Building a more complete client picture - Counseling Today Archive

Imagine picking up a stone on the side of a creek. Your task is to understand its markings, characteristics and shape solely through examination of the stone itself.

Using that method would result in a comparatively limited view of the stone, says Michelle Flaum Hall. “If, however, we acknowledge the forces within [the stone’s] environment — the wind, water, weather, geographic characteristics and contact with other stones — then we begin to build a fuller picture of that stone’s development,” she says.

The same idea applies to counseling work with clients, says Hall, an assistant professor in the Department of Counseling at Xavier University in Cincinnati. “We must examine clients within the context of their lives because it is within this context that they grow, develop, suffer and change,” she says. “When we strive to understand and help people, we cannot underestimate the impact that their environment has had and will continue to have on their well-being and development. Most clinical and nonclinical concerns do not rest solely within an individual; therefore, interventions should not solely target the intrapersonal.”

What Hall is describing is the ecological perspective in counseling, which, much like the study of ecology in the physical world, takes into account the many systems that influence and interact with individuals on a regular basis.

In Ellen Cook’s book Understanding People in Context: The Ecological Perspective in Counseling, published in 2012 by the American Counseling Association, she writes that the term ecosystem “refers to the sum total of interactive influences operating within an individual’s life in varying degrees of proximity, ranging from his or her biologically determined characteristics to the broader sociocultural context structuring human interactions. … What happens to an individual rarely occurs in a vacuum but rather is shaped by the confluence of events, propensities, relationships, memories and other features of a life elaborated over time and across settings.”

Hall, an ACA member who also runs a private practice in Dayton, Ohio, recalls one of her clients who was dealing with depression. Negative thought patterns exacerbated the client’s depression, Hall says, but she also had a long list of other issues affecting her life and emotional state. The client lived in unsafe housing, was in an abusive relationship, had financial concerns, felt disconnected from her church, had strained sibling relationships, felt disempowered at work because of discriminatory practices, felt isolated geographically by living in a rural setting and felt disconnected culturally because she was a member of a minority group and didn’t have any local connections with others who shared her culture. “If I were a cognitive behavioral therapist who focused solely on helping her change how she thinks about her life circumstances, I may be focusing too narrowly,” Hall says. “However, if I also use the lens of the ecological perspective, I can help her identify multiple paths for growth and change, which could all have some impact on her mental and emotional well-being.”

Alongside treatment for depression and low self-esteem, Hall worked with the client to prioritize a list of the aspects of her life she was unhappy about. “We targeted seemingly insignificant things first, such as painting her bedroom her favorite color,” Hall says. “This was something she had never done before, but she mentioned several times that even her room depressed her. She discovered that some things really are in her control and that she does have the power to change some aspects of her life.”

The client’s progress snowballed, Hall says, leading to big changes that were accomplished one step at a time. The woman gradually built a solid support network for herself by joining a local book club and walking club and making friends. Hall credits that action for eventually giving the woman the strength to leave her abusive relationship. She also found an apartment closer to a nearby city, visited local churches until she found one she liked and summoned the courage to speak to human resources to spark policy changes at her job.

“These were but a few changes my client made to help her transform her life,” Hall says. “She was healthier in mind, body and spirit and felt empowered to shape her life as she saw fit. In our last session together, she gave me an origami bird she had made using paper that was her favorite color — for teaching her ‘how to use her wings,’ she said.”

“A counselor oriented to the ecological perspective is a creative counselor who recognizes that all aspects of a client’s context can be placed on the table for assessment and intervention,” Hall says.

Life’s interactions

Susannah Coaston, a counselor and supervisor at a community mental health agency just outside Cincinnati, says the ecological perspective acknowledges that to best understand their clients, counselors must also understand the relationships clients have with the people and contexts around them.

“An individual acts on his or her environment, and in a reciprocal manner, the environment acts on the individual. It’s how the individual makes meaning of these interactions that can impact change,” says Coaston, an ACA member who contributed to Understanding People in Context and is also an adjunct instructor in the counseling program at Northern Kentucky University. “The change that is sought in counseling involves improving the [client’s] fit in the environment with the right balance of challenge and support. This fit is individualized to the person.”

Cook, a professor of counseling at the University of Cincinnati, also co-edited the 2004 book Ecological Counseling: An Innovative Approach to Conceptualizing Person-Environment Interaction with Robert K. Conyne. She says the ecological perspective first took hold within the helping professions four or five decades ago. In 1977, psychologist Urie Bronfenbrenner “organized human life contexts as a series of concentric circles with the individual nestled at the heart,” Cook writes in Understanding People in Context. Those circles, moving further out in terms of proximity to the individual, were dubbed the microsystem, mesosystem, exosystem and macrosystem.

“In my experience, however,” Cook writes in her book, “counselors are typically more comfortable thinking about the sites (e.g., home, school, neighborhood) involved in someone’s life than about abstract connections among systems that can be difficult to translate into the particulars of a person’s life. There are other ways to think ecologically about behavior while remaining faithful to Bronfenbrenner’s insightful schema. In our ecological perspective, then, we will refer to contexts differently than Bronfenbrenner did while retaining several of his key assumptions about the nature of contexts. These key assumptions about contexts concern proximity, salience and embeddedness.”

Cook’s view of the ecological perspective in counseling includes four propositions. The propositions aren’t new to counseling, she says, but combining them and viewing them all as equally important is innovative.

The first proposition is that all behavior is personal. In this sense, Cook says, a person’s behavior is a function of that person’s unique characteristics — both characteristics that are genetically based and those that have developed over time on the basis of the person’s past experiences.

The second proposition is that all behavior is contextual, meaning that it is influenced by the circumstances of a person’s life, Cook says. This can include both physical circumstances, such as the geographical climate or the quality of a person’s housing, and the human context, such as a person’s relationships and connections with groups, Cook explains.

The third proposition is that all behavior is interactional. That means even the simplest behaviors are influenced by the characteristics of the individual interacting with the characteristics of that individual’s life context. “The world around the client has an enormous impact on the person’s life,” Cook says. “Because we view behavior as interactional, counselors’ practice of focusing only on the client’s psyche leaves out much of the client’s reality that might be changed.”

The fourth proposition contends that all behavior is concerned with meaning. “In other words, it’s how people perceive, evaluate and predict events in their lives,” Cook says. “People can perceive the same things quite differently. Some of these perceptions are genetically based — our preference for certain flavors, for example — but most of the issues counselors and clients explore together are based on how the client has learned to perceive and evaluate stimuli, events, other people and so on.”

Listen and learn

One of the most important aspects of the ecological perspective in counseling is the ecological analysis, Coaston says. “I begin by building a strong therapeutic relationship so I can best understand [the client’s] situation,” she says. “I try to be mindful of how the client makes meaning of the situation. Here, I often use metaphor to help gain understanding. Understanding that a client feels as though they are in a hole in the ground, and every time they try to pull themselves up, more dirt falls from the walls, can help me to feel how the client feels in [his or her] circumstance.”

In the chapter Cook and Coaston co-authored in Understanding People in Context, they offer a wide variety of “questions to consider in developing an ecological analysis.” Among those questions:

How is the problem situated within the client’s ecology (who, what, when, where)? And what does it mean to the client?
Where does the client live out his or her life physically and interpersonally (where is the client’s ecological niche)?
What are the client’s important interactions with people? Groups? Community or neighborhood? Larger systems? How do these interactions influence the client’s life?
What life roles and identities appear salient to the client?
What central life meanings are salient to the client’s targeted concerns?

Coaston says these analysis questions are an excellent place for the general counseling practitioner to start. “The questions posed can be used to better understand clients beyond [what] is usually gained from most traditional intake or diagnostic paperwork. For example,” Coaston says, quoting from the book, “‘What impact does time have on the client? How does he or she experience time every day (e.g., is there too little or too much of it, is it going by too quickly or too slowly)? Where does the person feel he or she is in the life cycle? How age appropriate does the person feel important life events or problems are?’ [These questions are] unlikely to be easily answered by a clinician who does not work from an ecological perspective. However, [they] can give insight into the inner experience of a client in [his or her] daily life.”

At the agency where she works, Coaston is expected, for billing purposes, to develop goals for treatment during the first session. “However, after this first session, I let the client’s story marinate in a way and begin making connections based on my understanding,” she says. “These connections are discussed in future sessions so I can make sure I’m seeing the concern in a similar manner to the client.”

After reaching a better understanding of each client and situation, Coaston may teach the client new skills or offer resources so the client can address elements of the situation on his or her own. But Coaston also stays on the lookout for ways that the client’s environment could possibly be changed. “In our agency, we work closely with case management staff who can help counseling staff understand the home environment and identify community resources that could be helpful. I will also look at how the client creates meaning in [his or her] life and look to expand, adjust or keep the current meaning making for the health and well-being of the client.”

Some counseling perspectives tend to revolve around a belief that the potential for change rests solely within the client, Coaston says. In contrast, the ecological perspective takes into account how clients interact with their environment and contends that change sometimes must happen outside the client.

The ecological perspective also dissuades counselors from viewing clients as “unmotivated” to change, a label that Cook rejects as never being helpful. “Just what barriers to change does the client see? How might the counselor and client see the life concerns under question very differently?” Cook asks. “Clients may give up efforts to change their lives because the challenges seem insurmountable and their resources inadequate. If counselors are able to suspend their own perceptions and experiences in order to truly understand the client’s life from [the client’s] own perspective, the counselor will find it easier to identify resources and opportunities.”

Counselors who fail to take a client’s environment and meaning making into account run the risk of blaming the client, Coaston says. “It is easy to forget that our clients’ framework for perceiving the world may be different from our own. What may be straightforward, easy or not a big deal for us can be anxiety provoking, shaming and not worth it for our clients. When we can understand the relationship between the client and [his or her] context, we may find change is needed in the client, the environment or, often, both. However, when we look at our client without the environment, it is up to us [as counselors] to ‘fix’ the client to resolve the problem,” she says.

Much like counseling as a whole, Cook says the ecological perspective stresses that clients are the experts of their own lives and encourages counselors to focus on client strengths, such as a supportive network of relationships or an ability to make and carry out decisions. “In the ecological perspective, we encourage counselors to identify the resources and challenges the client has today,” she says. “What do they have to work with? What are the issues or roadblocks preventing them [from moving] ahead in life? If a counselor cannot identify any strengths or resources, it may be useful to consider whether the counselor has negative preconceptions that might prevent the counselor from truly helping the client. People do the best they can with what they have and what confronts them in life as they perceive it now. How have they been able to get this far?”

Cook points out that not all counselors have the skill or interest to help clients with every environmental factor. “Counselors may be uncomfortable exploring a client’s sexual orientation, religious questions, housing needs, weight issues … We all have limits to what we can do because of who we are as individuals and professionals. We need to build our own network of support in our professional lives — people we know can help our clients when we cannot do so. It’s worth our time to establish these networks so that we can refer as needed.”

Entering the client’s cave

Hall, who co-authored a chapter with her mentor, Geoffrey G. Yager, about training counselors in Understanding People in Context, says assessment from an ecological perspective demands that counselors formulate client problems accurately, in detail and within multiple dimensions. “Articulating the problem as ‘I am depressed’ or ‘I’m worried about my child’ is not enough,” Hall says. “The ecological perspective demands a detailed problem statement that answers the questions who, what, when, where, why and how often. We determine the challenges and supports at the ‘person’ and ‘environment’ levels and the health of the interaction between the two. We strive to understand the meaning the client derives from his or her life. Diagnostically, we understand the importance of all axes, and our conceptualization and targets of intervention must include Axis IV — deficits and strengths.”

Hall believes it is imperative to model the ecological perspective for her students. When sharing examples from her own experiences with clients, Hall says she uses the “language” of the ecological perspective so that students will learn from day one to expand their views of clients beyond the intrapersonal.

Even when prompted to use specific tools, her students learn to view clients within their complex, multidimensional contexts. “For instance,” Hall says, “if I give students a case to examine and I provide a multiaxial diagnosis, I am careful to spend as much time with Axis IV as I spend with Axis I. I prompt discussions about the relationship between person and environmental factors, and I make sure that we expand our lens to include strengths or nutritive factors as well as deficits, both within the person and his or her environment.”

Hall says counselor educators can use multidimensional role plays, case studies and case presentations that emphasize an ecological perspective, thereby inviting students to understand the rich context of clients’ lives and problems. “By providing ongoing supervision using an ecological perspective, our practicum and internship students will build a strong foundation for their work in the future,” Hall says.

Hall points to something she learned from Yager, a professor of counseling at the University of Cincinnati, who likened counseling to cave exploration. “If we enter into our client’s cave along with them, then we both will have expertise in various areas,” Hall says, recounting Yager’s lesson. “Because our client lives here, he or she will have knowledge about much of the geography of this cave, but may miss important aspects of the terrain due to the patterns of movement and awareness that he or she has developed. Some of these patterns can become self-limiting, to the point that our client would like to leave the cave or change the cave but cannot due to these patterns of behavior, meaning making and perceptions about self and environment. The counselor enters this cave not as an expert of this particular cave but with a fresh perspective and a set of tools to help the client uncover aspects of himself or herself, or of the environment, that perhaps the client has never seen. We need our client to show us around, and they need us to see with new eyes and to share our tools. An ecologically oriented counselor — and cave explorer — would focus just as much on understanding that cave as she would on understanding the client because, most likely, the changes, solutions and well-being will come from the interaction between the two.”

Many times, Hall says, people seek counseling because they are experiencing a poor fit between themselves and some aspect of their environment, whether that aspect is a relationship, a career, a peer group, a lifestyle or a geographic location. For instance, a large Air Force base is located near Dayton, where Hall practices. One of her clients was a military spouse who moved from Southern California to Ohio in the fall, never having been exposed to a cold-climate winter before. The woman loved the outdoors and typically remained very active year-round, but she started feeling paralyzed by the cold, dreary days of winter in her new home.

“This quickly impacted her mood, as she was no longer physically active, social or experiencing nature, which was her connection to her spiritual self,” Hall says. “Together, we worked to identify how she was interacting with this environment, the meaning she had created about this experience and then how she could begin to change this interaction. While it is true that we cannot change the weather, we can learn how to change our interaction with it and its interaction with us. The ecological perspective provided the lens, and cognitive behavior therapy [CBT] and mindfulness helped by giving tools to alter meaning making, appreciate the present moment and learn to tolerate the discomforts inherent in everyday life.”

The ecological perspective can complement almost any counseling theory, Cook says. Coaston calls it the lens through which she perceives each client and situation. Once the counselor has a clearer picture of what the client is hoping to achieve, different counseling theories can be utilized, she adds.

Cook explains that the ecological perspective is metatheoretical — not a theory itself but rather a series of principles that underline many other counseling theories. “The perspective is not meant to replace any other counseling approaches, and we [as proponents of the ecological perspective] certainly don’t mean to imply that there’s anything wrong with other approaches,” she says. “What we do recommend is that counselors learn to ask themselves what other aspects of the client’s life ecology they might be overlooking.”

Hall agrees. “The ecological perspective helps us conceptualize and intervene with our clients more fully than many single theoretical orientations,” she says. “It … weaves together constructs and processes to create a broad picture of the client’s life, from intrapersonal processes, including meaning making, to interactions with people, multiple environments, life events, history, culture and society across time. While a single theory often targets a small part of the dynamics contributing to the client’s life concerns, the ecological perspective provides the bigger picture. Therefore, with a wider lens, we have a greater range of possible targets of intervention.”

Cook and Coaston say the ecological perspective can apply to almost any counseling setting and client. “However,” Coaston says, “clients who are able to think abstractly, willing to make tough changes and motivated to look at their circumstances with new eyes are most successful.”

‘The problem isn’t the problem’

Schools are their own ecosystems — and that makes them a perfect place to implement the ecological perspective in counseling, says George McMahon, an assistant professor and counseling program coordinator at George Mason University in Fairfax, Va. He began researching the idea in 2007 and has presented on it at various conferences ever since.

Schools themselves are divided into multiple systems, McMahon says, such as social groups within the student body, different grade levels, teachers versus students, and so on. Schools are also a system nested within the larger community. The basic idea behind implementing an ecological perspective in a school counseling setting is to acknowledge that any problem or issue must be considered, and often solved, within the context of the system, McMahon says.

For example, a principal might say to a school counselor, “We’re having a problem with low attendance among our ninth-graders. They’re not getting to school on time.” Traditionally, attendance alone might have been viewed as the problem, says McMahon, a member of ACA and the American School Counselor Association, a division of ACA. “[But] from an ecological perspective, that’s feedback that something within the system is out of balance,” he says. “Maybe the kids aren’t coming to school on time because they don’t feel safe at school. Or maybe within their community, they’re not seeing kids graduate, so they value going to school and graduating differently. Or maybe many of these kids are older siblings and they’re getting their younger siblings ready, and that’s why they’re late. We tend to assume that the problem lies within the students, and we address it from a motivation standpoint.”

Considering contextual variables can lead counselors to seek solutions in more than one place, McMahon says. Take, for example, instances of school bullying that target those perceived to be sexual minorities or gender nonconformists. Using an ecological perspective, the counselor would first start on an intrapersonal level, McMahon says, working with the student on ways to stay safe and self-advocate. Then the counselor might look at how teachers intervene or the language that teachers allow students to use in their classrooms, he says. Next the school counselor might look at schoolwide policies, and if those policies don’t cover sexual minorities or gender nonconformists, the counselor might begin advocating for change.

Counselors are in the perfect position to apply this perspective, McMahon says, because they are among select few school personnel to have access to students, teachers, administrators, coaches, parents and community members. “Because collaboration is a vital component to this model, professional school counselors have a role as connectors, because they are in contact with such a wide variety of stakeholders,” McMahon says. “They can be the hub of the collaborative wheel, so to speak.” Additionally, he points out, school counselors have the skill set to foster collaboration, including skills centered on empathic listening, team building and advocacy.

Although it is prudent to consider all the contextual factors as a school counselor, McMahon acknowledges that can feel overwhelming. The good news, he says, is that just doing something — anything — can make a difference. “You don’t want to let yourself be paralyzed by how big a job it is. Make a guess [toward a solution], start somewhere and then evaluate along the way. Any change you make will ripple out.”

Another piece of good news? School counselors don’t need to change what they’ve been doing; they simply need to open their eyes more fully to what might be contributing to an issue, McMahon says. “The problem isn’t the problem. It’s an indication something else is going on,” he says. School counselors can utilize the relationships they have built, both within the school and the community, to address any issue, he adds.

The first step in bringing the ecological perspective to school counseling is to intentionally see and use the connections, McMahon says. “It’s really a paradigm shift, a shift in perception. But once you begin to see the interconnections, you can’t stop seeing them. At that point, the next step is just to act in accordance with what you see. When you realize that student scores are not just a result of a lack of study skills, [that] there may be several other factors — some outside of the school — that are affecting those scores, then think creatively about how to act in accordance to what you see. Address the larger factors, collaborate with others who have access or expertise you need, and work across levels rather than just ‘fixing the child.’ At that point, you are working ecologically.”

Taking an ecological perspective can also help to carry out the ASCA National Model, McMahon says. “The ASCA model promotes a vision of what to do and, to some extent, how,” he says. “The ecological model supplies the ‘why’ and expands on the ‘how’ by showing how all of the different roles and responsibilities are connected and working toward the same goal of helping to create and maintain a healthy, equitable, diverse and balanced system that graduates students who are ready to actively and positively participate in the larger community.”

Seeing life through the client’s eyes

Though Hall makes a point of exposing her students to the ecological perspective, Coaston says that isn’t the norm among counselor educators. Elements of the perspective may be touched on in some classes, she says, but as a whole, it generally goes uncovered.

But that shouldn’t stop counselors from learning about and applying the ecological perspective, says Coaston, who points to both of Cook’s books as good starting points. Formal training in the perspective isn’t necessary, she says, but she adds that supervision and consultation with someone who understands the perspective can help ensure fidelity.

Cook says most experienced counselors eventually end up applying the ecological perspective to some degree, even without training. “They realize that human behavior can never be understood in a very simple, straightforward way,” she says.

Cook suggests that counselors who are just starting their careers begin applying the perspective by looking for what the client has done right. At times, she says, counselors see clients who seem to have one problem on top of another, and in these instances, counselors may be tempted to look for what the client is doing wrong. “Supervisors need to remind counselors that clients do the best they can with what they have experienced and how they perceive it,” she says.

Cook reflects on one particular client who fit that description. The client had worked out a plan to support herself and her children throughout the month by using a mix of food assistance, financial assistance, free church suppers, food banks and donating her blood plasma for money. “She knew exactly where to go and when in order to provide for her children,” Cook says. “These strategies of exploring, identifying and utilizing community supports could be used in many ways to assist her family to change their lives permanently.”

Hall cautions beginning counselors not to fall into the trap of believing that any single theoretical orientation will fully explain a client’s situation or provide an all-encompassing list of interventions. “I would encourage them to learn about ecological counseling to help them widen their lens [because] I believe we can do clients a disservice when we limit our view,” she says. “Allow yourself to consider a full range of intervention targets, even if at first the change seems too miniscule or irrelevant. The client I spoke of [previously] began her path to transforming her life by painting her bedroom. To some, this could be considered irrelevant to the counseling process, but to an astute counselor, this can represent forward movement that should be nurtured in the hope that it leads to something bigger over time.”

Cook offers more-seasoned counselors reassurance that they haven’t been doing anything wrong up until this point. However, she says, applying a focus on the ecological perspective may assist them in noticing additional opportunities where change could occur for clients.

Hall agrees. “Ecological counseling can inject new life into counselors’ work by reminding us to be creative, open-minded and respectful of the multiple systems at work in the lives of our clients.”

The ecological perspective offers counselors the opportunity to see details of a client’s life they may have missed otherwise, Hall says. Generally speaking, she adds, counselors can miss important aspects of a client’s context, especially when the counselor is either too similar to or too different from the client. “If we perceive a great likeness to our clients, we run the risk of making assumptions about them because we’ve ‘filled in the blanks’ with our own experiences, perspectives and judgments,” she explains. “Likewise, if we perceive our clients as being vastly different from us, we can miss important aspects of their context because we don’t know what we don’t know, so to speak. By attempting to understand every client as fully as possible using an ecological lens, I believe we decrease the likelihood that our own contexts might impede us in our quest to both realize and appreciate our clients.”

In cutting across a wide range of current counseling theories and approaches, Cook says the ecological perspective implores counselors not only to gain a fuller understanding of their clients’ worlds but also to work toward change within those worlds. “In a nutshell, the ecological perspective offers a language and model for understanding human behavior that encourages counselors to think creatively and to reach outside their own offices to other professionals and services to build collaborative programs for change,” she says. “When we truly appreciate how clients’ lives are influenced by sociocultural forces and limitations outside their control, we can broaden our change efforts to work toward social justice for all people.”

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Multiculturalism and the ecological perspective

Comprehending diversity from an ecological perspective means understanding that a person’s cultural identity results from a combination of biological, psychological, physiological, physical and spiritual selves that interact in life spaces such as family and work settings, says Huma Bashir, who works as a counselor at a nonprofit community health center in Springfield, Ohio.

“When evaluating cultural identity, the ecological approach considers all levels of influence in a person’s life, looking at them in context,” says Bashir, who co-authored a chapter on the topic for Ellen Cook’s book Understanding People in Context: The Ecological Perspective in Counseling, published by the American Counseling Association. “The multifaceted nature of the ecological approach is essential to dissect cultural differences of individual clients, allowing a clinician to take a snapshot of contextual information. It is the multidimensional factors that could pose a challenge for the treatment of mental health issues for any population, [but they are] especially critical for ethnically diverse clients.”

Simply viewing diversity in terms of a person’s cultural background is ineffective because it negates the interactions between a comprehensive list of cultural factors, says Bashir, who conducted research on Pakistani Americans living in Springfield last year as part of her doctoral dissertation at the University of Cincinnati. For example, she says, the experiences of a female Pakistani American residing in a small rural community would be different from those of a female Pakistani American living in a metropolitan urban community.

Mental health issues and cultural factors must be viewed together, Bashir says, because cultural factors may affect the definition and acceptance of mental health disorders. “Muslims determine their mental health in the context of religious values,” explains Bashir, a member of ACA and the Association for Multicultural Counseling and Development, a division of ACA. “Cultural factors and religious views may influence the diagnosis and treatment of mental illness among Muslims within mental health services. Working with clients from a diverse ethnic group cannot be put in a pigeonhole, and utilizing the ecological perspective would offer a fluid, flexible and contextual [view] of life events. Using the ecological approach, which will help clinicians uncover particulars about cultural identity, can bring about an understanding of clients’ cultural contexts, which will help to avoid any misdiagnosis.”

Clinicians must remain cognizant of the many factors that can interact to create cultural identity and influence the effectiveness of counseling services, Bashir says. “For example, a counselor will be more effective if she understands the age and developmental level of her client and how those factors intersect with her family, parents and friends.”

Bashir recalls working with one client who presented with physical symptoms associated with malnutrition. “After investigation, [it ended up] the young woman was reacting to an arranged marriage she felt she was being forced into, and she was unable to communicate her upset and anger to her parents. By being aware of and understanding the relevance of culture, clinicians can provide more effective services.”

To contact Bashir, email hbashir@rockinghorsecenter.org.

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