April is Counseling Awareness Month, and every year, counselors dedicate efforts to promoting our profession through evaluation of service delivery, community promotion, and increased legislative advocacy efforts. This year, counselors are faced with an unprecedented challenge: to promote mental health while transitioning to telehealth session delivery, modeling physical distancing while closing cultural mental health gaps, and connecting clients with services from their own homes.

This is a critical time in our profession’s history, and we are needed now more than ever. Treatment is now largely shifting to a triage approach as counselors move to the front lines in psychosocial stabilization amid fear, isolation, anger, anxiety and depression.

One population being alarmingly affected is the Asian American population. The novel coronavirus global pandemic has observably spurred a stark increase in violent attacks on people of Asian descent. Xenophobic racism against Asian Americans has surged as the coronavirus sweeps the U.S., with reports of hate crimes averaging approximately 100 per day, according to Rep. Judy Chu (D-Calif.).

Counselors are now called upon to address the concerns of this population in our practice. Knowing the multicultural considerations of this population, and prioritizing culturally sensitive treatment approaches, has become an essential service now and for the foreseeable future.

Counselor advocacy

Through advocacy, we are able to influence the creation and delivery of transformative initiatives and programs that offer immediate and long-standing benefits to our clients. For example, we may lobby legislators to implement targeted mental health screening of at-risk populations, including clients with prior mental health diagnoses. The psychosocial needs and responses of Asian populations will be unique, and interventions should be trauma-focused, including components of building social support and community resources.

Address terminology: On March 20, the U.S. Commission on Civil Rights voted to issue a statement expressing “grave concern” regarding “growing anti-Asian racism and xenophobia” related to the coronavirus pandemic. The commission suggested that using terminology such as “Chinese coronavirus,” “Wuhan flu” and “Yellow Peril” was fueling xenophobic animosity toward Asian-Americans. Using racially based language to describe a pandemic attaches ethnicity to a viral outbreak and contributes to the instigation of race-based assaults.

We have an ethical obligation as counselors to redirect the language of our colleagues and to address this language with our clients as our approaches and frameworks allow. Using proper, professional terminology for this pandemic and directly addressing defamatory language with clients can expand a culturally humble dialogue and allow clients to explore their fears and anxieties in the safety of our offices.

Offer trainings: We may also use our expertise to offer site training in trauma and crisis response to help educate the public and health care workers about how best to deal with the immense pressure and anxiety of Asian American families. This may help minimize the detrimental psychosocial response in these times of crisis.

The American Counseling Association has compiled a comprehensive database of trauma resources and continuing education opportunities for counselors. ACA states that “disasters tend to stress emotional, cognitive, behavioral, physiological, and religious/spiritual beliefs.” Among the tools provides are external trauma and disaster resources, disaster mental health resources, sheltering-in-place resources, and trauma-related articles from Counseling Today. The database also offers information on resiliency, grief, and helping survivors manage skills and healing.

Educating our colleagues on the disaster impact and recovery model has particularly relevant and important applications at this time. This model incorporates several phases of assessment and identification of trauma stages preceding anticipated grief.

Client interventions

Asian Americans are experiencing exhaustion from elevated fears of harm beyond microaggressions outside of the home. Stress-based responses to dramatic environmental changes often lead to a dissolution of coping skills that previously have served as protective factors for Asian American clients.

As global attention is largely focused on the active physical treatment and recovery of patients on a medical level, the cultural considerations of specific populations have largely been left unaddressed. Many symptoms of post-trauma will not present for several months. Until then, we can rely only on our knowledge of disaster models to meet the needs of these clients.

Currently, our focus should be on intervention and prevention through building resiliency, developing community support, and encouraging social connectivity during physical distancing. Consider the following suggestions:

• Encourage individuals of Asian descent to reach out to one another through social media and other technologies to share experiences and feelings related to these fears and exposure to aggressive acts. It would be helpful to suggest joining an Asian American online community or advocacy organization to build feelings of self-agency and empowerment.
• Introduce mindfulness. When our clients notice sensations in their bodies such as a tightening in the chest or quickened heart rate, the observation of these feelings can build insight into the triggers. This helps clients develop awareness and a heightened sense of mind-body connection. Introduce mindfulness activities such as breathing, body mapping, and concentration to help clients focus on emotional balance. When in public, clients are more likely to access rapid-action options when they are calm, instead of habitually relying on immediate defensive or avoidant impulses.
• Directly address symptoms related to depression, anxiety and hypervigilance. Discussing these symptoms and suggesting evidence-based practices to aid in restoring rituals, connecting with family and friends, and incorporating spirituality may offer critical tools to prevent symptom-related impairment.
• Prompt clients to lean into literature, such as Grace Lee Boggs, Maxine Hong Kingston and Thich Nhat Hanh. Understanding how others of Asian descent have persevered through pain and difficulty is emboldening in a time of isolation and disenfranchisement.
• Be ready to discuss and disseminate resources on financial help, vocational disruption or academic distress, and maintenance of a cohesive family environment. Have handouts and weblinks prepared, phone numbers for emergency help and response, and community locations that will aid clients if they are in active crisis and cannot reach authorities or hospital treatment centers in their areas. As this public health crisis escalates, it is critical that Asian American clients have multiple resources on which they can rely for a sense of needed safety and security. 

Suicide prevention

The potential for suicide cannot be overlooked in this vulnerable, targeted population. Suicide screening should be done early and often. In Asian American clients, warning signs of suicidal ideation are often ignored because of stereotypes associated with Asian ethnicity. Counselors should approach the issue from a culturally informed perspective and consider intergenerational influences, pressures of perfection, collectivistic values, and the attributed image of being a “model minority.” The pressure of cultural expectations is elevated in times of severe stress and trauma exposure, and counselors should be direct when assessing risk factors, protective factors and treatment options.

According to the U.S. Department of Health and Human Services Office of Minority Health:

• Asian American females in grades 9-12 are 20% more likely to attempt suicide compared with non-Hispanic white female students.
• Southeast Asian refugees are at risk for posttraumatic stress disorder (PTSD) associated with trauma experienced before and after immigration to the U.S. One study found that 70% of Southeast Asian refugees receiving mental health care were diagnosed with PTSD.

The American Psychological Association offers additional data:

• Suicide is the second-leading cause of death for Asian Americans ages 15-34, which is consistent with the national data across all racial/ethnic groups (the second-leading cause for those 15 to 24 years old and the third-leading cause for those 25-34).
• Among all Asian-Americans, those ages 20-24 have the highest suicide rate (12.44 per 100,000).
• Among females from all racial backgrounds between the ages of 65 and 84, Asian Americans have the highest suicide rate.

Counselors should remember the importance of confidentiality and informed consent as a delicate balance between rapport and mandated reporting. Two tools to consider using in suicide screening are the Collaborative Assessment and Management of Suicidality model and the Suicide Intervention Response Inventory−2.

Other counselor considerations

Compassion fatigue. Effectively managing our own emotional responses to trauma has been a focus of training and continuing education for professional counselors. As of today, the majority of counselors have transitioned to providing online telebehavioralhealth services to their regular caseloads and have taken on additional responsibilities in their communities, including providing crisis intervention for individuals whose exposure to sudden violence has superseded their ability to cope effectively.

This presents unique challenges for counselors who are experiencing multiple pressures to fulfill additional responsibilities for decompensating clients and new referrals. It is not uncommon for counselors to feel physical, emotional and psychological fatigue daily due to our deep concern for the safety and well-being of our Asian American clients during the current circumstances. Dennis Portney (2011) described compassion fatigue as “burnout plus the accumulation of stress resulting from empathizing with clients over time.” Compassion fatigue may appear suddenly and feel pervasive, interfering with normally ascribed self-care routines. To combat compassion fatigue, counselors need to affirm for themselves that commitment, not perfectionism, is the key to maintaining energy during this time.

Self-care. Counselors should consider the work they do as essential, necessary and sacred. And we cannot minimize, trivialize or dismiss our own emotional trauma-based reactions through overidentification and countertransference. We should commit to honor ourselves and our mental health, just as we do with our Asian American clients, and monitor our investment in their care within this framework. As our resilience wears down, we may see our usual compartmentalization skills regress into exhaustion, anxiety, impaired sleep, and reduced investment in client care.

Another important application of self-care is diligently reminding ourselves to practice what we preach. We need to apply our prescribed coping skills to our own daily routine during this time. Yoga, breathing techniques, visualization, and staying connected with positive, supportive groups builds our resiliency and reminds us of Irving Yalom’s key principle of universality. The incorporation of coping skills that Asian cultures embrace are applicable to our own lives and will ease our own trauma-based reactivity during this time.

Promoting posttraumatic growth for ourselves and our clients In the Counseling Today article “The transformative power of trauma” (2012), Lea Flowers and Gerard Lawson suggest that positive psychological change experienced as the result of a struggle with highly challenging life circumstances can lead to personal transformation as a by-product of the traumatic experience itself.

Focusing on the client’s growth, and not just the circumstances of xenophobically based violence, can help Asian American clients deliberately build a repository of demonstrated strengths and skills to help them reframe their experiences. These reframes will shape their reactions to future traumatic events and build emotional, psychological and mental resilience.

In the words of Lawson, “This is right in our wheelhouse as counselors. What are the strengths that this person continues to demonstrate despite their traumatic experience? We need to be deliberate about highlighting those for our clients.”

And ourselves as counselor.

 

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Adrianne L. Johnson is a licensed professional clinical counselor supervisor and an associate professor at Wright State University in Dayton, Ohio. She is the past president (2018-2019) of the Ohio Counseling Association and the executive editor of the Journal of Counselor Practice. Contact her at adriannejohnson@gmail.com.

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