP standards. Retrieved from http://www.cacrep.org/wp-content/uploads/2018/05/2016-Standards-with-Glossary-5.3.2018.pdf
Dixon, G. (2001). The development of course content: Teaching child development from a multicultural perspective. National Association of African American Studies & National Association of Hispanic and Latino Studies: 2000 Literature Monograph Series. Retrieved from https://files.eric.ed.gov/fulltext/ED456182.pdf
Furco, A. (2002). Is service-learning really better than community service? A study of high school service program outcomes. In A. Furco & S. H. Billig (Eds.), Service-learning: The essence of the pedagogy (pp. 23–50). Greenwich, CT: Information Age Publishing.
Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world? Behavioral and Brain Sciences, 33(2/3), 61–83. doi:10.1017/S0140525X0999152X
Herlihy, B. R., & Watson, Z. E. P. (2007). Social justice and counseling ethics. In C. C. Lee (Ed.), Counseling for social justice (2nd ed., pp. 181–198). Alexandria, VA: American Counseling Association.
Hoover, S. M., & Morrow, S. L. (2016). A qualitative study of feminist multicultural trainees’ social justice development. Journal of Counseling & Development, 94, 306–318. doi:10.1002/jcad.12087
Hsieh, H. F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. doi:10.1177/1049732305276687
Hugg, R., & Wurdinger, S. (2007). A practical and progressive pedagogy for project based service learning. International Journal of Teaching and Learning in Higher Education, 19, 191–204.
Jacoby, B. (2015). Service-learning essentials. San Francisco, CA: Jossey-Bass.
Jett, S. T., & Delgado-Romero, E. A. (2009). Prepracticum service-learning in counselor education: A qualitative case study. Counselor Education and Supervision, 49, 106–121. doi:10.1002/j.1556-6978.2009.tb00091.x
Kiselica, M. S., & Robinson, M. (2001). Bringing advocacy counseling to life: The history, issues, and human dramas of social justice work in counseling. Journal of Counseling & Development, 79, 387–397. doi:10.1002/j.1556-6676.2001.tb01985.x
Kraus, K. L. (2008). Lenses: Applying lifespan development theories in counseling. Boston, MA: Houghton Mifflin Company.
Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159–174. doi:10.2307/2529310
Lee, K. A., & McAdams, C. R. (2017). Promoting social justice advocacy competency and cognitive development among counselor trainees in internship: A service-learning approach. Manuscript submitted for publication.
Lewis, J. A. (2011). Operationalizing social justice counseling: Paradigm to practice. The Journal of Humanistic Counseling, 50, 183–191. doi:10.1002/j.2161-1939.2011.tb00117.x
Lewis, J., Arnold, M. S., House, R., & Toporek, R. I. (2002). ACA advocacy competencies. Retrieved from https://www.counseling.org/Resources/Competencies/Advocacy_Competencies.pdf
Lewis, J. A., Lewis, M. D., Daniels, J. A., & D’Andrea, M. J. (1998). Community counseling: Empowerment strategies for a diverse society (2nd ed.). Pacific Grove, CA: Brooks/Cole.
MacLeod, B. P. (2013). Social justice at the microlevel: Working with clients’ prejudices. Journal of Multicultural Counseling and Development, 41, 169–184. doi:10.1002/j.2161-1912.2013.00035.x
Manis, A. A. (2012). A review of the literature on promoting cultural competence and social justice agency among students and counselor trainees: Piecing the evidence together to advance pedagogy and research. The Professional Counselor, 2, 48–57. doi:10.15241/aam.2.1.48
National Board for Certified Counselors. (2015). Candidate handbook for national certification with the National Counselor Examination for licensure and certification (NCE). Retrieved from http://www.nbcc.org/Assets/Exam/Handbooks/NCE.pdf
Parker-Gwin, R., & Mabry, J. B. (1998). Service-learning as pedagogy and civic education: Comparing outcomes for three models. Teaching Sociology, 26, 276–291. doi:10.2307/1318768
QSR International. (2012). NVivo 10 [Computer software]. Available from http://www.qsrinternational.com
Ratts, M. J. (2009). Social justice counseling: Toward the development of a fifth force among counseling paradigms. The Journal of Humanistic Counseling, Education and Development, 48, 160–172. doi:10.1002/j.2161-1939.2009.tb00076.x
Ratts, M. J., & Wood, C. (2011). The fierce urgency of now: Diffusion of innovation as a mechanism to integrate social justice in counselor education. Counselor Education and Supervision, 50, 207–223. doi:10.1002/j.1556-6978.2011.tb00120.x
Rogoff, B. (2003). The cultural nature of human development. New York, NY: Oxford University Press.
Rossman, G. B., & Rallis, S. F. (2003). Learning in the field: An introduction to qualitative research (2nd ed.). Thousand Oaks, CA: Sage.
Stennbarger, B. N., & LeClair, S. (1995). Beyond remediation and development: Mental health counseling in context. Journal of Mental Health Counseling, 17, 173–187.
Toporek, R. L., Gerstein, L. H., Fouad, N. A., Roysircar, G., & Israel, T. (Eds.). (2006). Handbook for social justice in counseling psychology: Leadership, vision, and action. Thousand Oaks, CA: Sage.
Warter, E. H., & Grossman, J. M. (2002). An application of developmental-contextualism to service-learning. In A. Furco & S. H. Billig (Eds.), Service-learning: The essence of the pedagogy (pp. 83–102). Greenwich, CT: Information Age Publishing.
West-Olatunji, C. (2010). If not now, when? Advocacy, social justice, and counselor education. Counseling and
Human Development, 42(8), 1–12.
Kristi A. Lee, NCC, is an associate professor at Seattle University. Daniel J. Kelley-Petersen, NCC, is an adjunct faculty member at Seattle University. Correspondence can be addressed to Kristi Lee, College of Education, 901 Twelfth Avenue, Seattle, WA 98122, leekrist@seattleu.edu.
Feb 10, 2017 | Volume 7 - Issue 1
Stacey Diane A. Litam
The social justice issue of human sex trafficking is a global form of oppression that places men, women and children at risk for sexual exploitation. Although a body of research exists on the topics of human trafficking, literature specific to the mental health implications for counselors working with this population is limited. Counselors should increase their awareness of the vulnerabilities that place persons at risk of becoming trafficked. Additionally, obtaining a deeper understanding of the indicators and processes through which persons become trafficked is necessary in order to provide appropriate services. Counselors should learn how force, fraud and coercion influence the wellness of trafficked persons. The following article provides an overview of the relevant information pertinent to sex trafficking and addresses the counseling implications for working with sex trafficked survivors.
Keywords: human sex trafficking, sexual exploitation, social justice, trafficked survivors, oppression
The sexual exploitation of men, women and children through sex trafficking continues to occur in the United States and across the globe at an increasingly alarming rate. Despite misconceptions that sex trafficking requires transportation across state or country borders, the majority of victims are domestically trafficked within their own country by persons of the same nationality (Shelley, 2010; U.S. Department of State, 2009). Rates of forced labor are unknown and notoriously difficult to obtain due to methodological deficiencies (Fedina, 2015) and issues related to reporting and victim identification (Chesnay, 2013; Hyland, 2001; Laczko & Gramegna, 2003). However, the International Labour Organization (n.d.) estimates 27 million people become trafficked annually—4.5 million of whom are victims of forced sexual exploitation. Children and adolescents are exceptionally vulnerable to forced entry into the sex trade. The National Center for Missing and Exploited Children (2014) reported that 1 in 5 runaways are at risk for forced sexual exploitation. This represents an increase from an estimated 1 in 6 in 2014 (Polaris, 2016). Additionally, a study conducted by Estes and Weiner (2002) estimated that 326,000 youth are at risk for child trafficking. Counselors must become educated in recognizing the signs of trafficked persons, vulnerabilities to becoming trafficked, and the processes by which persons are forced into sexual exploitation in order to obtain a deeper understanding of the client’s worldview and provide appropriate support.
Existing literature addressing the mental health needs of sex trafficked survivors remains extremely limited (Hossain, Zimmerman, Abas, Light, & Watts, 2010; Tsutsumi, Izutsu, Poudyal, Kato, & Marui, 2008). Instead, the current body of research has focused on the sexual consequences of trafficking-related health issues such as sexually transmitted infections and rates of HIV among trafficked women in Asia (Beyrer, 2001; Beyrer & Stachowiak, 2003; Silverman et al., 2006; Silverman et al., 2007). The following article provides a brief overview of the definition, terms and processes associated with human trafficking. Next, the vulnerabilities and signs that a person has been or is currently being trafficked are presented. Finally, we address the clinical implications of working with trafficked survivors and identify trauma-sensitive interventions. Although female pronouns are used in this article, this detail is not intended to minimize the fact that many cisgender men, as well as lesbian, gay, bisexual and transgender persons, become victims of forced sexual exploitation (Martinez & Kelle, 2013; Oram, Stöckl, Busza, Howard, & Zimmerman, 2012).
Definition, Terms and Processes of Sex Trafficking
Despite the growing awareness of modern day slavery, the act of human trafficking is not a new phenomenon. In Imperial Rome, it has been estimated that between 30–40% of the Roman population was comprised of slaves trafficked from nearby countries such as Thrase, Gaul, Britain and Germany (Collingridge, 2006). In fact, during the height of the Roman Empire, wars were fought solely to procure more slaves (Cahill, 1995; Goldsworthy, 2006). Human trafficking was not limited to European countries. Beginning in 1619, both White and African slaves were taken from their countries and imported to Virginia to help construct the colonies (D. Davis, 2006; Jordan & Walsh, 2007). Human trafficking and modern day slavery are acts of social injustice that have historically exploited men, women and children.
According to the Trafficking Victims Protection Act (U.S. Department of State, 2000), the act of human trafficking refers to the recruitment, harboring, transportation, provision or obtaining of a person for commercial sex through force, fraud or coercion, or in which the person induced to perform a sex act is under 18 years of age. Despite common misconceptions, for an act to be considered sex trafficking, forced movement across the state is not required (U.S. Department of State, 2000). Sex trafficking includes a wide variety of traditionally accepted forms of labor, including commercial sex, exotic dancing and pornography (Logan, Walker, & Hunt, 2009). The following sections address the three components of control associated with human trafficking, namely force, fraud and coercion. Specific strategies used by traffickers to obtain and maintain control also are described.
Force
As defined by the United States Department of Health and Human Services (2012), force pertains to the physical restraint or serious physical harm that traffickers use to obtain and maintain control. According to Chesnay (2013), methods of force are typically used to break down the victim’s spirit. Examples of force as a means of control include rape, physical violence, intimidation, physical confinement and restricted freedom (Williamson & Prior, 2009; Zimmerman et al., 2008). Traffickers may introduce an addiction to an illicit substance or use existing drug or alcohol addictions to force persons into exploitative circumstances (Raphael & Ashley, 2008; Raymond et al., 2002; Whitaker & Hinterlong, 2008; Williamson & Prior, 2009; Zimmerman, 2003). According to findings by Whitaker and Hinterlong (2008), victims’ resistance often leads to additional or more forceful control mechanisms used by traffickers. For example, traffickers may initially use physical or sexual violence and increase the severity (e.g., burning or torturing victims) when disobeyed. Additionally, Whitaker and Hinterlong discovered the presence of gendered patterns of control or the concept that different strategies are used when eliciting compliance from men and women (e.g., use of threats to community members and drug addiction in men, and threats to family relationships and references about the world being dangerous in women). It is important to note that not all trafficked persons experience physical suffering (Aradau, 2004; Belser, 2005).
Fraud
Fraud, or the use of false promises to lure persons into the human trafficking industry, is another method used by traffickers to control and exploit their victims (United States Department of Health and Human Services, 2012). Although fraud is typical in labor trafficking scenarios (e.g., women are offered appealing job opportunities overseas as a nanny or model and then forced into prostitution upon arrival), this tactic also is employed within sex trafficking scenarios (Belser, 2005; Whitaker & Hinterlong, 2008). Traffickers may recruit children from low-income families by promising parents that their children will be safer, better cared for and taught a useful skill or trade (Albanese, 2007; U.S. Department of State, 2009). Once recruited, victims enter into debt bondage and are promised freedom upon repayment to traffickers for their services (Williamson et al., 2010). Unfortunately, the result of debt bondage is a never-ending cycle from which victims cannot escape (Chesnay, 2013). Upon incurring a debt, persons in forced labor scenarios become trapped as traffickers enforce high interest rates, withhold payment, and charge for miscellaneous expenses such as the cost for food, transportation, condoms, and other supplies (International Labour Organization, 2005). Albanese (2007) described one case in which traffickers used fraud after recruiting two girls from Vancouver, British Columbia, and transporting them to Hawaii. In this scenario, the traffickers withheld the girl’s passports and threatened to circulate photographs of them engaging in sex acts in order to obtain their compliance. For many victims of forced labor, fraud is a strategy used by traffickers to exploit dreams or hope for a better life (U.S. Department of State, 2009).
Coercion
Coercion, or using threats of physical harm or physical restraint against a person, is another context of control associated with human trafficking (United States Department of Health and Human Services, 2012). Coercion can take the form of direct physical violence or be psychological in nature (Logan et al., 2009; U.S. Department of State, 2009). In many cases, traffickers coerce victims by threatening to harm their families if they do not comply with their demands (Whitaker & Hinterlong, 2008; Williamson & Prior, 2009). Coercive tactics can directly exploit cultural beliefs, such as the case described by Whitaker and Hinterlong (2008) in which a victim believed she had to obey a trafficker because he kept a lock of her hair. Homeless youth who lack resources (e.g., food, protection, drugs) become coerced by adults that provide shelter and later demand “payment” in the form of sex (Hagan & McCarthy, 1997, p. 48). Although some victims are controlled by traffickers, others are coerced into sexual exploitation by boyfriends, girlfriends and friends (Hagan & McCarthy, 1997; Widom & Kuhns, 1996). Traffickers may coerce their victim’s compliance through the use of a grooming process (Herman, 1992) in which a connection is forged between victims and their traffickers in order to produce intense loyalty (Priebe & Suhr, 2005). When threats, force or coercion is used for the purpose of exploitation, victim consent is not relevant (Logan, 2007).
The grooming process. The seasoning, or grooming, process refers to the progression of power used by traffickers to control their victims and, in some cases, forge a trauma bond (Smith, Vardaman, & Snow, 2009). Similar to “Stockholm syndrome,” in which hostages relate to and defend their captors (Smith et al., 2009), trauma bonding is a form of coercive control in which traffickers instill a sense of fear as well as gratitude for being allowed to live (United States Department of Health and Human Services, 2012). As outlined by O’Connor and Healy (2006), the grooming process stages are ensnaring, creating dependence, taking control, and total dominance. During the ensnaring phase, traffickers begin to identify themselves as a trustworthy and valuable person in the victim’s life (O’Connor & Healy, 2006). Traffickers may provide favors, purchase expensive gifts, show affection and enter into a romantic relationship with the victim (Albanese, 2007). For many adolescents, this façade may represent the only affirming, reliable and secure relationship in their lives, and victims quickly find themselves emotionally invested. Next, traffickers create dependence. During this process, victims gradually become separated from their families and friends (O’Connor & Healy, 2006). Traffickers may convince victims that other persons in their lives are unreliable or untrustworthy. At the completion of this stage, victims begin to rely solely on their traffickers for support and become isolated from their previous lives (O’Connor & Healy, 2006). The taking control stage is characterized by a shift in the traffickers’ behavior from caring and supportive to controlling and possessive (O’Connor & Healy, 2006). The trafficker may begin to use threats, violence and drugs as methods of control and dictate whom the victim sees and where she goes (Whitaker & Hinterlong, 2008). At the end of this stage, traffickers may test the victims’ commitment to the relationship and demand that they begin selling commercial sex to prove their love (O’Connor & Healy, 2006). Once victims have become completely dependent on their traffickers and are convinced that the easiest way to earn money and maintain their relationships is through selling sex, total dominance has been achieved (O’Connor & Healy, 2006). Although the grooming process outlined by O’Connor and Healy is a helpful model that represents how many persons become trafficked, these series of stages may not occur in every case. Persons may enter the commercial sex trade through a variety of avenues, and their experiences of becoming trafficked may be consistent with, or distinct from, O’Connor and Healy’s model.
Contexts of Control
Just as variability exists within the stages of grooming, different factors influence whether the grooming process itself results in victim compliance. Traffickers use a variety of recruitment techniques and forms of exploitation to obtain and maintain control (Shelley, 2010). Contexts of control acknowledge the complex associations that influence the relationship between victim and trafficker (Whitaker & Hinterlong, 2008). These factors include the individual resiliencies of trafficked persons, the grooming process, and the methods of force, fraud and coercion used by traffickers (Whitaker & Hinterlong, 2008). According to Whitaker and Hinterlong (2008), the four contexts of control include control-seeking, control mechanisms, controllability and resistance. The context of control-seeking refers to the trafficker’s desire to limit the victims’ choices in order to increase the likelihood that their desires are met (Whitaker & Hinterlong, 2008). Traffickers with higher rates of control-seeking seek more power over victims’ behaviors, appearance and travel (Whitaker & Hinterlong, 2008). They may determine what victims wear, control how they interact with buyers, confine persons to specific locations, identify and enforce a mandatory amount of earnings per day, or withhold passports, money and identifying documents (Whitaker & Hinterlong, 2008; Zimmerman, 2003). Traffickers use control mechanisms (e.g., threats of violence, debt bondage, psychological intimidation and acute violence) to obtain and maintain control of victims, and they may vary depending on the victims’ level of controllability, or capacity to resist due to their social or financial context, cultural or personal beliefs, physical limitations, or other deficiencies (Shelley, 2010; Whitaker & Hinterlong, 2008). Thus, a trafficker may attempt to recruit a young woman by showering her with expensive gifts and affection, but if she demonstrates a low level of controllability (e.g., she has a strong support system, is financially stable, has high self-efficacy), the control mechanisms are less effective (Whitaker & Hinterlong, 2008). Controllability can be further delineated into six subdomains: social, financial, physical, cultural, psychological and institutional (Whitaker & Hinterlong, 2008). Persons with a strong combination across these six subdomains have lower controllability levels and are less likely to become trafficked through the grooming process (Whitaker & Hinterlong, 2008). Because trafficked people are unable to predict or manage events that influence their health and safety, the methods of control in human trafficking are parallel to the characteristics of abuse described in the literature on torture (Saporta & Van der Kolk, 1992).
Vulnerabilities and Risk Factors
The market for commercial sex represents a diverse avenue that incorporates a wide spectrum of activities and transactions across many settings (Anderson & O’Connell Davidson, 2003). Although survivors of human trafficking are not limited to race, ethnicity, age, gender or socioeconomic status, vulnerabilities such as location, poverty, sexual minority status and childhood trauma history, among other factors, influence higher rates for potential sexual exploitation (Albanese, 2007; Bales, 2007; Hyland, 2001; Kidd & Liborio, 2011; Martinez & Kelle, 2013). The following section outlines a variety of risk factors that have been linked to entrance into the sex trafficking trade.
Location as Risk Factor
Within the global human trafficking industry, there are origin and destination countries that influence the direction of movement and likelihood that persons become victims of forced sexual exploitation (Bales, 2007). Often, third world countries are origin countries characterized by locations with a large supply of available victims (Bales, 2007). The country may be in a state of conflict and social unrest or have high rates of poverty, government corruption and a lack of viable employment opportunities (Bales, 2007). Because trafficking is strongly linked to rates of poverty and minimal employment opportunities (Loff & Sanghera, 2004), many people willingly go with traffickers believing they will receive better opportunities abroad and can send money home to their families (Chung, 2009). Once recruited from origin countries, survivors are transported to destination countries, characterized by locations with high demand for commercial sex (Bales, 2007). Some locations, such as the United States, are bidirectional countries, in which victims are both recruited and put to work (Farr, 2005).
Although many persons become trafficked across international borders, the majority of victims in the United States are trafficked domestically (U.S. Department of State, 2009), with an increase of minors recruited from the Midwest (Williamson & Prior, 2009). In a study of 13 youth involved with forced sexual exploitation, respondents explained that recruitment occurred on the streets, while walking to friends’ houses, with peers, at corner stores, at malls, at their own homes, and waiting to meet with a probation officer outside the juvenile justice center (Williamson & Prior, 2009). In most cases, youth were approached by someone they knew, a mutual acquaintance, or people they recognized from their community (Williamson & Prior, 2009). Thus, counselors need to become familiar with recruitment cities, destination cities and bidirectional cities (Williamson & Prior, 2009). Recruitment and destination cities respectively refer to locations where persons are obtained and transported to meet the growing demand for commercial sex (K. Davis, 2006). Although victims may become recruited and forced into sexual exploitation in any city across the United States, smaller cities in the Midwest have been linked to increased rates of recruitment (K. Davis, 2006). Recruitment cities share similar characteristics, such as access to numerous highways that facilitate victim transportation to destination cities where demand for commercial sex is greatest (K. Davis, 2006). Once obtained, victims are transported to high-demand locations such as Chicago, Detroit and Las Vegas (Wilson & Dalton, 2007. Additional factors that seem to link location to sex trafficking exist. Previous studies have found increased rates of commercial sexual exploitation in areas with higher ratios of females to males (Rao & Presenti, 2012), in places with legalized prostitution (Cho, Dreher, & Neumayer, 2013), and within areas characterized by large populations of transient males such as military personnel, truckers, tourists, and conventioneers (Estes & Weiner, 2002; Farley & Kelly, 2000).
Interpersonal and Intrapersonal Risk Factors
In addition to location, other vulnerabilities to becoming trafficked exist, including individual, family, peer-related and environmental factors (Williamson & Prior, 2009). Persons from any socioeconomic background, race or ethnicity may become trafficked (McClain & Garrity, 2010). A study exploring the shared characteristics of adolescent females in the commercial sex industry identified low IQ scores and multiple mental health disorders as common factors (Twill, Green, & Traylor, 2010). History of risky or deviant behavior exposes adolescents to increased risk for becoming trafficked. For example, adolescents selling, buying and using drugs all increase the likelihood of crossing paths with a trafficker (McClain & Garrity, 2010; Walsh & Donaldson, 2010). Additional risk factors such as poverty, unemployment, isolation, low self-efficacy, drug addiction and history of physical and sexual abuse have been linked with entrance into the sex trafficking industry (Bales, 2007; Kidd & Liborio, 2011). Although not all trafficked persons have histories of childhood abuse (Chudakov, Ilan, Belmaker, & Cwikel, 2002), persons forced into sexual exploitation have commonly experienced violence prior to becoming trafficked, which increases their vulnerability to entering the sex trafficking trade and influences the greater likelihood of developing future mental health concerns (Hossain et al., 2010).
Homelessness and Sexual Minority Status as Risk Factors
Runaway, homeless or throwaway children are recruited into trafficking rings and exposed to extreme forms of abuse (Estes & Weiner, 2002). Many are killed as a result of violence or from diseases incurred from their sexual victimization (Estes & Weiner, 2002; Mitchell, Finkelhor, & Wolak, 2010). Adolescents are typically approached by traffickers within 48 hours of living on the street (Jordan, Patel, & Rapp, 2013). Traffickers are predatory in nature and adept at identifying vulnerable persons in need of safety, security and protection (Albanese, 2007; Jordan et al., 2013). LGBT persons are especially at risk of forced sexual exploitation due to increased rates of high-risk behaviors and homelessness (Martinez & Keele, 2013). According to the National Coalition for the Homeless (2009), sexual minority youth are twice as likely to experience sexual abuse before the age of 12 and are 7.4 times more likely to become victims of sexual violence. Counselors working with LGBT adolescents must assess their clients’ histories and explore whether they have engaged in survival sex or substance abuse or have been homeless. Survival sex is characterized by the exchange of sexual acts for shelter, food, money, protection, favors or other resources (Estes & Weiner, 2002; Williams & Frederick, 2009). It is important to note that persons from stable families may become trafficked. Young women may go willingly with friends to parties and become enamored with charming men involved in the sex trafficking trade or become flattered by the attentions of predatory older men (Chesnay, 2013). According to a study conducted by Raphael and Myers-Powell (2010) that interviewed 25 ex-pimps in Chicago, the prime candidate for recruitment was a blonde runaway.
Social Media and Internet Use as Risk Factor
Free access and anonymity with the Internet has created greater opportunity for offenders to purchase sex online where a wider variety of options exist (Chung, 2009; McCarthy, 2010; Raphael & Myers-Powell, 2010). Social media Web sites such as Myspace, Twitter and Facebook have been identified as a frequent tool used by traffickers to recruit adolescents into the sex trafficking trade (Demir, 2010; Jordan et al., 2013; Raphael & Myers-Powell, 2010; Williamson & Prior, 2009). Offenders cited the use of social media Web sites to contact, groom and connect with their victims, whereas online advertisement Web sites such as Craigslist were used to sell their victims (Raphael & Myers-Powell, 2010).
Adolescents with low levels of self-efficacy may be at increased risk for victimization due to higher rates of social media use. According to the Pew Research Center (2013), 74% of adults online use social networking sites, with young adults ages 18 to 29 representing the vast majority of social media users. Research exploring the relationship between social media use and the well-being of young adults has yielded significant findings that promote a deeper understanding of how traffickers select and recruit victims online. A study conducted by Meier and Gray (2014) linked photo activity on Facebook with greater than ideal internalization and self-objectification. Michikyan, Subrahmanyam, and Dennis (2014) additionally discovered that young adults experiencing emotional instability were more strategic in their online self-presentation, presumably to seek reassurance. Social networking site use also has been found to increase levels of self-efficacy, satisfy a need for belonging and improve self-esteem in college-aged students (Gangadharbatla, 2008). Upon examination of these pre-existing vulnerabilities, counselors can acquire a deeper understanding of how the grooming process may result in trauma bonds and entrance into the sex trafficking trade. For at-risk adolescents that lack a strong support system, experience low levels of self-efficacy and seek affirmation through their social media presence, online connections with traffickers may satisfy their deep desires for validation. Because traffickers are predatory in nature and gravitate toward vulnerable persons with low self-efficacy and high rates of controllability, counselors working with adolescents and young adults should provide education on topics related to Internet safety and the consequences of promoting a sexually suggestive online presence.
Possible Signs of Trafficking
Counselors working with at-risk populations (e.g., clients with addictions, and a history of homelessness and trauma) must recognize the possible signs that clients are being trafficked. Because many victims remain invisible to law enforcement (Hyland, 2001) and counselors, the identification and treatment of victims represents one of the greatest challenges in working with this population (McClain & Garrity, 2010). According to Polaris (2015), a variety of indicators exist that may suggest forced exploitation.
Signs of Trafficking in Mental Health Settings
Counselors and other helping professionals should assess clients for signs of trafficking, including instances in which clients are under 18 and providing commercial sex acts, have a controlling older boyfriend, work excessively long or unusual hours, or have few personal possessions (Polaris, 2015). Within behavioral health settings, clients may present as fearful, anxious, depressed, submissive or tense with avoidant eye contact (Polaris, 2015). Trafficked persons rarely seek counseling independently and have likely endured intense, ongoing victimization and may present with depression, dissociative reactions, suicidal ideation, post-traumatic stress disorder, feelings of guilt, shame and self-mutilation (Chesnay, 2013). Clients also may have histories of solicitation charges, substance use issues, or a need for safe and stable housing, lack a strong support system, and have visible bruises or branding (Chesnay, 2013; Hyland, 2001; Jordan et al., 2013). Branding refers to a method of identification used by traffickers to indicate ownership and may be tattoos or carvings (Jordan et al., 2013; Shared Hope International, 2016). It is the author’s experience that some clients that become addicted to opiates by their oppressors are forced to inject in locations on their bodies that will not detract from their overall marketability as a reusable commodity. In many cases, these locations include the inner thighs or between the fingers or toes. As one anonymous survivor (a client of the author) explained, “Nobody is going to buy someone with track marks.” A trend exists in which offenders trafficking drugs are beginning to traffic people (Shelley, 2010). Whereas drugs can be sold once, people can be sold repeatedly and thus represent a more profitable and less risky business venture (Neville & Martinez, 2004; Shelley, 2010).
Signs of Trafficking in Medical Settings
Trafficked persons may present in health care settings, although these instances occur at a low rate. Persons are only allowed to seek medical attention when traffickers believe their condition prevents monetary gain, at which point they can become disposable (Chesnay, 2013; Neville & Martinez, 2004). Medical issues associated with trafficked survivors within health care settings may include sexually transmitted infections, pregnancy, history of unsafe abortions, chronic pain, malnutrition, substance use issues, and sleep deprivation (Chesnay, 2013; Estes & Weiner, 2002). Counselors and medical professionals may additionally note that trafficked survivors struggle during a mental status exam (Chesnay, 2013). Due to a combination of working long hours, exhaustion, and frequent transportation to and from locations, trafficked persons may respond incorrectly to questions regarding time, place and person (Chesnay, 2013).
Signs of Trafficking in School Settings
School counselors need to be mindful of signs that students are being trafficked. Adolescents may be trafficked out of their own homes and transported to and from school by their oppressor (U.S. Department of Education, 2013). Possible signs that students are being trafficked within educational settings include references to frequent travel to other cities, signs of bruising, presence of depression, anxiety, or fear, coached or rehearsed responses to questions, and inappropriate dress based on weather conditions (U.S. Department of Education, 2013). Additionally, school counselors need to be mindful of children who have significantly older boyfriends or girlfriends, describe concern for the safety of family members if they disclose, or care for children that are not family members (U.S. Department of Education, 2013). When a child is being sex trafficked, they may be absent from school or miss periods of time while being sold to other communities (Williamson & Prior, 2009).
Challenges of Working With Trafficked Clients
Counselors may experience feelings of frustration and helplessness upon discovery that clients are rarely willing to leave their traffickers despite their dire situations. It is important to remember that many adolescents who become sex trafficked experience neurological effects from childhood physical, emotional and sexual trauma that inhibits their abilities to make pragmatic choices or escape their traffickers (Reid & Jones, 2011). The presence of chronic fear can inflict barriers to cognitive processing and decision making, which explains why some survivors do not escape when the opportunity arises (Loewenstein, Weber, Hsee, & Welch, 2001; Logan, Walker, Jordan, & Leukefelt, 2006). Due to the familiarity of unhealthy relationships and the lack of self-efficacy required to pursue change, childhood victims of sexual trauma are more likely to accept situations characterized by abuse (Reid & Jones, 2011). Counselors are encouraged to seek supervision, connect with colleagues and practice regular self-care routines in order to avoid experiencing burnout, secondary trauma, and compassion fatigue when working with this population.
Counselors working with trafficked clients are often faced with a series of challenges since an intervention modality specific to sex trafficked survivors has not yet been developed (Jordan et al., 2013). Although a small body of research exists on the health consequences associated with human trafficking, limited research has explored the mental health consequences of trafficking (Hossain et al., 2010; Tsutsumi et al., 2008). Current treatments are borrowed from evidence-based interventions originally developed for post-traumatic stress disorder and survivors of domestic violence, slavery and captivity (Jordan et al., 2013).
Assess Client’s Current State
Whether providing individual or group counseling to sex trafficked clients, several treatment considerations should be examined. First, counselors should assess whether the client is currently being trafficked or whether a sex trafficking history exists. Naturally, the counselor’s role will differ significantly depending on the client’s present situation. In the author’s experience, clients that are currently trafficked rarely seek mental health services independently. Instead, clients may present to counseling as the result of court mandates associated with drug or solicitation charges. Clients that are currently trafficked often resist help from mental health providers and avoid reporting due to well-founded fears of physical violence or threats of retribution if they disclose their situation (Flores, 2010). Therefore, building strong rapport with sex trafficked clients is critical (Chesnay, 2013). Because of the fraud and deception used by traffickers during the grooming process, many trafficked persons demonstrate marked difficulty with trusting others (Belser, 2005). It is essential that counselors build trust with the client by demonstrating unconditional positive regard, empathy and authenticity. Counselors may support clients by developing individualized safety plans and sharing valuable resources (e.g., The National Human Trafficking Hotline: 1-888-373-7888). Once a strong therapeutic relationship has been established, counselors may begin pursuing a variety of counseling goals, including psychoeducation, supporting clients through the stages of personal change, engaging in group counseling, medication management, addressing substance use issues, and promoting reintegration through education and job training.
Counselors working with sex trafficked survivors must assess whether the client has access to necessary resources, including housing, food, water, shelter and medicine. Ensuring that survivors are equipped with safe and stable homes minimizes the likelihood that they are simply returning to the same endangering conditions (Feingold, 2005). Counselors should work with sex trafficked clients to explore the circumstances that increased their risk for sexual exploitation. Once the situations are identified, counselors must work collaboratively with clients to create a sustainable maintenance promotion plan. Chesnay (2013) explained that once basic physiological needs and safe housing are obtained, mental health professionals can begin reframing the client’s worldview from “victim” to “survivor” to “thriving survivor.”
Asking Helpful Questions
In addition to taking the client’s trafficking situation into consideration, it is important to remain mindful of the language used when working with this population. Clients will rarely, if ever, identify with the term trafficked and also are likely to struggle with identifying their partner and protector as a pimp or trafficker (Chesnay, 2013). Trafficked clients may explain that they are working to help their boyfriends (Priebe & Suhr, 2005). Counselors and other mental health professionals are encouraged to accept the client’s identified terms and work within their individual framework (Chesnay, 2013).
Providing psychoeducation on the process, rates and prevalence of sex trafficking may be beneficial for clients to promote insight. Educational modalities that shift pertinent information from general to specific may be helpful in gradually exposing clients to difficult concepts. Counselors should work collaboratively with clients to identify salient issues and validate their experiences to promote recognition and exploration on the effects of trafficking. Counselors may use statements such as, “Many young adolescents living on the streets feel scared and find someone to protect and care for them. I wonder whether this is true for you?” Or, “Some people care so much about their partners that they feel obligated to prove their love and begin doing things they are not really comfortable with. I am curious whether this has been your experience as well?” Offering opportunities for clients to disclose information in a safe, nonjudgmental and accepting environment can increase client insight, promote counselor awareness of client history and facilitate therapeutic growth. Additionally, counselors should determine whether clients have access to safe and stable housing. If basic physiological needs are not met, clients may struggle to focus on higher order needs such as developing a safety plan or emotion regulation.
Assess Client’s Stage of Change
For clients that are currently trafficked, the stages of change outlined by Norcross, Krebs, and Prochaska (2011) may be a helpful tool for examining clients’ willingness to engage in counseling. Clients in the precontemplation stage may respond positively to counseling strategies aimed at increasing education and awareness. When clients present in the stage of contemplation, counselors may be most supportive by exploring client ambivalence. Counselors may facilitate costs and benefits analyses with the client regarding their current predicaments. Regardless of the client’s stage of change it is important that counselors do not force the client to leave their oppressor. This may put the client, their families and other loved ones at risk (Flores, 2010). Instead, counselors must listen, affirm and provide the client with resources such as the trafficking hotline and empower them to call when ready. It is important that counselors assess the severity and duration of trafficking-related abuse and recognize how these experiences influence recovery time (Hossain et al., 2010). In a sample of 204 trafficked girls and women, the presence of sexual violence during a trafficking experience had an independent effect on mental health symptoms (Hossain et al., 2010). Hossain and colleagues (2010) concluded that persons trafficked for longer periods of time have an increased likelihood of abusive episodes and prolonged feelings of entrapment, alienation, loss of control, humiliation and helplessness—all of which are associated with developing mental health disorders in the future. Counselors can better accommodate the needs of persons that have been trafficked for longer periods of time by providing longer duration post-trafficking care.
Assess Entrance Into Trafficking
Other treatment considerations pertain to the process through which clients became trafficked. Clients recruited and controlled through a grooming process may struggle to identify their captors as oppressors due to the presence of a trauma bond (United States Department of Health and Human Services, n.d.). Cases also exist in which clients have been trafficked by family members or sold to traffickers by their parents (Shelley, 2010). In some instances, adolescents and children are forced into sexual exploitation by their parents or siblings in order to support drug addictions or to avoid financial burdens (Estes & Weiner, 2002). One survivor, a client of the author, reported that a family member diagnosed with schizoaffective disorder trafficked her for a period of 2 months. The client described how the family member would hold a firearm to his neck and threaten to commit suicide if she did not provide him with heroin. The client explained how she felt forced to complete commercial sex acts with drug dealers, as this strategy was the quickest and easiest way to obtain illicit substances within her impoverished community. Counselors should work to identify their biases regarding how persons are trafficked, and by whom, in order to identify survivors and provide appropriate services.
Counseling Sex Trafficked Clients
Counselors working with sex trafficked survivors should be prepared to employ a variety of trauma-sensitive interventions to support the individual needs of each client. Trauma-sensitive interventions identify safety as the foundation for working with persons to eliminate self-harm, develop trustworthy relationships, overcome challenges, promote wellness and remove themselves from dangerous situations (Najavits, 2002). Helping traumatized clients to regain a sense of control is critical (Goodman & Calderon, 2012). For example, counselors may use mindfulness-based activities such as body scans and body awareness exercises to help clients differentiate between current and past experiences (Rothschild, 2000). Counselors can use other mindfulness techniques, such as focusing on the present and emphasizing the mind-body connection, to help clients identify and reduce the somatic symptoms of arousal when no threats are present (Goodman & Calderon, 2012). Finally, counselors can help clients practice imagining, and returning attention to, comforting images to increase their sense of safety and decrease arousal (Goodman & Calderon, 2012). Ideally, counselors will empower their clients to redefine their lives not by their pasts, but by their futures (Chesnay, 2013).
Creative Interventions
Creative-based interventions are especially powerful with sex trafficked clients because they provide opportunities for clients to make choices. For clients who have long been told what to do and have lived according to their trafficker’s demands, the presentation of choices and sense of control may represent an exciting and difficult challenge. Creative arts interventions have received a great deal of empirical support for clients presenting with trauma. Research that investigated resiliency has identified the importance of creativity, humor, flexibility, and movement as effective interventions to improve traumatized clients’ self-esteem, hope and prosocial behaviors (Johnson, Lahad, & Gray, 2009; Lahad, 2000; Raynor, 2002). Additionally, therapeutic art has been shown to be efficacious for work with clients presenting with emotional disturbances, grief and loss, low self-efficacy, depression, post-traumatic stress disorder, anxiety, and feelings of guilt and shame (Johnson et al., 2009; Slayton, D’Archer, & Kaplan, 2010). Creative interventions can be used to help clients reframe ideas, shift perspectives, externalize emotions and gain deeper understanding of events (Bradley, Whiting, Hendricks, Parr, & Jones, 2008). According to Lev-Weisel (1998), clients that struggle to find words to describe their traumatic experiences may prefer creative interventions as a means of expression. Counselors can integrate the use of creative and expressive interventions using mandalas or other art mediums to support clients in promoting openness while providing a sense of structure. Future areas of research are needed to determine the efficacy of creative interventions specific to clients with a history of sex trafficking.
Cognitive Behavioral Therapies
Clients with a history of sex trafficking can benefit from cognitive behavioral therapies due to their internalization of derogatory labels (Hickle & Roe-Sepowitz, 2014). Counselors working with trafficked clients can identify and challenge these labels in order to decrease the presence of shame and other meta-emotions (e.g., anger at oneself for feeling shame). Additional evidence-based counseling interventions that may be useful for sex trafficked client populations include Eye Movement Desensitization and Reprocessing with adults (Maxfield, 2003; Shapiro, 1989) and trauma-focused cognitive behavioral therapy with children (Cohen, Berliner, & Mannarino, 2010; Cohen, Mannarino, Berliner, & Deblinger, 2000). The use of dialectical trauma-focused cognitive behavioral therapy is effective with both children (Racco & Vis, 2015) and adults with histories of trauma and post-traumatic stress disorder (Wagner, Rizvi, & Harned, 2007). Although trauma-focused cognitive behavioral therapy and dialectical trauma-focused cognitive behavioral therapy have not been tested specifically for sex trafficked populations, research indicates that these modalities are successful in helping children overcome histories of trauma and abuse (Classen, Koopman, Nevill-Manning, & Spiegel, 2001; Cohen & Mannarino, 1997). Future research studies should investigate the efficacy of cognitive behavioral therapies with sex trafficking survivors in order to standardize appropriate treatment methods for this unique population.
Group Counseling
Providing survivors of forced sexual exploitation with an opportunity to participate in group counseling can empower persons to share similar experiences while creating a sense of community and support (Hickle & Roe-Sepowitz, 2014). Peer support is a crucial component for treatment since bearing witness to the similar lived experiences of other survivors provides a unique dimension of support and sense of universality (Chesnay, 2013). Counselors working with trafficked persons may focus on accomplishing a variety of treatment goals, including feeling identification, establishing safety, addressing substance use, countering internalized stigma and labels, providing psychoeducation and establishing healthy boundaries. Shame can be reduced by prompting discussions about taboo and stigmatizing topics within group settings (Hickle & Roe-Sepowitz, 2014). Many trafficked survivors have upheld the belief that they are the only ones who have been trafficked by parents, have engaged in survival sex, or who have been forced into sexual exploitation by boyfriends or girlfriends. According to Estes and Weiner (2002), boys that performed oral sex on adult males as a result of forced sexual exploitation experienced a profound sense of shame. Addressing these foci of shame can help clients recognize the universality of their experiences, build rapport with peers and facilitate trust in the group setting. Counselors should listen openly to the client’s stories of shame and receive them with empathy in order to dispel their negativistic beliefs. Psychoeducation within group settings can be used to explain how traffickers use coercion and other techniques to recruit young women (Hickle & Roe-Sepowitz, 2014).
Expressive techniques that allow group members to process trauma experiences without dissociating from the event are beneficial in promoting therapeutic growth (Hickle & Roe-Sepowitz, 2014). Clients can use markers, colored pencils and other artistic mediums to draw, color or write on an outlined body where they feel specific emotions such as pain, shame, anger, fear and guilt (Hickle & Roe-Sepowitz, 2014). Words and pictures from magazines also can be used to represent emotions or past and present states of mind and facilitate the healing process. The author has facilitated mask exercises within group settings to support trafficked clients in identifying and processing their ideal and actual selves. Once completed, the pictures and masks can be processed with other group members and similar or different experiences, emotions and challenges can be discussed.
Conclusion
Although social and cultural norms, poverty, gendered inequality and childhood history represent important vulnerability factors, the social injustice known as sex trafficking could not occur without the demand for sexual exploitation (Matheson & Finkel, 2013). A deeper understanding is needed to comprehend how persons become trafficked (Whitaker & Hinterlong, 2008). Additionally, a dearth of research remains that identifies specific evidence-based and trauma-sensitive modalities developed specifically for sex trafficked survivors (Chesnay, 2013; Jordan et al., 2013). The experiences, challenges and reflections of the author have been presented with the intention of providing education, support and guidance to other counselors serving this unique population. Regardless of which counseling tools are used, establishing and building a strong therapeutic alliance is a valuable tool that counselors can employ to support sex trafficked persons (Chesnay, 2013). Although challenging at times, establishing rapport requires a nonjudgmental attitude and a willingness to bear witness to clients’ experiences, without pointing out what survivors could have done differently (Chesnay, 2013).
It is important to remember that trafficked persons are often survivors of long-term childhood trauma characterized by instability within the home, childhood sexual trauma and community violence (Bales, 2007; Hossain et al., 2010; Kidd & Liborio, 2011; Williamson & Prior, 2009). Many adolescents were targeted, recruited and trafficked due to pre-existing vulnerabilities and high controllability factors (Whitaker & Hinterlong, 2008). Counselors are tasked with a unique position to provide corrective relational experiences characterized by the nonjudgmental acceptance, support and affirmation desperately needed by this population. Fewer resources and services exist for trafficked survivors than for victims of any other crime (Clawson, Dutch, & Cummings, 2006). Counselors should connect sex trafficked survivors to necessary social service supports, including case management services, safe and stable housing, and services aimed at supporting the successful reintegration of clients into the community through education and job training (Williamson & Prior, 2009). Future areas of research should explore the profiles of traffickers and standardize how mental health and medical providers can better identify, serve, protect, and support trafficked survivors (Bales, 2005). Finally, counselors are called to continue promoting awareness on the prevalence and signs of sex trafficked survivors. Increasing awareness and decreasing demand for sexually exploited persons are the fundamental steps necessary to end the human rights violation of sex trafficking (Chung, 2009; Kotrla, 2010).
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Albanese, J. (2007). Commercial sexual exploitation of children: What do we know and what do we do about it? Retrieved from http://www.ncjrs.gov/pdfFiles1/nij/215733.pdf
Anderson, B., & O’Connell Davidson, J. (2003). Is trafficking in human beings demand driven? A multi-country pilot study. Retrieved from https://www.compas.ox.ac.uk/media/ER-2004-Trafficking_Demand_Driven_IOM.pdf
Aradau, C. (2004). The perverse politics of four-letter words: Risk and pity in the securitisation of human trafficking. Millennium Journal of International Studies, 33, 251–277.
Bales, K. (2005). Understanding global slavery: A reader. Berkeley, CA: University of California Press.
Bales, K. (2007). What predicts human trafficking? International Journal of Comparative and Applied Criminal Justice, 31, 269–279. doi:10.1080/01924036.2007.9678771
Belser, P. (2005). Forced labor and human trafficking: Estimating the profits. Retrieved from http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1016&context=forcedlabor
Beyrer, C. (2001). Shan women and girls and the sex industry in Southeast Asia: Political causes and human rights implications. Social Science & Medicine, 53, 543–550.
Beyrer, C., & Stachowiak, J. (2003). Health consequences of trafficking of women and girls in Southeast Asia. The Brown Journal of World Affairs, 10, 105–117.
Bradley, L. J., Whiting, P., Hendricks, B., Parr, G., & Jones, E. G., Jr. (2008). The use of expressive techniques in counseling. Journal of Creativity in Mental Health, 3, 44–59.
Cahill, T. (1995). How the Irish saved civilization: The untold story of Ireland’s heroic role from the fall of Rome to the rise of Medieval Europe (The Hinges of History). New York: Random House.
Chesnay, M. D. (2013). Psychiatric-mental health nurses and the sex trafficking pandemic. Issues in Mental Health Nursing, 34, 901–907. doi:10.3109/01612849.2013.857200
Cho, S. Y., Dreher, A., & Neumayer, E. (2013). Does legalized prostitution increase human trafficking? World Development, 41, 67–82.
Chudakov, B., Ilan, K., Belmaker, R. H., & Cwikel, J. (2002). The motivation and mental health of sex workers. Journal of Sex and Marital Therapy, 28, 305–315. doi:10.1080/00926230290001439
Chung, R. C-Y. (2009). Cultural perspectives on child trafficking, human rights & social justice: A model for psychologists. Counselling Psychology Quarterly, 22,85–96.
Classen, C., Koopman, C., Nevill-Manning, K., & Spiegel, D. (2001). A preliminary report comparing trauma-focused and present-focused group therapy against a wait-listed condition among childhood sexual abuse survivors with PTSD. Journal of Aggression, Maltreatment & Trauma, 4, 265–288.
Clawson, H. J., Dutch, N., & Cummings, M. (2006). Law enforcement response to human trafficking and the implica-tions for victims: Current practices and lessons learned. Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/216547.pdf
Cohen, J. A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with co-occurring trauma and behavior problems. Child Abuse & Neglect, 34, 215–224.
Cohen, J. A., & Mannarino, A. P. (1997). A treatment study for sexually abused preschool children: Outcome during a one-year follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 1228–1235.
Cohen, J. A., Mannarino, A. P., Berliner, L., & Deblinger, E. (2000). Trauma-focused cognitive behavioral therapy for children and adolescents: An empirical update. Journal of Interpersonal Violence, 15, 1202–1223.
Collingridge, V. (2006). Boudica: The life and legends of Britain’s warrior queen. Woodstock, NY: Overlook Press.
Davis, D. B. (2006). Inhuman bondage: The rise and fall of slavery in the New World. New York, NY: Oxford University Press.
Davis, K. Y. S. (2006). Human trafficking and modern day slavery in Ohio. Washington, DC: Polaris Project. Retrieved from http://www.ccv.org/wp-content/uploads/2010/04/Ohio-Report-on-Trafficking.pdf
Demir, O. O. (2010). Methods of sex trafficking: Findings of a case study in Turkey. Global Crime, 11, 314–335.
doi:10.1080/17440572.2010.490636
Estes, R. J., & Weiner, N. A. (2002). The commercial sexual exploitation of children in the U.S., Canada, and Mexico. Retrieved fromhttp://abolitionistmom.org/wp-content/uploads/2014/05/Complete_CSEC_0estes-weiner.pdf
Farley, M., & Kelly, V. (2000). Prostitution: A critical review of the medical and social sciences literature. Women & Criminal Justice, 11(4), 29–64.
Farr, K. (2005). Sex trafficking: The global market in women and children. New York, NY: Worth.
Fedina, L. (2015). Use and misuse of research in books on sex trafficking: Implications for interdisciplinary
research, practitioners, and advocates. Trauma, Violence, and Abuse, 16, 188–198. doi:10.1177/1524838014523337
Feingold, D. A. (2005). Human trafficking. Foreign Policy, 150, 26–30.
Flores, T. (2010). The slave across the street: The true story of how an American teen survived the world of human trafficking. Boise, ID: Ampelon.
Gangadharbatla, H. (2008). Facebook me: Collective self-esteem, need to belong, and internet self-efficacy as predictors of the iGeneration’s attitudes toward social networking sites. Journal of Interactive Advertising, 8(2), 1–28.
Goldsworthy, A. (2006). Caesar: Life of a colossus. New Haven, CT: Yale University Press.
Goodman, R. D., & Calderon, A. M. (2012). The use of mindfulness in trauma counseling. Journal of Mental Health Counseling, 34(3), 254–268.
Hagan, J., & McCarthy, B. (1997). Mean streets: Youth crime and homelessness. Cambridge, England: Cambridge University Press.
Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York, NY: Basic Books.
Hickle, K. E., & Roe-Sepowitz, D. E. (2014). Putting the pieces back together: A group intervention for sexually exploited adolescent girls. Social Work with Groups, 37, 99–113. doi:10.1080/01609513.2013.8233838
Hossain, M., Zimmerman, C., Abas, M., Light, M., & Watts, C. (2010). The relationship of trauma to mental disorders among trafficked and sexually exploited girls and women. American Journal of Public Health, 100, 2442–2449.
Hyland, K. E. (2001). Protecting human victims of trafficking: An American framework. Berkeley Women’s Law Journal, 16, 29–71.
International Labour Organization. (n.d.). Forced labour, modern slavery and human trafficking. Retrieved from http://www.ilo.org/global/topics/forced-labour/lang–en/index.htm
International Labour Organization. (2005). Global report on forced labour in Asia: Debt bondage, trafficking and state-
imposed forced labour. Retrieved from http://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_07
5504/lang–en/index.htm
Johnson, D. R., Lahad, M., & Gray, A. (2009). Creative therapies for adults. In E. B. Foa, T. M. Keane, M. J. Fried-
man, & J. A. Cohen (Eds.), Effective treatments for PTSD. Practice guidelines from the International Society for Traumatic Stress Studies (pp. 479–490). New York, NY: Guilford Press.
Jordan, D., & Walsh, M. (2007). White cargo: The forgotten history of Britain’s white slaves in America. New York: New York University Press.
Jordan, J., Patel, B., & Rapp, L. (2013). Domestic minor sex trafficking; A social work perspective on misidentifi-cation, victims, buyers, traffickers, treatment, and reform of current practice. The Journal of Human Behavior in the Social Environment, 23, 356–369.
Kidd, S. A., & Liborio, R. M. C. (2011). Sex trade involvement in Sao Paulo, Brazil, and Toronto, Canada: Narra-tives of social exclusion and fragmented identities. Youth & Society, 43, 982–1009.
Kotrla, K. (2010). Domestic minor sex trafficking in the United States. The National Association of Social Workers, 55, 181–187.
Laczko, F., & Gramegna, M. A. (2003). Developing better indicators of human trafficking. The Brown Journal of World Affairs, 10, 179–194.
Lahad, M. (2000). Darkness over the abyss: Supervising crisis intervention teams following disaster. Traumatology, 6, 273–293.
Lev-Weisel, R. (1998). Use of drawing technique to encourage verbalization in adult survivor of sexual abuse. The Arts in Psychotherapy, 25, 257–262.
Loewenstein, G., Weber, E. U., Hsee, C. K., & Welch, N. (2001). Risk as feelings. Psychology Bulletin, 127, 267–286.
Loff, B., & Sanghera, J. (2004). Distortions and difficulties in data for trafficking, The Lancet, 363, 566.
Logan, T. (2007). Human trafficking in Kentucky. Retrieved from http://www.cdar.uky.edu/CoerciveControl/docs/Human%20Trafficking%20in%20Kentucky.pdf
Logan, T. K., Walker, R., & Hunt, G. (2009). Understanding human trafficking in the United States. Trauma, Violence, and Abuse, 10(3), 3–30. doi:10.11777/15249=838008327262
Logan, T. K., Walker, R., Jordan, C. E., & Leukefelt, C. (2006). Women and victimization: Contributing factors, inter-ventions, and implications. Washington, DC: American Psychological Association.
Martinez, O., & Kelle, G. (2013). Sex trafficking of LGBT individuals: A call for service provision, research, and action. International Law News, 42(4), 1–6.
Matheson, C. M., & Finkel, R. (2013). Sex trafficking and the Vancouver winter Olympic games: Perceptions and preventative measures. Tourism Management, 36, 613–628.
Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61–81.
McCarthy, J. A. (2010). Internet sexual activity: A comparison between contact and non-contact child pornography offenders. Journal of Sexual Aggression, 16, 181–195.
McClain, N. M., & Garrity, S. E., (2010). Sex trafficking and the exploitation of adolescents. The Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40, 243–252. doi:10.1111/j.1552-6909.2011.01221.x
Meier, E. P., & Gray, J. (2014). Facebook photo activity associated with body image disturbance in adolescent girls. Cyberpsychology, Behavior, and Social Networking, 17, 199–206. doi:10.1089/cyber.2013.0305
Michikyan, M., Subrahmanyam, K., & Dennis, J. (2014). Can you tell who I am? Neuroticism, extraversion, and online self-presentation among young adults. Computers in Human Behavior, 33, 179–183.
Mitchell, K. J., Finkelhor, D., & Wolak, J. (2010). Conceptualizing juvenile prostitution as child maltreatment:
Findings from the national juvenile prostitution study. Child Maltreatment, 15, 18–36. doi:10.1177/1077559509349443
Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press.
National Center for Missing and Exploited Children. (2014). Child sex trafficking. Retrieved from http://www.missingkids.com/1in6
National Coalition for the Homeless. (2009). LGBT Homeless. Retrieved from http://www.nationalhomeless.org/factsheets/lgbtq.html
Neville, S., & Martinez, S. (2004). The law of human trafficking. What legal aid providers should know. Clearing-house Review Journal of Poverty Law and Policy, 37, 551–556.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67, 143–154. doi:10.1002/jclp.20758
O’Connor, M., & Healy, G. (2006) The links between prostitution and sex trafficking: A briefing handbook. Retrieved from http://www.catwinternational.org/Home/Article/175-the-links-between-prostitution-and-sex-trafficking-a-briefing-handbook
Oram, S., Stöckl, H., Busza, J., Howard, L. M., & Zimmerman, C. (2012). Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review. PLOS Medicine, 9(5), 1–13. doi:10.1371/journal.pmed.1001224
Pew Research Center. (2013). Social networking fact sheet. Retrieved from http://www.pewinternet.org/fact-sheets/social-networking-fact-sheet
Polaris. (2015). Recognize the signs. Retrieved from https://polarisproject.org/recognize-signs
Polaris. (2016). 2015 NHTRC annual report. Washington, DC: Author. Retrieved from https://humantrafficking
hotline.org/resources/2015-nhtrc-annual-report
Priebe, A., & Suhr, C. (2005). Hidden in plain view: The commercial sexual exploitation of girls in Atlanta. Atlanta, GA: The Atlanta Women’s Agenda.
Racco, A., & Vis, J.-A. (2015). Evidence based trauma treatment for children and youth. Child and Adolescent Social Work Journal, 32, 121–129.
Rao, S., & Presenti, C. (2012). Understanding human trafficking origin: A cross-country empirical analysis. Feminist Economics, 18, 231–263.
Raphael, J., & Ashley, J. (2008). Domestic sex trafficking of Chicago women and girls. Retrieved from http://www.icjia.state.il.us/assets/pdf/ResearchReports/Sex%20Trafficking%20Report%20May%202008.pdf
Raphael, J., & Myers-Powell, B. (2010). From victims to victimizers: Interview with 25 ex-pimps in Chicago. Retrieved from https://law.depaul.edu/about/centers-and-institutes/schiller-ducanto-fleck-family-law-center/Documents/interview_ex_pimps.pdf
Raymond, J. G., D’Cunha, J., Dzuhayatin, S. R., Hynes, H. P., Rodriguez, Z. R., & Santos, A. (2002). A comparative study of women trafficked in the migration process: Patterns, profiles, and health consequences of sexual exploita-tion in five countries (Indonesia, the Philippines, Thailand, Venezuela, and the United States). Belgium: Coalition Against Trafficking in Women. Retrieved from http://www.catwinternational.org/Content/Images/Article/96/attachment.pdf
Raynor, C. M. (2002). The role of play in the recovery process. In W. N. Zubenko & J. A. Capozzoli (Eds.), Children and disasters: A practical guide to healing and recovery (pp. 124–134). New York, NY: Oxford University Press.
Reid, J. A., & Jones, S. (2011). Exploited vulnerability: Legal and psychological perspectives on child sex traffick-ing victims. Victims & Offenders, 6, 207–231. doi:10.1080/15564884.2011.557327
Rothschild, B. (2000). The body remembers. New York, NY: W. W. Norton.
Saporta, J. A., & Van der Kolk, B. A. (1992). Psychobiological consequences of trauma. In M. Basoglu (Ed.), Torture and its consequences: Current treatment approaches (pp. 151–181). Cambridge, England: Cambridge University Press.
Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199–223. doi:10.1002/jts.2490020207
Shared Hope International. (2016). Trafficking terms. Retrieved from http://sharedhope.org/the-problem/traffick
ing-terms
Shelley, L. (2010). Human trafficking: A global perspective. New York: Cambridge Universitiy Press
Silverman, J. G., Decker, M. R., Gupta, J., Maheshwari, A., Patel, V., & Raj, A. (2006). HIV prevalence and pre-dictors among rescued sex-trafficked women and girls in Mumbai, India. Journal of Acquired Immune Deficiency Syndromes, 43, 588–593.
Silverman, J. G., Decker, M. R., Gupta, J., Maheshwari, A., Willis, B. M., & Raj, A. (2007). HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. Journal of the American Medical Association, 298, 536–542.
Slayton, S. C., D’Archer, J., & Kaplan, F. (2010). Outcome studies on the efficacy of art therapy: A review of find-ings. Art Therapy: Journal of the American Art Therapy Association, 27(3), 108–119.
Smith, L., Vardaman, S., & Snow, M. (2009). The national report on domestic minor sex trafficking: America’s prostitu-ted children. Retrieved from https://sharedhope.org/wp-content/uploads/2012/09/SHI_National_Report_on_DMST_2009.pdf
Tsutsumi, A., Izutsu, T., Poudyal, A. K., Kato, S., & Marui, E. (2008). Mental health of female survivors of human trafficking in Nepal. Social Science & Medicine, 66, 1841–1847.
Twill, S. E., Green, D. M., & Traylor, A. (2010). A descriptive study on sexually exploited children in residential treatment. Child & Youth Care Forum, 39, 187–199. doi:10.1007/s10566-010-9098-2
U.S. Department of Education. (2013). Human trafficking of children in the United States: A fact sheet for schools. Re-trieved from https://www2.ed.gov/about/offices/list/oese/oshs/tipfactsheet91913.pdf
U.S. Department of Health and Human Services. (2012). Fact sheet: Human trafficking. Retrieved from http://www.acf.hhs.gov/endtrafficking/resource/fact-sheet-human-trafficking
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (n.d.). Human trafficking into and within the United States: A review of the literature. Retrieved from http://aspe.hhs.gov/hsp/07/humantrafficking/litrev/index.pdf
U.S. Department of State. (2000). Victims of trafficking and violence protection act of 2000. Retrieved from http://www.state.gov/j/tip/laws/61124.htm
U.S. Department of State. (2009). Trafficking in persons report 2010. Washington, DC: Author. Retrieved from http://www.state.gov/g/tip/rls/tiprpt/2010.
Wagner, A. W., Rizvi, S. L., & Harned, M. S. (2007). Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: When one case formulation does not fit all. Journal of Traumatic Stress, 20, 391–400.
Walsh, S. M., & Donaldson, R. E. (2010). Invited commentary: National safe place: Meeting the immediate needs of runaway and homeless youth. Journal of Youth and Adolescence, 39, 437–445.
doi:10.1007/s10964-010-9522-9
Whitaker, M. P., & Hinterlong, J. (2008). Contexts of control: Modern slavery in the United States. Social Develop-ment Issues, 30(3), 27–41.
Widom, C. S., & Kuhns, J. B. (1996). Childhood victimization and subsequent risk for promiscuity, prostitution, and teenage pregnancy: A prospective study. American Journal of Public Health, 86, 1607–1612.
Williams, L. M., & Frederick, M. E. (2009). Pathways into and out of commercial sexual victimization of children: Understanding and responding to sexually exploited teens. Lowell, MA: University of Massachusetts Lowell. Retrieved from http://faculty.uml.edu/lwilliams/Williams%20Pathways%20Final%20Report%202006-MU-FX-0060%2010-31-09L.pdf
Williamson, C., Karandikar-Chheda, S., Barrows, J., Smouse, T., Kelly, G., Swartz, G., . . . Tame, C. (2010). Ohio trafficking in persons study commission research and analysis sub-committee report on the prevalence of human trafficking in Ohio. Retrieved from http://docplayer.net/12555115-Ohio-trafficking-in-persons-study-commission-research-and-analysis-sub-committee-report-on-the-prevalence-of-human-trafficking-in-ohio.html
Williamson, C., & Prior, M. (2009). Domestic minor sex trafficking: A network of underground players in the Midwest. Journal of Child & Adolescent Trauma, 2, 46–61.
Wilson, J. M., & Dalton, E. (2007). Human trafficking in Ohio: Markets, responses, and considerations. Retrieved from http://www.rand.org/pubs/monographs/2007/RAND_MG689.pdf
Zimmerman, C. (2003). The health risks and consequences of trafficking in women and adolescents: Findings from a European study. London, England: London School of Hygiene & Tropical Medicine. Retrieved from http://www.lshtm.ac.uk/php/ghd/docs/traffickingfinal.pdf
Zimmerman, C., Hossain, M., Yun, K., Gajdadziev, V., Guzun, N., Tchomarova, M., . . . Watts, C. (2008). The
health of trafficked women: A survey of women entering posttrafficking services in Europe. American Journal of Public Health, 98, 55–59.
Stacey Diane A. Litam is a doctoral candidate at Kent State University and a mental health counselor at Moore Counseling and Mediation Services Inc. Correspondence can be addressed to Stacey Litam, Moore Counseling and Mediation Services, 4600 Carnegie Avenue, Cleveland, Ohio 44103, slitam@kent.edu.
