Immigration’s growing impact on counseling

They come by air, land and sea. In airplanes, on overcrowded boats, aboard shipping vessels, by train or even on foot. They are immigrants and refugees looking for the same things as previous generations of people who willingly came to the United States: hope, sanctuary and the possibility of a better life.

Everyone in the United States who is not an American Indian or Alaska Native is of course an immigrant or a descendant of immigrants, whether by choice or because of slavery. For much of our nation’s history, most immigrants were of European descent. However, the Immigration and Nationality Act of 1965 eliminated the immigration quotas that favored Northern Europeans. Current immigration policy gives preference to applicants with family ties to U.S. citizens or legal residents and to skilled workers.

Because immigration policy no longer gives preference to European immigrants, today’s immigrants come from all over the world but particularly from Latin America and Asia. As a result, the United States is a much more ethnically diverse place than it was 50 years ago.

According to the Migration Policy Institute (MPI), a nonprofit think tank that analyzes worldwide migration, an estimated 41.3 million immigrants lived in the United States as of 2013 (the most recent year for which statistics are available), constituting 13 percent of the population. MPI says that approximately 19.3 million of these immigrants are naturalized U.S. citizens, while the remaining number are lawful permanent residents, unauthorized immigrants or legal residents on temporary visas, such as students and temporary workers. According to the Department of Homeland Security (DHS), approximately 1 million people were granted lawful permanent resident status in 2013, meaning they can legally work and live in the United States but are not yet eligible for citizenship; slightly less than half of these immigrants were new arrivals. DHS records also indicate that 69,909 refugees were admitted to the United States in 2013, while 25,199 immigrants already in the U.S. or at a U.S. port of entry were granted asylum. The DHS estimates that there were 11.4 million unauthorized or undocumented immigrants living in the U.S. as of 2013.

Not everyone is comfortable with this reality. From Republican Party presidential candidate Donald Trump’s stated plans to build a wall on the U.S.-Mexico border and bar entry to Muslim immigrants to the numerous state governors who have announced they will not accept refugees from Syria, current headlines vividly demonstrate the obstacles confronting many immigrants and refugees, ranging from bureaucratic and legal battles to suspicion, prejudice and outright hostility.

Many immigrants and refugees are also unaware that there are professionals such as counselors who can help them navigate this strange new landscape. Those who work with these populations say that as part of the cultural diversity that the counseling profession has embraced, counselors have a responsibility to help immigrants and refugees with everyday challenges associated with community, school, work, health care and other systems.

Strange new world

Although every immigrant’s story is different, they all share one overarching truth — that every aspect of life will be affected by the immigrant experience, says Shabnam Etemadi, a doctoral counseling student at Tennessee State University in Nashville. Etemadi studies and works with immigrants. She is also an immigrant herself.

Most immigrants come from a collectivist culture to settle in the United States, which features an individualist culture, Etemadi says. This means they must grapple with a society whose very nature is fundamentally different from their own, she points out.

Etemadi and her family emigrated from Iran when she was 6, settling in Nashville. Even though the city is home to a large Iranian American population, the family often felt very isolated. Language was probably the biggest barrier to her family’s adjustment, she says. Knowing very little English, the family was afraid to go outside and interact with the world at large. “The main way we learned English was by watching TV,” Etemadi says. “[We would watch] simple kids shows and soap operas.” Her family members also practiced reading, but Etemadi says the television was particularly important because it helped them learn cultural nuances.

Another language barrier had to do with learning that certain phrases and words had meanings beyond their literal definitions, Etemadi says. For example, she vividly remembers her classmates taunting her one day for “cutting.”

“They kept saying, ‘You’re cutting! You’re cutting!” she remembers. Bewildered because she was not physically cutting her classmates, Etemadi eventually realized that cutting meant “cutting in line.”

That one instance offers a small but insightful example of how coming to America fundamentally changed who Etemadi was. “I was an extrovert back home, and when I came here, I became an introvert,” she says. “I was shy, withdrawn and fearful because I didn’t speak the language. I was bullied in elementary [school], and I never made any meaningful relationships with the teachers.”

Etemadi says all the teachers spoke to her in a way that she perceived as “weird” as a child. In reality, she says, they were doing something that many Americans do when trying to communicate with someone who doesn’t speak much English — talking very loudly.

Etemadi says she also felt “marked” because she was in the English as a second language (ESL) program. “I would be a part of [my homeroom] class and, suddenly, I would be taken out by an ESL teacher to talk about my schoolwork,” she recalls. “I was learning English, which was great, but I felt isolated, and my peers would wonder why I was taken out of class every other day.”

School also proved bewildering for her parents, Etemadi says. For example, the grading system was based on a different set of numbers than they were used to, so their understanding of their children’s reports cards was limited. The idea of participating in extracurricular activities — which in the United States plays an important role in getting into a good college, among other things — was virtually inexplicable to her parents, Etemadi says. In Iran, she says, students go to school strictly to study, so her parents had trouble understanding why she might need or want to stay at school after classes were over for the day.

Talking to other Iranian American families in the community eventually proved helpful in understanding the importance of extracurricular activities, Etemadi says. But as a whole, Iranians are protective of their personal lives, she explains, so the family tried to cope with many struggles on their own.

The most profound event for which the family needed support happened a few years after moving to the United States, when Etemadi’s brother died under traumatic circumstances. Unfortunately, the family was still relatively isolated in their new home country and didn’t have anyone to turn to to help them process what had happened. Even the teachers at her school barely acknowledged her brother’s death, let alone her grief surrounding it, Etemadi says.

It is those types of events that might push many Americans to seek counseling. But the idea of counseling is completely alien to Iranians because it just doesn’t exist in their country, Etemadi explains. And that is a point that counselors in the United States need to understand — they should not expect that members of most immigrant communities will simply show up at a counselor’s office if and when they need help.

That is why Etemadi says counselors can and should be advocates for immigrants. She believes that from the beginning of the immigration process, immigrants need someone who can speak their language to provide them with mental health support. They also need to be told that counselors can continue to provide assistance if they run into barriers that they have trouble surmounting.

Because of her personal experiences, Etemadi developed an interest in studying the immigrant experience. As she learned that the types of difficulties faced by immigrants of all cultures are similar, she decided she wanted to help. She ultimately chose to become a counselor because she felt that counseling’s emphasis not just on mental health but also wellness and personal development would be most palatable — and useful — to immigrant populations.

As part of her dissertation, Etemadi is currently studying whether it is possible to develop best practices specifically for counseling with immigrant and refugee populations. Because the notion of counseling is typically foreign to immigrant populations, she believes it might be particularly difficult for these clients to grasp that emotions are connected to actions. Etemadi has found narrative therapy to be particularly useful because it helps clients who have immigrated to the U.S. to look at their stories from an outside perspective, while allowing her to identify cultural differences between the client’s culture and American culture. She can then partner with clients to explore how these differences may be causing difficulties.

The primary thing Etemadi wants counselors to know about the immigrant and refugee populations, however, is that they need help acculturating but don’t generally know where to find this help. She says counselors have a responsibility to reach out to immigrant communities. Because there is often stigma surrounding counseling, especially in these communities, she suggests that counselors use a soft approach to raise awareness. For example, she says, counselors could post their business cards in international restaurants or even settings such as the tire store. She also advises that counselors work with local physicians to make connections. In some cultures, she explains, the suggestion to seek help from a counselor will be much better received if it originates with a doctor.

Communicate to advocate

Saari Amri, a licensed professional counselor in Falls Church, Virginia, agrees that very few immigrants are going to walk into a practitioner’s office. “It’s rare that we have immigrants in general proactively seek out mental health counseling,” she says. “When they come in, they come in after crisis or have gotten to a tipping point. … With torture survivors, domestic violence, they come in through referrals, usually law enforcement or social services.”

Amri practices at Northern Virginia Family Services Multicultural Center, a clinic that receives many of its referrals because the counselors who work there are multilingual and culturally responsive, she says. Many of the clinic’s clients are seeking a counselor who is an Arabic speaker or a Muslim. Amri, a member of the American Counseling Association, is both.

Although similarities exist between different Arabic cultures (including those whose members may be largely Christian) and Muslim societies, Amri cautions against making assumptions. “Cultural competency is a dynamic process even for someone like myself who has a lot of experience with the population and shares their culture and religion,” she says. “I’m always learning something new. [Counselors] always need to explore and understand.”

To get a full sense of the sociopolitical context of a client’s story, Amri says it is important to know not only where that client is from but also to ask about his or her particular experience. For instance, Amri recently had a client who was a former refugee from Somalia. She assumed the woman would be presenting with posttraumatic stress disorder, but it turned out her presenting issue was unrelated to her refugee experience.

Many of the issues with which Amri’s clients present — including depression, trouble sleeping and difficulties parenting their children — are common experiences for those who are struggling to acculturate, she says. She notes that she tries to keep the primary focus of her counseling on addressing clients’ immediate needs and safety. Within her clients’ cultures, people are generally seeking help for a specific issue and aren’t interested in anything touching on the psychoanalytic, she explains. Amri doesn’t believe there is any one method or practice that is most effective with clients who are immigrants or refugees. “You can’t go wrong with keeping it client-centered and meeting the client where they are,” she says.

However, it is important to understand that the immigration journey intertwines with everything the client is experiencing, Amri says. “It’s important to normalize what they are going through, whether it’s struggling with acculturation or coping with the effects of war or torture.”

It isn’t common for the clinic to see immigrants soon after they’ve arrived in the United States, Amri says. Instead, they usually come in years later as problems develop or grow worse. In many instances, this includes providing support to asylum seekers, who are generally coping with mental health issues related to whatever it is they have fled, including torture, war, political oppression or other circumstances.

Many of Amri’s clients are Arabic-speaking women who are subjected to domestic violence. In some cases, the women are immigrants from the Middle East who entered into arranged marriages in which an American man came to the woman’s home country, “picked” her out and brought her to the United States. Once in the United States, the husband becomes abusive. It’s very difficult for these women to find help, Amri says, because they don’t speak the language and may not be allowed to leave the home. The abuse often goes on until neighbors call the police or the woman flees, Amri says. These women often end up in her office through referrals from social services or law enforcement.

Amri also works with couples who are experiencing major cultural clashes as part of an interethnic or interracial marriage. They struggle in particular once they have children and realize that their child-rearing styles and basic values may be very different, she says.

Amri and the other counselors at her clinic also help clients navigate social service providers, school systems, the juvenile justice system and health care providers. The clients find it useful to be accompanied by people who speak the same language they do but, more importantly, Amri says, the counselors are there to make sure these clients actually get their needs met. Because the concept of negotiating with school systems, public service providers and health providers is often completely alien to these clients (let alone trying to do it in a foreign language or new country), Amri and her colleagues are there to help them navigate the cultural nuances and secure the services they need.

With situations such as this, Amri and other counselors have to go beyond traditional counseling techniques. They provide a source of support but also help the clients find outside services they need, such as occupational therapy.

Amri acknowledges that it may be difficult for a counselor who doesn’t come from an immigrant’s culture to provide effective services. At the same time, she says, it is inevitable that counselors will end up working with clients who are immigrants unless the counselors limit themselves to engaging with a specific client group or clinical issue. For that reason, Amri would like to see counseling education programs and professional groups provide more opportunities for multicultural training.

Connecting with the community

If clients won’t come to the counselor, sometimes the counselor needs to go to the clients, says Johanna Nilsson, director of the Empowerment Program, which is part of the Division of Counseling and Educational Psychology at the University of Missouri–Kansas City. The program provides free case management and mental health services to immigrant and refugee women and their families.

The Empowerment Program has a small staff supplemented by women from the immigrant and refugee community. These women not only provide a link to the various immigrant communities but also function as advocates for the clients. Nilsson, a professor currently on sabbatical, also has her students work in the program, coordinating psychoeducational workshops for the immigrant community or counseling women who seek mental health services in the division’s training clinic, Community Counseling and Assessment Services (CCAS). She says this enhances students’ knowledge of cultural diversity and is a good way to introduce the next generation of counselors and psychologists to immigrant communities.

Most of the program’s clients are women who are struggling with family, employment and cultural adjustment issues, says Nilsson, an ACA member. Kansas City’s immigrant population is diverse, but the Empowerment Program’s largest client groups come from Somalia, South America, Central America and Vietnam.

One common concern is parenting, Nilsson says. Many of the women are experiencing a loss of parental authority and struggling with how to parent in an unfamiliar culture in which they are confronted with new expectations for how to raise children. In addition, they tend to lag behind in understanding the language and culture in which their children are so quickly immersed, Nilsson says. The counselors provide a substantial amount of individual psychoeducation, both in CCAS sessions and workshops and when working in conjunction with advocates on visits to clients’ homes. The counselors also present workshops at religious institutions and service organizations on topics such as parenting, physical and mental health, trauma and domestic violence.

In the parenting workshops, the counselors teach parenting skills, conduct role-plays and even bring in local teachers and principals so the parents can get a better idea of how school systems (and public systems in general) work in the United States and how to interact to get what they need from people in positions of authority. One of the larger lessons these workshops help to promote is that immigrants and refugees “have the right to ask questions and seek help,” Nilsson says.

The program also occasionally holds family nights with immigrants and refugees from different cultures. Although language is often a barrier, Nilsson witnesses the women in particular bonding over their shared concerns about family, which helps them recognize that their struggles are common across cultures. In other words, they’re not alone. “It feels very energetic,” Nilsson says.

Nilsson believes it is also important to meet with clients in their homes. The counselors and students are accompanied by the community advocates on these visits. This approach tends to lessen the inherent language and cultural barriers while also helping to put the families more at ease. The home visits provide a way for the counselors and students to get to know members of the immigrant community, see how they are doing and learn what they might need. The visits also allow for opportunities to educate immigrants and refugees about available services, Nilsson says. A nurse will sometimes accompany the team to give health checks and provide additional information.

The program focuses on women not only because responsibility for home and child care often rests on their shoulders but also because refugee communities in particular have high numbers of families that have been separated, Nilsson explains. In many instances, the men have been unable to leave their home countries, so the women and children enter the U.S. on their own, she says.

Unfortunately, program workers also see cases of domestic violence. In addition to the danger and fear experienced by all people who endure domestic violence, women who are immigrants or refugees also tend to face language and cultural barriers that make them feel even more isolated and vulnerable, Nilsson points out. In many cases, these women might not even know what a shelter is or report that the shelter’s staff members don’t seem to understand them, she says. The idea of sharing space with other women and children at a shelter can also be particularly frightening to women who are immigrants or refugees, Nilsson explains.

To compound matters, domestic violence may be widely overlooked or even accepted in the woman’s culture. In fact, choosing to leave an abusive home situation might traditionally result in the woman being shunned, Nilsson says.

The Empowerment Program does partner with a shelter, so there is a place that staff members can take women and children in an emergency, but many immigrant and refugee clients are simply not ready to leave, Nilsson says. In such cases, staff members provide information on what the women’s rights are, what resources are available and how to access those resources. This information is also provided in the program’s workshops and sometimes in the women’s homes if it is safe to do so, Nilsson says.

Nilsson reminds her students that when they encounter instances of domestic violence, it is essential to start with the basics: Does the client have food, clothing and a safe place to live? Like Amri, she also believes that counselors are responsible for supporting immigrants and refugees with whatever they need, even when those needs fall outside the traditional realm of counseling. The Empowerment Program provides assistance with immigration paperwork and also serves as a bridge to other organizations that offer services the program is not equipped to handle.

Nilsson believes stepping outside of the office and into the community to provide what clients need is the future of counseling. She also thinks this kind of training is essential for students. “If students only attend a diversity class, the population is still foreign to you,” she emphasizes. “You have to bring the student out into the community.” It’s not solely the responsibility of immigrants and refugees to seek out counseling, she asserts. Instead, counselors must be intentional about reaching out to and connecting with these individuals and communities.

Undocumented and disadvantaged

As difficult as the immigration experience can be for those who are legal permanent residents, entering the United States without documentation presents an extra layer of barriers.

“This is a population that is frequently and repeatedly marginalized and scapegoated,” says Selma Yznaga, who helped establish the Community Counseling and Training Clinic at the University of Texas-Rio Grande Valley (formerly the Community Counseling and Training Clinic at the University of Texas-Brownsville). “They struggle with prejudice and discrimination, lack of access to basic services, housing and fair wages.”

Brownsville is on the U.S.–Mexico border, so many of the clinic’s clients are from Mexico. The clinic staff does not ask about immigration status, says Yznaga, who is also the interim chair of the university’s department of counseling and guidance. “Their residency status wouldn’t change anything about the way that we serve them and could raise suspicions about our intent for asking,” she explains. Regardless, some of the clients’ circumstances surface in the biopsychosocial histories that counselors gather during assessment, and these factors are considered holistically, she says.

“Clients come in for many of the same reasons people seek counseling in other parts of the country — relational problems, school referrals, issues related to poverty,” says Yznaga, a past president of Counselors for Social Justice, a division of ACA. “The majority of our referrals come from the local department of health and human services and the school districts.”

However, as with any other immigrant or refugee population, these clients’ presenting issues are always intertwined with their cultural struggles, she says. “For many of the undocumented population, basic resources for survival are a priority,” she says.

Obtaining these resources is a constant struggle because although there is a thriving black market in the Rio Grande Valley in which almost anything can be obtained for a price — driver’s licenses, green cards, Social Security cards and jobs — the market is ruthless, Yznaga says. Undocumented workers aren’t protected by labor laws, so they get paid below minimum wage or sometimes don’t get paid at all and are threatened with deportation if they complain, she says.

Not surprisingly, counseling is not typically a priority for this population. In fact, Yznaga says, people from Mexico are unfamiliar with counseling as a concept. In Mexico, mental health services are provided by psychiatrists and psychologists, she explains.

However, Yznaga and other clinic staff work to promote wellness within the immigrant community by going to places such as housing developments, where they can help organize health fairs that include diabetes screenings and depression assessments.

Clinic staff members also educate clients at the health fairs and in the clinic itself about systemic discrimination and marginalization and help clients learn to advocate for themselves. “We help them differentiate between mental health and mental illness and [work] to destigmatize help-seeking,” she says.

Because the undocumented immigrant population is such a stigmatized group, counselors should be careful to avoid the “missionary posture,” Yznaga says. “Undocumented individuals are sensitive and perceptive to people treating them as ‘less than,’ and sometimes well-intentioned assistance can be mistaken for pity,” she cautions. “Mexicans are proud of their tolerance and ability to survive under harsh conditions and can be shamed by the counselor’s perception that they are weak.”

Yznaga also notes the importance of counselors understanding the diversity inherent within the Mexican population. “We should all be very aware of in-group differences and avoid stereotyping any immigrant group,” she says. “For example, there are 31 states in Mexico, as diverse and unique as the 50 United States.”

“When possible, we should do our own background research and tentatively explore what resonates with the client as it relates to the presenting problem,” Yznaga continues. “In other words, as much as we want to know about a new culture, we shouldn’t make it the client’s responsibility to teach us in their counseling sessions.”

Working toward the future

Historically, many immigrants have come to the United States in pursuit of the fabled American Dream — not just for themselves, but especially for their children. That hasn’t really changed in the 240 years since the United States came into being. The path to that dream has undergone some significant detours, however.

In some ways, today’s children who are first- or second-generation immigrants may have greater opportunities for education than did prior generations. After all, these children do not need documentation to enroll in school — only a local address. However, once in school, they may not be given all the resources they need to learn everything the school has to offer, which can hamper their hopes of graduating, getting a job or going to college.

The biggest barrier, of course, is language. Many counselors have heard the occasional news story about schools in areas with large Latino/Latina populations that refuse to offer bilingual education. But most people aren’t aware that in a growing number of areas in the U.S., it is not uncommon for schools to have a student body that speaks five, 10 or even more different languages. How can any school system accommodate that?

This is where school counselors come in, says Diana Wildermuth, a former school counselor who worked predominately with the English-language learner (ELL) population for 14 years. There is much that school counselors can’t control, Wildermuth acknowledges, but she still urges school counselors to be aware of the ELL laws in their states so they can help to ensure that students receive the language services to which they are entitled. These services can vary widely, depending on the state. Students in California, for instance, may have access to bilingual education, but in certain areas of other states, there might not be any teachers who speak Spanish or other needed languages.

Some schools at least maintain a translator service so teachers can meet with parents who don’t speak English or who have limited English proficiency. If the school doesn’t have a translation service or can’t provide translation for a particular language, Wildermuth, now a professor of psychology and education at Caldwell University in New Jersey, recommends contacting local community organizations. At her former school, there was a need for someone who could speak Ukrainian, so she contacted a local community organization that could provide people to assist in translating.

Although this may help the parents, these translation services aren’t typically available to students, she points out. In some places, ELL services may consist of students following along as best they can or being paired with a native English speaker who can help explain through demonstration, she says.

Language isn’t the only barrier with which ELL students contend. The cultural and functional differences in the school experience can contribute to these students feeling like strangers in a strange land, says Wildermuth, a member of ACA. “For instance, in U.S. high schools, students move from classroom to classroom throughout the day,” she explains. “But in other countries such as South Korea, the teacher moves from class to class.”

This may not seem like much more than a stylistic difference, but imagine, Wildermuth says, being a new Korean student who is pointed toward homeroom and then expected to know how to navigate the school schedule for the rest of the day. School counselors need to be aware of these and other barriers that students who have immigrated to the U.S. might face, she says.

“If a brand-new student is coming to school, you have the opportunity to meet and greet them, make them [feel] comfortable and welcome,” she says. Simply letting the student know that you, as the school counselor, are a safe person to come to with any problems or concerns is important, Wildermuth emphasizes.

School counselors can also use some creative approaches to further ease these students’ sense of awkwardness and even help them build their English-language skills, she says. Wildermuth suggests organizing a scavenger hunt for ELL students at the beginning of the school year to assist them in learning the locations of classrooms and other facilities. If the clues are accompanied by short notes, the scavenger hunt can help reinforce the names of the locations in English, she adds.

Wildermuth also suggests engaging in role-play by asking questions with students so they can learn what is considered to be appropriate teacher–student interaction. It’s also important for counselors to make teachers aware of how difficult it can be for ELL students to know what to do or how to behave in the classroom, she says. Teachers are often uncomfortable with ELL students and tend to leave them out of class interactions and discussions, Wildermuth points out, but by educating teachers beforehand, counselors can ease some of their anxieties and pave the way for a smoother transition for the student.

Finally, Wildermuth says that much of what school counselors need to do with ELL students mirrors what they need to do with American-born students — namely, educating them on the role of the school counselor and how the counselor can help the student.

 

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The professionals interviewed for this article realize that it is unrealistic to expect the average counselor to possess all of the skills needed to work with every client who is an immigrant or refugee. At the same time, they emphasize that all counselors need to educate themselves and seek training in those skills. As a growing number of people from diverse cultures continue to enter the United States, these counselors emphasize that our society and, accordingly, the role of the counselor must continue to evolve.

 

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Additional resources

For those who would like to learn more about the topics addressed in this article, the American Counseling Association offers the following resources:

Books (counseling.org/bookstore)

• International Counseling Case Studies Handbook edited by Roy Moodley, Marguerite Lengyell, Rosa Wu & Uwe P. Gielen
• Culturally Responsive Counseling With Latinas/os by Patricia Arredondo, Maritza Gallardo-Cooper, Edward A. Delgado-Romero & Angela L. Zapata
• Counseling for Multiculturalism and Social Justice: Integration, Theory and Application, Fourth Edition, by Manivong J. Ratts and Paul B. Pedersen
• Counseling Around the World: An International Handbook edited by Thomas H. Hohenshil, Norman E. Amundson & Spencer G. Niles
• Multicultural Issues in Counseling: New Approaches to Diversity, Fourth Edition, edited by Courtland C. Lee

Webinars (counseling.org/continuing-education/webinars)

From ACA’s trauma webinar series:

• ABCs of Trauma: Introductory Session with Stephen Lenz
• Children and Trauma with Kimberly N. Frazier
• Dissociation and Trauma Spectrum with Mike Dubi
• Counseling Refugees with Rachael D. Goodman
• Human Trafficking with Jared S. Rose
• Traumatic Stress and Marginalized Groups with Cirecie A. West-Olatunji

Podcasts (counseling.org/knowledge-center/podcasts)

• Multiculturalism and Diversity: What’s the Difference? Is Not Counseling … Counseling? Why Does It Matter? with Courtland Lee

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org