Tag Archives: women

The maternal mental health of Black women

By Lisa R. Rhodes March 2, 2023

A Black mother sits on a sofa with a baby stroller in front of her. She is looking down. She looks tired and stressed.

Andrey_Popov/Shutterstock.com

A professional Black woman in her early 30s arrives at a hospital with her husband to give birth to her first child. Although the woman has lupus and is considered a high-risk pregnancy, her doctor assured her that her pregnancy was normal and had been progressing well. They give her an epidural before she goes into active labor, and she expects to have a vaginal delivery with no complications and a healthy baby.

After about 12 hours into labor, the woman begins to feel weak, tired and dehydrated, and she starts to experience cramping in her uterus. She mentions this pain and discomfort to her doctor, but the doctor looks at a monitoring device and tells the woman she is simply experiencing contractions.

“The baby’s heart rate is fine. You just need to rest,” the doctor says, directing a nurse to give the woman some ice chips for her dehydration.

The woman exchanges a concerned glance with her husband. “I just don’t feel right,” she says again. But she begins to think that the doctor knows best and maybe she’s just being nervous.

About 14 hours into labor, the pain intensifies. The baby’s heart rate and the woman’s blood pressure both suddenly drop and set off the alarm on the baby’s and woman’s monitors. The doctor and nurses rush into the birthing room and announce she has to have an emergency cesarean section to save her and the baby. Then, she is whisked away from her husband into the emergency room where they discovered that the baby is breeched. The doctor performs a C-section, and they stop the woman’s hemorrhaging. The baby is placed in the neonatal intensive care unit for jaundice and low blood levels and remains in the hospital for two days after the new mother is discharged.

Six weeks after the delivery, the woman went to see Caren Cooper, a licensed professional counselor (LPC) supervisor, because she was struggling with anxiety, depression and intrusive thoughts about her birth experience.

“She was really traumatized,” recalls Cooper, a certified perinatal mental health counselor and owner of Cooper Counseling & Wellness LLC in Houston. “She was unable to look at photos from the hospital. They were a trigger for her.”

Cooper says it’s common for Black female clients to come to therapy after a traumatic birth experience and present with symptoms of posttraumatic stress disorder (PTSD) and other perinatal mood and anxiety disorders, such as anxiety, depression and obsessive-compulsive disorder. These women report having trouble bonding with their newborn, feeling sad that their pregnancy experience didn’t go as planned or feeling anxious that they may not fully recover from childbirth and have to return to the hospital.

Disparities in maternal health

Although women of other races and ethnic backgrounds may also experience mental health disorders during and after pregnancy, Black maternal and mental health organizations report that Black women are at higher risk for these aliments because of the pervasiveness of racism and racial discrimination.

In a blog post published by Anxiety & Depression Association of America, Lediya Dumessa and Johanna Kaplan note that in addition to the physical changes that arise during pregnancy and postpartum, about 20% of women experience challenges to their mental health. Black women, however, “are at a higher risk for perinatal and postnatal mood and anxiety disorders (PMADs) such as depression, anxiety, obsessive compulsive disorder, and posttraumatic stress disorder,” they report, adding that Black mothers’ risks for PMADs is estimated to be double that of the general population.

According to a Maternal Mental Health Leadership Alliance fact sheet, Black women are twice as likely as white women to experience maternal mental health conditions, but they are half as likely to receive treatment. A more chilling fact is that childbirth can often be deadly for Black women and newborns. Dumessa and Kaplan also note that in the United States, Black women are three times more likely to die from childbirth and Black infants are two times more likely to die before they turn one.

Shivonne Odom, a licensed clinical professional counselor in Maryland and LPC in Washington, D.C., says Black women come to her private practice because of the dire statistics about the Black maternal health crisis.

“The fear of dying during childbirth is a real concern. The reason why clients come to therapy [is] they want to get their mental health underneath their control,” Odom explains. “They don’t want themselves or their babies to die due to the impact of race-related stress.”

According to the Maternal Mental Health Leadership Alliance, common barriers Black women encounter when seeking care for maternal mental health disorders include systematic and interpersonal racism, distrust of the health care system, shame and stigma, logistical barriers, and screening tools that are not culturally appropriate. All these factors contribute to the challenges Black women face in receiving quality and culturally sensitive care.

JaNae West, a licensed marriage and family therapist at the Maternal Wellness Center in Hatboro, Pennsylvania, says a common theme she has noticed among her clients is that they question whether the disrespect that they encounter is due to racial discrimination or bad medical treatment.

“The fact that this question has to even be posed speaks to the impact that racial discrimination has on the experience of my clients,” West says. “Clients have expressed fears that their needs will not be met depending on who is responsible for caring for them.”

West says some of her clients say they are worried about retaliation from their maternal care providers if they raise concerns about racial discrimination in the patient-doctor relationship.

Tabria Corprew, an LPC in Georgia and Florida, says many of her clients have had traumatizing birth experiences with providers because of the color of their skin. Financial resources or a high level of education does not make a Black woman immune from covert and overt racism when working with maternal health or mental health providers, she adds.

“Black women are not being provided equal, quality and safe reproductive services from health care providers,” Corprew stresses. “They are often dismissed, overlooked, disrespected, belittled and treated as if their bodies and their babies don’t matter.”

The good news is that Black women are not waiting on the sidelines to get the help they need, notes Corprew, owner of Compassionate Counseling & Support Services LLC in the Savannah, Georgia, area. The more knowledge they have about Black women’s mortality rate, the more they’re being proactive and seeking support and treatment to prevent perinatal and postpartum mood and anxiety disorders and health risks, she says.

Because of these negative experiences, Black women often seek out maternal mental health providers who look like them and who share their lived experience. “Over the past few years, I have seen a movement take place in the Black community where [Black women and birthing people] seek out providers that they desire to work with rather than defaulting to a referral,” says LaShonda Sims Duncan, a licensed professional clinical counselor supervisor and owner of Sims Counseling & Consulting LLC in Louisville, Kentucky. Many of her clients say they prefer Black women as providers because “certain things are [just] understood,” she notes.

Assessing for interpersonal factors

The counselors interviewed for this article use assessment tools to help establish the therapeutic relationship and gain insight into a client’s therapeutic goals. Odom, a certified perinatal mental health therapist and owner of Akoma Counseling Concepts LLC, uses the interpersonal inventory, developed by the International Society of Interpersonal Psychotherapy, to help her determine if a client is suffering from one of four interpersonal problem areas: grief, role transition, role dispute or interpersonal deficits. For example, she may ask a client, “Have there been any changes in your romantic relationships during the past year?” or “Have you had any deaths in your life during the past year?”

This inventory helps counselors assess if there have been any changes in the client’s life six months before beginning therapy that may have contributed to the client’s present depressed state, Odom explains. Counselors may discover, for example, that a client is suffering from a perinatal mood disorder because of their recent role transition to motherhood. If this is the case, Odom says she would work with the client to explore how they feel about the changes they are experiencing after becoming a mother such as a loss of personal freedom or time to do other things they enjoy.

This assessment tool also helps Odom work with the client to establish therapeutic goals based on where the client feels change has most affected their life during or after pregnancy.

Part of Sims Duncan’s intake process also includes working with clients to figure out what they feel is missing from their lives and what they feel they need more of to sustain their new life and come to a healthier place. She may ask clients, “If you could wave a magic wand and everything could be just as it should be or what you desire to it be, what would you experience?”

She encourages clients to think and frame their desired experiences as what they need more or less of, and they often respond saying:

I need more healthy relationships.
I need more boundaries.
I need less stress and less drama.

“I find this approach helps individuals label the reason they are seeking therapy outside of what is captured on standard intake documents,” says Sims Duncan, who is also a licensed clinical mental health counselor in North Carolina.

The counselors interviewed say some common therapeutic goals for their clients include:

To feel like themselves again
To reduce the symptoms of their mental health disorders
To feel more in control of their lives
To learn how to integrate their identity of self with their identity as a new mother
To improve their relationship with their partner

Anxiety and cognitive distortions

Sims Duncan says her clients often report feeling anxious, irritable and nervous and dealing with racing thoughts. Black women are most anxious when they first learn they are pregnant, she says. They worry whether the timing is right, if their finances are secure and if they are in a good place in their relationship with their partner.

Corprew says some of her clients present with adjustment disorder and tell her they are having trouble handling the physical and emotional roller coaster of pregnancy or struggling to take care of their newborn child. Some clients feel embarrassed and ashamed that pregnancy — which is often portrayed by society as the “best time in a woman’s life” — is often a source of emotional distress, she adds.

A pregnant woman in deep thought looks out a window worrying about something

zulufoto/Shutterstock.com

Corprew uses cognitive defusion, a technique used in acceptance and commitment therapy (ACT), to help Black women reduce their feelings of anxiety and negative thoughts. For instance, if a client makes a statement such as “Did I make a mistake?” “Am I a bad mother?” or “I wish I could escape this,” Corprew may ask them to relax, take a few deep breaths and try to enter a calm, meditative state. She would then have the clients observe any thoughts or feelings that enter their mind during this state.

The intervention aims to help clients put some distance between themselves and the thoughts and feelings they observe without judgment, so they can become more aware of the thoughts and feelings that could be detrimental to their mental health during the postpartum period, Corprew explains. Sometimes simply noticing thoughts and feelings helps clients recognize the power negative thoughts and feelings have over them. This can help clients feel a sense of relief, Corprew adds, and reduces the pressure they may feel to change or improve their circumstances.

“ACT cognitive defusion is not meant to judge your current situation. It is more [to be] aware of your current situation,” she says. “If moms attempt to change their situation, it could appear that something is wrong, which becomes a judgment. That is not how the intervention is intended to be used. … For this particular skill, the goal is just to identify how we are impacted by our feelings and thoughts, not to improve our circumstance, just simply [to notice] them.”

Sims Duncan has noticed that cognitive distortions about motherhood usually manifest as clients move closer to their delivery date. They often express fears about not being ready and having doubts about motherhood. When this happens, Sims Duncan recommends counselors use cognitive behavior therapy (CBT) techniques to help clients develop healthier thoughts about their ability to be a good parent.

She often works with clients to explore the foundation of these beliefs by “putting their thoughts on trial” to consider what evidence supports these distorted thoughts. For a client who is concerned about being a bad mother, Sims Duncan may ask the following questions:

What do you think are the qualities of a good mother?
What does being a “good mother” mean to you?
What are some realistic expectations for how a good mother raises a child?
How do you want to show up as a mother?

Then together Sims Duncan helps clients process their answers to these questions. The goal of the exercise is to encourage clients to define motherhood for themselves, she says.

Sims Duncan also uses somatic experiencing to help Black women recognize the harmful impact distorted thoughts can have on their bodies and mental health. She once used this approach with a client who did not feel prepared for motherhood because the client did not have a good role model growing up.

Sims Duncan asked the client to sit still with her thoughts and notice what happened in her body when she verbalized her thoughts and fears. The client said she felt a tightness in her chest, and Sims Duncan told her to stay with that feeling and notice what else was coming up. The client responded, “I feel a pulsating, sharp pain in my chest.” Sims Duncan asked her to describe what she was experiencing using one word. The client said, “Fear. I don’t know how to be a mother.” Sims Duncan then directed the client to take a few deep breaths, and the client noticed that this helped reduce the tightness and pain she felt in her body.

When Sims Duncan and the client later discussed the exercise, the client said her body naturally took a deep breath when she was aware of feeling afraid. The client’s deep breath was instinctive and offered her a sense of release, awareness and acceptance, Sims Duncan recalls.

“That was a teaching moment,” Sims Duncan says. She told the client to remember this experience and use the deep breathing exercise whenever she had negative thoughts about motherhood or any other area of her life. The client’s curiosity about what she was feeling in her body brought her clarity, Sims Duncan adds.

Feelings of hopelessness

Cooper uses a CBT technique called behavior activation to help Black women who struggle with depression during or after pregnancy. These clients report feeling hopeless and less engaged with the world around them.

Cooper asks clients with depressive symptoms to write down everything they do for two days and bring the list with them to their next session. Cooper reviews the list with the client and looks to see where the client is spending most of her energy. How much time is she spending on herself, her baby, or others such as her partner, family members or work-related activities?

Often Black women focus more on everyone else and neglect their own needs, Cooper says. To help clients reprioritize themselves, she often asks them, “What are some activities that you enjoy? And how much joy would that activity bring you?” If the client tells her that they enjoy reading or exercising, then Cooper advises the client to find ways to incorporate that activity in their daily routine. She might suggest, for example, that the client read one of their favorite books while they are nursing their baby.

Making time for themselves will help lessen Black women’s depressive symptoms by allowing them to re-engage with the pleasures they experienced before becoming a mother, Cooper says.

Sims Duncan says for some Black women, postpartum depression is the most pressing mental health problem. “Based on my experience, I would say that Black women have a higher risk of experiencing postpartum depression due to the lack of support, [an un]willingness and ability to seek treatment, and inaccurate diagnoses,” she explains. Black women report an inability to complete tasks, problems concentrating, fatigue, difficulty sleeping, and withdrawal from family, friends and the activities they enjoyed before becoming pregnant.

Feelings of guilt can also accompany postpartum depression, Odom notes. Clients often tell her they feel guilty for feeling depressed after childbirth. Even though they love their baby and being a mother, they miss the life they had before they became a mother, she says.

And this guilt can also lead to fear, Odom says. Black women may wonder, “Are people going to label me a bad woman or a bad mom because I’m not presenting as happy or jovial?”

Black women may also seek therapy support after experiencing a traumatic birth experience, which sometimes includes a miscarriage, stillbirth or an unexpected surgical procedure. For these clients, PTSD can be acute or chronic, Corprew says. If clients have experienced earlier traumatic experiences, negative childbirth experiences can sometimes trigger certain symptoms from the former traumatic situations, resulting in flashbacks, intrusive and unwanted thoughts, and other signs of emotional and psychological distress.

Sims Duncan’s clients who present with PTSD symptoms tell her they are living their lives but their existence seems like an out-of-body experience and it’s “hard to show up and be present.” And some Black women experience suicidal ideation during and after pregnancy, she adds.

“These Black women are overwhelmed,” Sims Duncan notes. “After birthing children, the expectation is to snap back into the routines they know. In some cases, the new mothers are attempting to take on as much as they did before having a child.”

In addition, the fear of being a burden or perceived as not being able to balance motherhood and their life before conceiving may prevent these clients from asking for help, Sims Duncan says.

“The hopelessness comes from a lack of support — whether that be a partner, family, friends or employers,” she explains. “Many new mothers struggle to communicate their needs. For many Black women this may be the first time they have asked for additional accommodations or considerations. Navigating this new unfamiliar help-seeking space is difficult and is often avoided or delayed.”

Sims Duncan says when Black women delay or avoid asking for support, it contributes to the overwhelming feelings that they present in her office. The “concerns and needs that [are] communicated to maternal health care providers, employers, family and friends are not always met empathetically or as a priority,” she adds. “Black mothers without support typically press on through adversity, which can lead to much more of the [sense of] imbalance and hopelessness.”

Clients often experience a lack of sleep, poor nutrition and unrealistic expectations of what they “should” be able to do. And some of these clients, Sims Duncan says, make statements such as

“Sometimes I just don’t want to be here anymore.”
“If it wasn’t for my child, I probably wouldn’t be here.”
“Sometimes I just want to keep sleeping and not wake up anymore.”
“I feel like if I was out of the picture, my child would be better off.”

To help these clients, Sims Duncan says she gets curious about their statements and encourages them to explore the root of what they are feeling. She uses a combination of somatic experiencing and CBT to invite the women to notice where they may feel a sensation in their body when they share these thoughts and to stay with that feeling until more insights become apparent.

The importance of self-care

An essential part of treatment to prevent perinatal mood and anxiety disorders is psychoeducation about the importance of self-care before, during and after pregnancy. Black women have “never been taught what self-care is [and] what it looks like to try to nourish and care for our bodies,” Corprew says.

In addition, the counselors all agree that their clients often struggle with the stereotype of being “a strong Black woman,” and the societal and cultural expectation that Black women withstand the detrimental impact of racial and gender oppression while also tending to the needs of others.

Black mothers always put themselves on the back burner to be sure everyone else is OK, Corprew notes, and this often results in burnout and an increased risk of poor health outcomes at a time when Black women need support, empathy and patience.

Dealing with the challenges of pregnancy and the postpartum experience can leave some Black women feeling helpless and isolated. “Clients that I see tend to present as if they have everything under control, when in reality they need help,” Sims Duncan says. “They need support but are often unwilling to verbalize it. In some cases, they do verbalize their needs, but the people closest to them don’t have the capacity to show up and support them in the way they need.”

In addition, some Black women internalize their struggles and seldom confide in others, Sims Duncan continues, which leads to what she calls “the empty cup.”

“When needs go unmet for so long, I find that my clients stop asking for support,” Sims Duncan explains, which can leave some clients feeling isolated and lonely. The toll of the pregnancy journey can become unbearable and lead clients to their breaking point, which is when they may seek counseling, she adds.

Creating a self-care and rest plan is part of treatment for Sims Duncan’s clients. “I find that often [the] Black women I work with don’t know how to rest and take good care of themselves,” she says. “In most cases, there is an unlearning and redefining process that needs to take place for my clients to understand that their current way of living is not sustainable.”

Sims Duncan says the unlearning and redefining process happens in session. “Oftentimes people are unaware of intergenerational traumas, legacy burdens and dysfunctional patterns of behavior that plague their family system and ultimately shape the way they’ve learned to show up in the world,” she notes. “In session, unlearning and redefining may look like psychoeducation, challenging presenting beliefs, self-care planning and boundary setting.”

The self-care and rest plan is always customized to meet the needs of each client, and it can include mindfulness exercises, breathing techniques, suggestions for movement (e.g., walking, jogging, running, yoga, stretching) and a resource list of community spaces where Black women can feel they belong (e.g., online support groups for new Black mothers, community organizations centered on families, local book clubs, religious fellowship).

To help reduce the risk for perinatal mood and anxiety disorders, Corprew works with her clients to create a postpartum care plan, which includes information for mothers and fathers on topics such as nutrition, infant feeding, lactation support, proper rest and contact information for medical professionals. The plan is a tangible resource tool that allows clients to address important issues and identify resources before they are needed to help reduce stress and help mothers transition to their new role, Corprew explains.

The intersection of general and mental health

Black women also need to be better informed about the link between their general health, pregnancy and maternal mental health disorders. The perinatal experience is complex and varied, West notes, and there isn’t one area of a woman’s life that is left untouched while going through the perinatal journey. So it is not surprising that some women experience changes in their mental health.

“There is certainly an interplay of both the physical experience and the emotional experience,” West explains. “Physically, clients are experiencing rapid changes in hormones, sleep deprivation, changes in their body, physical recovery, sometimes nursing complications, and so much more. Of course, those impact our emotional experiences. The reverse is also true. When clients are dealing with significant emotional upheaval, their sleep, eating patterns, energy levels and other physical arenas are often impacted.”

Cooper, Corprew, Odom and Sims Duncan say they have treated clients who have chronic illnesses such as high blood pressure, diabetes, obesity, lupus and sickle cell anemia. When this happens, they often collaborate with primary care physicians and medical specialists to ensure that their clients have access to medication management, if necessary, and appropriate medical care.

Black women are often not aware of how their general health can make them vulnerable to a high-risk pregnancy. “Addressing common preexisting health issues in Black women such as obesity, hypertension and diabetes are also conversations I feel Black women could be better educated on and how those health conditions impact mom and baby during pregnancy,” Corprew says.

Sims Duncan agrees. She says being aware of a preexisting condition that could complicate the pregnancy or birthing process can save the life of the mother and the child.

But more knowledge can bring on additional stress for some women. “While being informed is empowering, it can also heighten concern and worry in clients,” Sims Duncan says. “I’ve seen more awareness of general health manifest into anxiety and stress during pregnancy.”

Cooper says many of her clients with chronic illnesses have also experienced increased anxiety about their health and well-being as well as their baby’s. They are fearful that the illness could trigger a miscarriage or preterm birth, she explains. Attending additional medical appointments and being labeled “high risk” can trigger intrusive thoughts and excessive worrying throughout the pregnancy.

To counter the mental distress that can come along with chronic illnesses, Corprew sometimes refers her clients to Operation MIST (Monitor, Intervene, Survive, Thrive), a remote health consulting company led by Black female physical therapists who are committed to tackling the maternal mortality crisis. The company monitors a mother’s health data 24/7 using a smart device during and up to one year after pregnancy. The first responders reach out to clients when the device detects a health risk such as fibroids, hypertension, anxiety and gestational diabetes.

“This preventative device has a huge impact on my clients’ mental health,” says Corprew, who also provides perinatal mental health services for Black women who are referred to her from the company. Operation MIST is “an additional layer of support” for reducing anxiety and worry in Black women who want to prevent a negative pregnancy or childbirth experience, she notes. Corprew says she has noticed that her clients often feel more at ease and reassured when using the device.

The need for education and change

Educating Black women about maternal and mental health is only one part of the solution to reduce perinatal mood and anxiety disorders in this clientele. Counselors can also help Black women become more confident in their ability to advocate for their own well-being and the life of their unborn child.

“I teach my clients effective and assertive communication,” Sims Duncan says. “I encourage them to advocate for themselves and find a provider that feels easy to talk to.”

Cooper encourages her clients to make a list of questions or concerns that they have about their pregnancy and their health and review it with their providers at their appointments. “I remind clients that the physicians are there to provide a service, which includes addressing concerns and providing information,” she says. “Additionally, I sometimes role-play with clients in session to assist them with becoming comfortable with being more assertive.”

West says “a real systemic change” is needed in maternal mental health care to ensure Black and other women of color receive the treatment they deserve. “Doula care and maternal health support need to be accessible to everyone regardless of socioeconomic status,” she stresses.

Assessment tools for perinatal mood and anxiety disorders are not culturally informed, and peer-reviewed research articles often omit various populations of Black women, such as those who live in suburban and rural areas or the U.S. territories, Odom says. Affluent Black woman ages 25 and older, for example, are often omitted from research studies, she notes. (For more on counselor advocacy and maternal mental health, listen to an ACA podcast episode featuring Odom.)

It is also important for providers to have more education, health, diversity and sensitivity training, West adds. “As we increase the representation of marginalized identities in the medical professions, we will see an improvement in the quality of care, research and support to those populations,” she says.

Cooper agrees. “Mandating formal training,” she says, “will place more accountability on providers to ensure they are providing compassionate and supportive care for patients, especially Black women.”

Black maternal health after the overturn of Roe v. Wade

On June 24, 2022, the Supreme Court overturned Roe v. Wade, the landmark piece of legislation that affirmed women’s constitutional right to abortion. This decision now allows states to decide whether an abortion is legal.

A study published in Demography in 2021 found that non-Hispanic Black women would experience the greatest increase in deaths if people were denied access to abortions in the United States. In a Reuters article published in June 2022, Nandita Bose cited this finding and noted that “more Black women live in states that will likely ban abortion, and those living in southern states — with the most restrictive laws — will bear the brunt.”

Even before the overturn of Roe v. Wade, Black women’s maternal mortality rates were troubling. According to the Centers for Disease Control and Prevention, non-Hispanic Black women had 55.3 deaths per 100,000 live births in 2020, which is 2.9 times the rate for non-Hispanic White women.

The counselors interviewed for this article say that in addition to rising maternal mortality rates, the overturn of Roe v. Wade is likely to lead to an increase in psychological distress for Black women.

Tabria Corprew, a licensed professional counselor (LPC) at Compassionate Counseling & Support Services LLC in the Savannah, Georgia, area, says Black women being forced to conceive when they do not want to “comes with an increase in perinatal mood and anxiety disorders and other health and mental health risks.”

Although Pennsylvania has not yet enacted new limitations on access to reproductive health care, JaNae West, a licensed marriage and family therapist at the Maternal Wellness Center in Hatboro, Pennsylvania, says her practice has heard from many worried clients. “Clients have expressed a sense of fear around how women’s health care will be impacted around fertility and pregnancy,” she says. “They worry that it will be hard to access lifesaving care in the event that it is needed.”

Shivonne Odom, a licensed clinical professional counselor and LPC working in Maryland and Washington, D.C., witnessed the anxiety her clients faced in the weeks leading up to and immediately after the Supreme Court decision. Some of her clients reported not being able to make appointments at abortion clinics weeks before the decision because they were booked, and others said they had to wait several weeks for the procedure, which increased the length of their pregnancies and made it more challenging for them to find a provider willing to perform an abortion.

The mental stress placed on these women is a form of trauma, says Odom, owner of Akoma Counseling Concepts LLC. More clients are seeking her services because they say they need help processing the anxiety and trauma caused by this ruling.

“All I can do is listen and affirm and really have compassion because this is traumatizing and a lot of it is dehumanizing,” she says.

Odom also advises her clients to check with local legal resources to find out what their rights are regarding their reproductive health. “I want to be sure that my clients are informed in any decision that they make,” she adds.

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling Connoisseur: Fostering female mentorship in counseling

By Cheryl Fisher August 31, 2022

My cell phone lights up with a text from my 15-year-old client. He is mad at his parents who are constantly arguing and often use him as a pawn, and he has skipped school to make a point. He took his bike and rode to a local convenience store. His text says, “I will show them!”

In the process of calling my client, I get another call: It is his father. The call goes to voicemail, and he leaves a message saying that he is worried because his son left a note that he is running away. He has called the police and wonders if I have heard from his son.

I am torn. I want to maintain the trust of my client, but I also recognize that he is a minor and could be putting himself in harm’s way. His parents are extremely dysfunctional and are no doubt blaming each other for their son’s disappearance.

I take a deep breath and then pull up the phone numbers of three women who have served as my professors, clinical supervisors and now dear friends. I text, “I need a consult now. Are you available?” Within seconds my phone lights up again. When I answer, I hear the calm voice of one of my mentors. I summarize the situation and my concerns. She reiterates that my client is a minor and regardless of how dysfunctional the estranged parents are, they need to know the location of their son. After processing with her, I decide to call the father and provide him with the son’s location. I also point out for the 100th time that he and his ex-wife need to seek counseling to better navigate co-parenting because the current situation is too stressful for their son. The father thanks me and hangs up.

I immediately call my client to let him know that his father is on his way to find him and to give the client space to diffuse from the morning’s event. I apologize for the breach of his confidence and remind him that as a minor he could be in harm’s way by running off. I validate his frustration. And I ask for his forgiveness. He pauses a moment and then says, “Yeah, I figured you’d have to tell my parents. I am mad … but not at you. We’re good!” Then he sees his dad’s car pull into the parking lot and says, “I guess I’ll see you in session.”

I let out the breath that I felt like I had had been holding since my client’s initial text and call my mentor to thank her for the consultation and support.

The benefits of mentorship

Mentorship is when a more experienced person provides guidance to a less experienced person. The relationship may be formal (e.g., programs for emerging leaders) or informal (e.g., naturally occurring relationships that may develop between student and faculty). In a 2011 article published in Counselor Education and Supervision, L. DiAnne Borders and colleagues found informal mentoring relationships to be more “visible, meaningful, comfortable, individualized, effective, and long-lasting.”

Stephanie Maccombs and Christine Bhat, in 2020 article published in the Journal of Counselor Leadership and Advocacy, identified two areas where mentorship relationships can be most impactful: career development and psychosocial development. In addition to providing a way for the mentee to make connections in the industry, research consistently finds that engaging in a mentoring relationship is associated with positive outcomes for both mentor and mentee. For example, people who receive mentoring are more likely to experience career satisfaction and advancement. Additionally, students in mentoring relationships are more likely to complete dissertations and take advantage of professional leadership and research opportunities. This is especially true for female students.

Women in counselor education

Currently, there is not much data on women’s leadership in higher education. Ashley Gray, a senior analyst for the American Council on Education (ACE), studies leadership patterns in higher education and recommends that a deeper dive into the intersectionality of identities and experiences are needed to inform policy and practice of higher education (see Gray’s article in the 2021 edition of ACE’s International Briefs for Higher Education Leaders).

Although there are more women enrolled in higher education and appointed to junior faculty roles, too few female leaders exist in counselor education. Female leadership styles have historically been found to emphasize collaboration and teamwork which tend to promote innovation, and we need more innovative and transformative leadership to help navigate the existing challenges resulting from the COVID-19 pandemic.

Vectorium/Shutterstock.com

Systemic barriers

Women in higher education must often navigate competing efforts. These include balancing family and work responsibilities, navigating pregnancy and childbirth with the tenure time frame, and establishing relational networks that may be diminished by a patriarchal social structure. The pandemic further highlighted and exacerbated gender inequities: The increase in virtual learning brought the classroom into the home and caused women in higher education to navigate remote work and child care.

In their article “Only second-class tickets for women in the COVID-19 race. A study on manuscript submissions and reviews” (published in PLoS ONE in 2021), Flaminio Squazzoni and colleagues used the term “she-cession” to describe the disproportionate gender disadvantages created by the pandemic. Women submitted fewer manuscripts, participated in less research and applied for fewer research grants during the pandemic. However, there appeared to be an opposite impact on men in higher education, with more men publishing academic works during the pandemic.

Challon Casto and colleagues noted in their 2005 article published in the Journal of Counseling & Development that female counselor educators often lack the inside knowledge of internal structures and politics across department and university structures. This places women at a disadvantage in traditional “good old boy” systems that thrive on strong networks. The authors recommended creating a formal and informal system that connects female graduate students and marginalized students with mentors to help navigate the unspoken rules of graduate school and advancement.

Women’s Inclusion Mentorship Framework

Maccombs and Bhat created the Women’s Inclusion Mentorship Framework (WIMF), a model of mentorship specifically for women in counselor education programs. The WIMF provides mentorship opportunities and leadership development to any interested female student or faculty member. Based on their extensive review of research of higher education and mentorship in counselor education, Maccombs and Bhat identified four areas emphasized in the WIMF approach: (a) a relational-cultural focus, (b) quality mentors and mentor-mentee matches, (c) vision and plan development and (d) mentoring interventions specific to counseling and women.

A relational-cultural focus

Research consistently finds that mentorship relationships in counselor education contribute to psychosocial and clinical growth and, as noted by Maccombs and Bhat, to “a sense of empowerment, increased insight, increased self-efficacy” that results in mutual respect and empathy. Therefore, Maccombs and Bhat recommend that mentorship relationships are fostered between mentor and mentees who self-identify as women. Women mentors emphasize nurturing the relationship and encourage interconnectedness and the sharing of empowerment and authenticity. Interventions in line with this approach include self-reflection, self-care, connection to groups (such as in group writing) and recognition of the collective accomplishments of other women in the academic community.

Quality mentors and mentor-mentee matches

Quality mentorship can be challenging. Faculty are inundated with responsibilities and even the most well-intended mentor may fall short if they do not have the time to commit to the relationship. Additionally, incompatible pairing can be frustrating to both mentor and mentee. Mentors need ongoing training and support to be effective and sustainable. Maccombs and Bhat suggest that female mentors actively recruit other women in counselor education programs to a meet-and-greet event at the beginning of the academic year. This approach allows for an informal connection to occur organically between mentor and mentee, as mentors and mentees exchange information regarding research interests and academic and leadership experiences. And it also reduces the chances of incompatible pairing.

Vision and plan development

Maccombs and Bhat also recommend that that counselors outline the expectations of the mentorship relationship. Research indicates that clear expectations are associated with a more effective and satisfying mentorship experience. Additionally, mentees are encouraged to identify clear indicators of their academic and career vision. These could include increasing industry networking or scholarships such as publications or conference presentations. In addition to performance indicators, leader attributes and behaviors can be explored in a more measurable approach by using Chi Sigma Iota’s Principles and Practices of Leadership Excellence or the Dynamic Leadership in Counseling Scale — Self- Report (developed by W. Bradley McKibben and colleagues).

Mentoring interventions specific to counseling and women

Maccombs and Bhat encourage counselor education departments to consider allowing two to four hours of dedicated mentoring time a month. A flexible meeting schedule that works best for the mentor and mentee will be more successful. Additionally, a family-friendly approach that allows for child-care options or virtual meetings will be supportive of female mentees and mentors who may be caregivers. Service, research and teaching success include learning how to navigate these demands and other obligations. During pre-enrollment interviews, I encourage student applicants to approach their graduate degree as a “family degree” by recruiting the support of their partners, friends and family members in a variety of ways, including outsourcing some tasks and setting healthy boundaries. For example, family members can help with setting timers for lunch breaks on the weekend when the graduate student is immersed in research and writing papers.

According to Maccombs and Bhat, additional strategies around research and service include “being persistent, … avoiding personalizing the barriers, staying true to one’s personal plan or vision, and engaging in self-care.” It also helps if you are surrounded by a support system who can cheer you on during challenging times, such as dissertation editing.

Focusing on service activities that align with your areas of expertise or personal interests can create an extension of your personal worldview. My research interest in nature therapy, for example, has led me to be more engaged in sustainable ways and serve as the Green Office Ambassador for my counseling program. In this role, I helped the department identify ways to be more responsible with resources and sustainable in practices.

Finally, creating an environment of collaboration will aid in accessing the resources and knowledge to be successful in scholarship, teaching and service. Recently, I identified an area for growth at my university around research support for online faculty, who are mostly women in my department. I met with executive leadership and discussed my observations and suggestions. This resulted in plans to form a student and faculty clearinghouse for resources (e.g., research projects, grant opportunities) and a forum for trainings and mentorship on research development, implementation and publication.

Conclusion

Research indicates that mentorship relationships promote growth and satisfaction, professionally and personally. Women are often disadvantaged by historical academic and professional structures. But the WIMF provides one approach to capitalize on the mentorship relationship between women.

I have been fortunate in my career because I have always been surrounded by wise and empowered women. Women who dared to offer their secrets of success and wisdom in mentorship. They have shaped me professionally, informed me clinically and ultimately transformed me personally.

Whether it was providing me with feedback to hone my clinical skills, observing and ever so gently illuminating countertransference observed in a session, or simply bearing witness to my struggles of navigating work, family and graduate school, these women crafted a web of support as well as strategy that continues to sustain me as a clinician, counselor educator and administrator of a counselor education program.

I am forever grateful to the wise women who not only taught me how to be a strong clinical counselor but also guided me into my role as a counselor educator so that I may also mentor women entering the field of counseling.

In appreciation to my mentors, Sharon Cheston, Gerry Fialkowski and Rev. Anne Stewart.

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and associate professor for Alliant International University California School of Professional Psychology’s online master’s in clinical counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. Contact her at cyfisherphd@gmail.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling girls and women in the current cultural climate

By Tracy Peed, Crissa Allen, Mary A. Hermann, J. Richelle Joe and Anna M. Viviani May 5, 2022

This piece is the second of a three-part series for CT Online. It is the result of the work of ACA President S. Kent Butler’s Gender Equity Task Force. The first article, “Breaking the binary: Transgender and gender expansive equality,” was published on April 4 and the third article “The effects of gender socialization on boys and men,” was published on June 15.

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In this article, we highlight gender equity issues that impact girls and women and provide recommendations for counselors who work with this population.

Complex realities of girls and women

Girls and women experience complex realities. Despite their increased opportunities in the past several decades, they face pervasive limiting gender norms. For example, girls and women are still dissuaded from entering STEM fields and encounter a “chilly climate” in STEM classrooms, resulting in significant underrepresentation in STEM fields. Furthermore, girls and women with additional marginalized identities experience heightened challenges.

The supergirl and superwoman ideals permeate popular culture and media. Selective, digitally altered social media posts send the message that the superwoman ideal is achievable, and even easily accessible. The narrow construct of feminine beauty further complicates these messages. Girls’ and women’s socialization to “have it all” has become more difficult, with work hours continuing to increase in many professions as technology creates new norms related to worker availability.

In addition, women engage in the invisible work of navigating the gender bias that remains prevalent in the workplace. Women still earn significantly less than men for the same work, and this reality is compounded by racism. For example, white, non-Hispanic women who work full time earn 79% of what white, non-Hispanic men earn, whereas African American women earn approximately 64% and Hispanic women earn 57% of what white, non-Hispanic men earn. Adding to this challenge, negotiating a higher salary is more complicated for women because it defies social stereotypes.

Women who are mothers have experienced heightened parenting expectations in recent decades. They engage in more child-centered activities than mothers did in the 1960s, a time when most mothers of young children did not work outside of the home. Yet, prior to the COVID-19 pandemic, almost 75% of mothers of young children worked outside of the home.

Working mothers in the United States attempt to meet societal motherhood expectations while maintaining employment without the supportive infrastructure found in almost all other industrialized countries. The cost of child care often exceeds the cost of rent. Paid family leave is not available in many work settings, driving 25% of mothers back on the job within two weeks of giving birth. And despite the lack of paid family leave, the promotion of breastfeeding as imperative is a message new mothers receive from almost everyone today, including medical professionals — a puzzling phenomenon in light of contradictory studies on the benefits of breastfeeding. Even women who adopt their babies experience pressure to breastfeed. Women experience judgment and shame if they are not in a position or choose not to breastfeed, which can lead to negative mental health outcomes.

Why now: Refocusing on the needs of girls and women

Although men have increased their participation in household activities in the past few generations, the second shift still falls primarily on women. Furthermore, expectations related to second-shift activities have continued to rise in what Susan Douglas and Meredith Michaels call the “Martha Stewartization of America,” where women are judged on their parenting and the appearance of their homes under these elevated standards while men are not. In fact, men are often glorified for participating in basic parenting activities, which Anne-Marie Slaughter called the “halo dad syndrome.”

Intersectional identities add new layers to these challenges. For example, girls and women who identify as part of the LGBTQ+ communities are vulnerable to increased risk of depression, anxiety and suicide as a result of discrimination. Although the need for mental health services is high, members of these communities often experience a disproportionate lack of access to these resources.

According to the cultural narrative, women are expected to navigate discrimination, harassment, rising work hours, increased motherhood expectations, heightened second-shift cultural standards and current unattainable beauty ideals without ever asking for help. Many women blame themselves when they believe they are failing to meet societal standards, but in reality, the cultural system is failing them.

Similarly, girls and women encounter sexism, bullying, sexual harassment and toxic body image messages. They are encouraged to take advantage of all opportunities and to strive to be perfect at everything. Thus, they are socialized to reach for impossible standards of success. Social media often intensifies these messages.

Yet benefits of social media exist as well. Some girls and women have found supportive communities through social media, which have provided them new channels toward justice and change. Since its inception in 2006 by Tarana Burke, the #MeToo movement has promoted empowerment and support for girls and women who have experienced sexual violence. The social media hashtag has evolved into real-world measures of accountability for aggressors, notably in the entertainment industry. Use of social media for revealing information on sexual abuse does, however, have repercussions. Girls and women have cited instances of harassment, stalking and bullying on the web after posting the hashtag, leading to increased isolation, grief and retraumatization.

The COVID-19 pandemic has exacerbated many of the challenges girls and women encounter. Gender inequities in the United States are further exposed during the crisis. For example, mothers experience a higher burden in managing family life during the pandemic. In the early days of the pandemic, most working mothers lost their access to child care and other support systems. Even two years into the pandemic, isolation and quarantine mandates continue to disrupt the availability of child care on a regular basis, including the child supervision provided by schools.

The pandemic-related challenges have lingered far longer than expected, often resulting in significant mental, physical and emotional fatigue. Not surprisingly, the pandemic negatively affected women’s workforce participation. In 2019, women accounted for approximately 50% of the U.S. labor force; by the end of 2020, there were 2.1 million fewer women working.

As women were leaving the workforce at alarming rates, men’s workforce participation increased. Systemic racism exacerbated these gender inequities. African American women experienced an unemployment rate of approximately 41%, and Latinx women experienced an unemployment rate of over 38%. While the economy improved in 2021, less than 50% of these women returned to the workforce. For many workers who remained employed, on-the-job hours increased as staffing shortages grew.

Culturally responsive counseling with girls and women

Although it is important to understand the various challenges that girls and women may experience, it is also critical to avoid assumptions and stereotypes related to gender when counseling girls and women.

Identifying as a girl or woman is just one aspect of an individual’s multifaceted identity. The combination of various intersectional identities coupled with one’s environment ensures that individuals have vastly different life experiences. Furthermore, one’s identities may result in more collective privileges, compounded marginalization or a mix of both.

Therefore, it is important to understand not only a client’s gender identity but also their other social and ethnic group identities and how these various identities intersect and influence aspects of a client’s life. It would be unjust to assume that a white, upper-class, heterosexual, cisgender woman has had the same lived experiences as a Latinx, working-class, pansexual, transgender woman. As counselors, we need to be mindful of and provide an accepting space for women to explore the development of their multiple identities in counseling.

When working with girls and women, counselors need to consider several salient concerns regarding career interests, such as career choice alignment with familial and cultural expectations, traditional versus nontraditional career choice, as well as navigating harassment, bias, the glass ceiling and the gender pay gap. Tread carefully in this work, and remember that people put limits on themselves in the career domain based on their self-concept and their belief that they are a fit for or could do a particular job.

Girls and women are likely to engage in circumscription, eliminating careers that appear too masculine in the eyes of society or seem unsuitable or out of reach of their capabilities. Or girls and women compromise, selecting or short-listing careers that they see women within their social environment pursuing. Counselors must strive to monitor girls’ and women’s reactions and responses to and support of career-related endeavors, recognizing that they may be trimming their options based on the counselor’s response.

It is important to use gender-neutral language and present a wide array of potential options when introducing and exploring jobs/careers. Being a girl or a woman can come with a multitude of career expectations, relationships and society. Counselors provide women with an environment to process their numerous roles, determine if role strain or role conflict exists, and work together to navigate role-related issues based on the client’s authentic choices.

Counselors must consider how to be more gender aware, attuned and affirming in their approaches and interventions. Many postmodern approaches and theories lend themselves to this aim. The following are a few to consider alongside your current approaches. Keep in mind that this list is not exhaustive; a search of multicultural and social justice-oriented theories will provide a more extensive list.

Multicultural counseling and therapy acknowledges all individuals as cultural beings and, as such, their various cultural identities, values and biases are an important part of the counseling process.
The Multicultural and Social Justice Counseling Competencies provide additional support for working with a diverse clientele.
Feminist therapy allows counselors to view clients and their concerns through a lens that incorporates concepts of gender, power, privilege and oppression.
Relational-cultural theory focuses on finding identity through relationships and culture as a powerful influence on these relationships.

By shifting their approach, counselors create culturally responsive ways to meet the growing needs of girls and women.

Advocacy interventions with girls and women

In addition to counseling individuals and groups, advocating for clients is a vital and necessary part of our practice. Advocacy can occur on multiple levels, ranging from micro to macro. A counselor can engage on behalf of the client or with the client/group, with an overall goal of empowerment and eliminating individual and systemic barriers and oppression.

At the individual level (microlevel advocacy), the focus is on empowerment interventions with or on behalf of individual clients. Advocacy might include activities such as negotiating inequitable child care and second-shift expectations in a relationship. Counselors can navigate these actions using theoretical approaches and interventions that allow for identity development, are strength-based and are focused on empowerment.

Counselors may observe girls and women struggling with similar issues. Although counselors will likely work on individual empowerment, larger scale intervention may be needed to address more pervasive systemic issues. In this midlevel advocacy, counselors would advocate for community change with and on behalf of girls and women. Examples of community-level advocacy include advocating in schools against unfair dress code policies that marginalize girls, advocating at the local school board for curriculum to support girls and young women in mathematics and science, and advocating to local employers to support women’s needs from health care to child care in the workforce.

Although not all counselors feel comfortable or ready to advocate on a systems level, they are strongly encouraged to note their clients’ needs and get involved. Even a small advocacy endeavor has a ripple effect.

It is therefore important to know and understand the issues facing girls and women, not only in your community but also at the state, national and international level. We can all advocate for just social policies and strive to dismantle systemic inequities experienced by girls and women, such as lack of affordable access to quality health care and child care, the minimal amount of paid family leave and support for working mothers, pay inequities and work/career barriers.

For more help with advocacy initiatives, consult the ACA Advocacy Competencies for guidance.

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Find out more about ACA’s Gender Equity Task Force at acagenderequity.weebly.com

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Tracy Peed is a licensed professional school counselor in Illinois and Minnesota, an assistant professor and doctoral coordinator in the Department of Counseling and Student Personnel at Minnesota State University, Mankato, and a member of the ACA Gender Equity Task Force. Contact her at tracy.peed@mnsu.edu.

Crissa Allen is a doctoral student at East Carolina University and a licensed clinical addictions specialist associate. Contact her at allenc13@students.ecu.edu.

Mary A. Hermann is a licensed professional counselor, a certified school counselor, an associate professor in the Department of Counseling and Special Education, and affiliate faculty in the Institute of Women’s Health at Virginia Commonwealth University. She is the co-chair of the ACA Gender Equity Task Force and founder and director of the Women’s Lifespan Development Research Lab. Contact her at mahermann@vcu.edu.

Richelle Joe is an associate professor in the Department of Counselor Education and School Psychology at the University of Central Florida. Contact her at jacqueline.joe@ucf.edu.

Anna M. Viviani is an associate professor at Indiana State University, a licensed professional counselor in Indiana and Illinois, an approved clinical supervisor and a member of the ACA Gender Equity Taskforce. Contact her at Anna.Viviani@indstate.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Women and alcohol: Drinking to cope

By Bethany Bray November 2, 2021

Holly Wilson, a licensed professional counselor (LPC) candidate in Colorado, knows firsthand that women can feel disconnected or overlooked in addiction recovery programs. When she decided to seek help for alcohol dependency through 12-step and other treatment programs, Wilson kept hearing staff in these facilities talk about addiction in terms of “hitting rock bottom” and “failure” and make blanket statements such as “all addicts are liars.”

These types of statements didn’t fit Wilson’s experience, but they did add to the self-criticism she was already feeling. A self-described “high-functioning drinker,” Wilson had always been able to hold down a job and had never been cited for drunken driving. She didn’t fit the messy, drunken stereotype that many people associate with those who need treatment for addiction.

“I kept drinking for a long time because I was able to show up and look good, but I was really dying inside,” says Wilson, a member of the American Counseling Association. “I just got sick of myself and saw that I wasn’t achieving what I could.”

Declaring in treatment that “failure” had brought her to this point didn’t feel accurate or helpful, Wilson recalls. “I had to subscribe to calling myself an alcoholic and [agree to] ‘your best thinking got you here.’ It reinforced a lot of the shame that I was already feeling about myself,” she says. “I was actively seeking help and wanted to get better, and the system I experienced felt like it was forcing me into this box that I was a rock-bottom failure. … I kept hearing the message that you have to hit rock bottom before you can get well, and I thought that was really dangerous.”

The focus that some treatment programs place on admitting failure or a sense of powerlessness over a substance can alienate or even drive away female clients because many women already carry intense feelings of shame about their alcohol use, Wilson notes.

Despite Wilson’s difficult initial experience with treatment, she stuck with it and eventually found outpatient group therapy and individual therapy that felt welcoming and helped her learn more about the reasons why she drank. During her time in a women-only sober living house, she and her housemates were able to have deep and honest conversations about the trauma they had experienced — much more so than in the dialogue she’d experienced in coed groups, Wilson says.

Wilson’s recovery journey inspired her to help other women with similar experiences. After becoming a counselor and working in numerous positions in different substance use programs, she founded Women’s Recovery, an outpatient addiction treatment center for women with locations in Denver and Dillon, Colorado. Wilson serves as chief empowerment officer of the treatment center, which combines trauma-informed care with clinical treatment. The organization has a client-focused model that begins with asking clients what they want to get out of life, rather than prescribing what they should or have to do, Wilson says.

Treatment for alcoholism “doesn’t have to be through the lens of [a] power struggle over [a] substance,” Wilson says. “There is a misnomer that people have to get to rock bottom before getting help. … I would love to see a psychic shift [away from] that. It’s a problem whenever alcohol is getting in the way of things they want out of life. … The best thing we can do as counselors is shift our focus from that kind of rock-bottom-drunk perspective to an early intervention approach. We don’t have to wait until our clients lose everything and burn their life down to help.”

Multiple factors at play

Alcohol consumption and rates of alcohol use disorder among American women have been rising steadily in recent decades. Data compiled by the National Institute on Alcohol Abuse and Alcoholism indicates that although men consume more alcohol overall than women do, the gender gap is closing. In the nearly nine decades since Prohibition ended, the male-to-female ratio for measures of alcohol consumption — including prevalence and frequency, binge drinking and early onset drinking — has gradually narrowed from 3-to-1 to close to 1-to-1.

Rates of alcohol-related hospitalizations and health concerns, such as liver problems and cardiovascular disease, are also increasing for women. In an article published last year in Alcohol Research: Current Reviews, researcher Aaron White noted that “although women tend to drink less than men, a risk-severity paradox occurs wherein women suffer greater harms than men at lower levels of alcohol exposure. … Because women reach higher blood alcohol levels than do men of comparable weight, their body tissues are exposed to more alcohol and acetaldehyde, a toxic metabolite of alcohol, with each drink.”

The stress of the COVID-19 pandemic, of which women are bearing the brunt with job loss and child care and caretaking pressures, is exacerbating these trends, says Todd Lewis, an LPC who authored chapters on alcohol addiction and prescription drug addiction in the ACA-published book Treatment Strategies for Substance and Process Addictions. Alcohol is often used as a fast-acting way to temporarily ease or ignore one’s emotions or psychological pain, notes Lewis, a professor of counselor education at North Dakota State University who also sees clients at a private practice one day per week. The immense stress that many women have faced throughout the pandemic, coupled with increased isolation and the extra strain on relationships, has played a role in furthering the rise in alcohol use among women, he says.

Although many factors are at play, Sarah Moore, an LPC with a private practice in Arlington, Virginia, points to the intersection of alcohol being readily used as a coping mechanism and alcohol being widely available and interwoven into social norms and expectations. The expectation to drink can also dovetail with the pressure to be thin and other issues related to body image that women face, including disordered eating, she adds.

It’s more challenging than counselors may realize, Moore says, for emerging adults to foster and maintain social relationships through activities that don’t involve alcohol. “For a lot of 20- and 30-somethings, that [drinking alcohol] is their entire social life. Older generations may not be aware of how hard it would be to skip out, how integral that is to social situations,” she notes.

Moore, an ACA member, specializes in counseling for women, including issues related to alcohol dependency. She co-moderates a therapeutic group for women — Me, My Body and Alcohol — with Jyotika Vazirani, a psychiatric nurse practitioner and psychotherapist.

Alcohol is easily accessible and seemingly everywhere, Moore notes. It is often a part of sporting events and professional networking events, in which participation can be seen as a way to further one’s career, especially in high-pressure fields such as technology and law. The popularity of touring craft breweries and wineries also continues to grow. In many areas, alcohol can be purchased via delivery or curbside pickup at grocery or liquor stores.

One ironic aspect of American culture is that it frowns on both alcoholism and sobriety, Moore and Lewis note. “If you lose weight or quit smoking, everyone wants to know your secret,” Moore says, “but if you say you’re not drinking, they don’t know how to respond” in social settings.

And if individuals choose not to drink in social situations, they can face stigmatizing comments such as “you’re not having any fun,” Lewis adds.

In counseling, Moore role-plays and talks through scenarios with clients who have anxiety about declining alcohol at work events and in social situations because drinking has become so ingrained in these settings. She works with clients to plan and practice ways to artfully dodge questions and comments about their beverage choice.

Intertwined with trauma

All of the counselors interviewed for this article note that women who have an unhealthy relationship with alcohol often have experienced trauma in their past, are currently experiencing trauma or, in some cases, both. It is imperative that counselors are sensitive to this potential connection; use trauma-informed methods; are able to screen for posttraumatic stress disorder, intimate partner violence and abuse (physical, emotional, sexual, etc.); and know when and how to refer clients for specialized care when appropriate.

Sophie Hipke, an LPC in training at Women’s Recovery Journey, a women’s-only outpatient recovery program within the counseling clinic at Family Services of Northeast Wisconsin, says a vast majority of clients there have experienced (or are experiencing) “significant” trauma and turned to alcohol to cover up or numb painful emotions. Clients are often aware that alcohol won’t fix their problems, but they feel that it holds the promise of offering temporary relief, notes Hipke, who is training to be fully certified as a substance abuse counselor.

Many of the clients that Hipke and the counselors at Women’s Recovery Journey treat started drinking alcohol at an early age, sometimes as young as 11 or 12. For these clients, alcohol was often a way to escape an abusive household or deal with a loss or trauma, Hipke says.

“Substance use is often just a symptom, and the client has been self-medicating [to cope with] trauma or mental illness or both,” Wilson says. “We find that the majority of people who are seeking substance use disorder counseling have a reported history of trauma. There’s been a shift [among mental health practitioners] in the recent decade to recognize that it’s intertwined. … In order to really help people recover, we have to help them dig out of that trauma that has built up over time.”

For Wilson, the trauma of her brother’s death was what “pushed her over the edge” with her drinking, she says.

Clients who have a substance use disorder and a trauma history need a two-pronged approach in counseling, Wilson notes. They need to process and heal from past trauma and develop skills that allow them to deal with new traumas as they (inevitably) happen. “With both ‘big T’ trauma and ‘little t’ trauma, every person has a threshold and level of internal resiliency, and they can only take so much,” Wilson says. “If they don’t have the ability to cope as new trauma comes in, they are overwhelmed. [That’s when] we find ourselves continuing to turn to that substance over and over.”

Building rapport with clients is always an important aspect of counseling, but that is especially true with this population, Moore says. Women often feel intense amounts of pain and shame related to their trauma and alcohol dependency or addiction, so it’s vital that counselors focus on fostering a nonjudgmental and trusting relationship with these clients before delving into the hard stuff. Practitioners should also be patient, understanding that it may take these clients a long time before they feel stable enough to process their trauma, Moore advises.

Because trauma commonly dovetails with alcoholism and problem drinking in women, counselors should carefully choose treatment methods that are appropriate for this population, Moore stresses. Supports that are commonly used with male clients may not be helpful for female clients, especially if they have experienced sexual abuse or domestic violence.

Moore and the other counselors interviewed emphasize that recovery treatments that involve mixed-gender groups may not be appropriate — and could even be harmful — for female clients who have a substance use disorder. The vulnerability involved in talking about deeply personal issues that tie into their alcohol use can be triggering in coed settings for this client population, especially if they have experienced past trauma involving a man.

Counselors should thoroughly vet their local Alcoholics Anonymous (AA) chapter and other coed support groups before recommending them to female clients, Moore cautions, because these groups could exacerbate clients’ feelings of shame and possibly even retraumatize them. “AA can feel disempowering to women clients,” she says. “A lot of these women have a history of sexual trauma, and being around men is not therapeutic [for them] necessarily.” On the other hand, female-only group counseling or support groups can be powerful settings for female clients to feel supported and understood.

Lewis notes that although mutual aid groups such as AA can be a helpful supplement to counseling for some clients, practitioners should be mindful that AA’s 12-step method has a Western, patriarchal and masculine bias. The organization’s founding roots also have ties to Christianity, which can further alienate some clients, he adds.

Women for Sobriety (womenforsobriety.org) can be a helpful alternative, Lewis says. The organization’s model is based on a series of steps, like AA, but with an empowering focus, he explains.

Lifting the shame

Feelings of shame are common with women who have an unhealthy relationship with alcohol. Because of this, these clients often harbor denial or strong urges to hide their problem even from their therapist, which can affect the dynamic in counseling sessions, Moore notes. It can also cause these clients to cancel sessions or stop counseling altogether.

Moore urges counselors to be prepared for — and patient with — the resistant behaviors that this population may exhibit. “This is a challenging population to treat,” Moore acknowledges. “It [alcohol use] is something that can be a very closely guarded part of their life.”

Resistance and secrecy can be especially prevalent among female clients who are successful in their careers or who work in helping professions such as medicine or counseling, Moore says. Throughout her career in the mental health field, she says, she has witnessed many peers “quietly struggle” with alcohol misuse.

Women are often socialized to be concerned with how others might judge them, which can cause perfectionist tendencies and feelings of shame, Wilson points out. “One of the things that keeps women from getting help is that they can show up, put their best foot forward and play the part of someone who is well when they’re suffering inside. That can be really hard to break through as a counselor,” Wilson says. “Women also have an incredibly high pain threshold. We can take a lot before we break down.”

Hipke finds that women’s shame around drinking often dovetails with parenting issues and feelings of failure as a mother. Many of the clients in the recovery program where Hipke works have had child protective services involved with their family or children removed from the home because of alcohol- or substance-related offenses. These women often feel ashamed for being a burden to family or others who care for their children when they are unable to. The feeling of being a bad mother “really cuts deep for them,” Hipke says.

“Society’s expectation is that women are supposed to naturally be a good mother,” Hipke points out. “Society sees them as doing this [being addicted to alcohol] to their kids rather than doing it to themselves.”

Clients always need an atmosphere of nonjudgment in counseling, but that need is magnified exponentially for this client population because of the associated shame, Hipke says. Practitioners should be hyperaware of the language they use with these clients to ensure they are not reinforcing feelings of shame, she stresses. Counselors must also be careful not to frame a client’s situation as something that they brought on themselves. Statements that assign blame, such as “you’re choosing alcohol over your children,” are not only hurtful for these clients, Hipke says, but also carry the false message that substance use disorder is a choice.

“Be aware of how you’re talking about addiction [and] reiterate that addiction is not a choice,” Hipke urges. “We don’t see any other mental illness as a choice, but people often see addiction that way.”

Part of fostering a welcoming and nonjudgmental atmosphere in counseling is being sensitive to the needs and stressors that women might be juggling outside of counseling, such as child care or transportation. This might call for clinicians to exercise greater flexibility by offering to use telebehavioral health with these clients or allowing them to bring an infant or small child into counseling sessions when child care is unavailable.

Wilson’s facility offers group counseling both in the mornings and the evenings to accommodate clients’ schedules. “We [counselors] need to accommodate women who have a lot of balls in the air already,” she says. “There can be a lot of pressure for women to be the anchor of their family, the scheduler, and that can be something we need to be cognizant of.”

Practitioners may also need to think of creative ways to broach the subject of alcohol use with female clients in counseling sessions without being too direct or aggressive. Otherwise, these clients may stop attending. One method Moore likes is asking clients detailed questions about their sleep habits, including whether they use alcohol as a sleep aid.

“Find ways to get the conversation started early. Don’t wait for it to come up,” Moore says. “It can be hard to get an authentic answer from women regarding alcohol because of the [associated] shame. Sleep can be a good way to ask and bring it up because alcohol use can really mess up sleep.”

Lewis also urges counselors to weave assessment questions regarding alcohol use into conversation with clients rather than firing one question after another at them. This approach intersperses questions about what is happening in the client’s life beyond drinking, such as in their home and family life and relationships, he says.

Instead of asking direct questions about the quantity and frequency of their alcohol consumption, using prompts such as “What does a typical week look like for you in terms of drinking?” can offer a gentler way to query clients about their alcohol use, Lewis says.

For his doctoral dissertation, Lewis researched binge drinking among college students through the lens of Adlerian theory. He found that unhealthy relationships, including problems forming and maintaining relationships, were more often a predictor of women’s drinking behaviors than of men’s. As he points out, dependence on alcohol can cultivate an unhealthy cycle: Poor or absent relationships can contribute to alcohol use, which in turn can hinder an individual’s ability to maintain or build new relationships. So, asking female clients about their relationships and social supports can help counselors understand when further questioning about alcohol use might be needed, Lewis says.

(See the Counseling Today article “Becoming shameless” for an in-depth look at helping clients with feelings of shame.)

Tailoring treatment

Equipping clients with coping mechanisms, including ways to quell critical self-talk, is another important part of working with this population. Clients will need robust, healthy coping skills as they work to eliminate alcohol consumption — the quick, accessible coping tool they have come to rely on.

Vicky Gosselin/Shutterstock.com

Providing psychoeducation that addiction is a disease and that recovery involves rewiring one’s neural pathways for decision-making is helpful, Wilson says. Her initial work with clients includes a focus on coping mechanisms that will help them regulate their emotions. She also works to build up clients’ communication and social skills, which may be underdeveloped because of the individual’s history of trauma, mental illness and substance use.

“The only thing they’ve known to use to cope is the substance, so we need to replace that right away,” Wilson says. “We [the staff at Women’s Recovery] are big believers in skill building. We start with loading clients up with all sorts of coping and grounding skills [as well as] the message that this is going to be a lifelong journey. Clients are recovering, and it will take constant work.”

One nice thing about outpatient treatment is that clients learn to live without substance use in everyday life during treatment, Wilson notes. Clients can see what triggers come up and learn how to address them as they navigate work, family life and relationships while living at home.

Hipke notes that group counseling can also be a rich setting for female clients to learn coping mechanisms, both because they are exposed to the lessons that other women have learned during their recovery journeys and because they are provided with a safe place to strengthen their social and relationship skills.

“Group [counseling] is the most powerful part of our program. It resonates with them to hear others’ stories, helps them build bonds and also holds them accountable,” Hipke says. “It’s powerful [for clients] to know they can share stories and talk about whatever they need to, and it won’t leave the room. As a therapist, we can point things out to them all day long, but it’s so much more powerful to hear it from a peer.” Hipke has noticed that she can say something repeatedly to a client in an individual session, but it often won’t “click” until the client hears the same message in the group.

Lewis and Hipke note that in individual counseling, motivational interviewing is a useful method for building rapport and helping clients who may be resistant or ambivalent to behavioral change. This approach can also be beneficial when counseling female clients who are in denial or who have complicated feelings that are exacerbated by the stigma and shame associated with their alcohol use.

The counselors interviewed for this article also mentioned cognitive behavior therapy (CBT), Gestalt techniques and trauma-informed modalities, including eye movement desensitization and reprocessing, as being particularly helpful with this client population. Hipke says that using a strengths-based approach can also be useful, as can including a client’s partner or family in sessions, when appropriate.

Including clients’ family members or others in counseling sessions can help clear up misunderstandings and hurtful feelings that linger regarding a client’s addiction and past behavior, Hipke explains. In these cases, a counselor can act as moderator to support and guide conversations toward healing. “Having kids, parents or siblings join in on sessions for the therapist and client to be able to talk more about addiction and provide a safe and neutral space to have discussions can be very healing for both the client and their family,” she says.

These clients may also need to spend significant time working on self-talk and intrusive thoughts and learning how to deal with difficult feelings in a healthy way. With self-talk, part of the work involves helping female clients hold themselves accountable while resisting the urge to be overly critical and beat themselves up, Hipke says. Mindfulness and CBT can be particularly helpful in these areas, she adds.

Many clients, especially those with abuse histories, must unlearn behaviors they adopted over time to block out powerful emotions such as anger, sadness and happiness, Hipke says. These women often struggle to find the words to explain what they are feeling. Hipke uses an emotion wheel to help clients name their emotion, recognize how it manifests in their body and identify why it’s a difficult feeling for them to experience.

“For many clients, they were either punished or wouldn’t get their needs met if they showed emotion. … They often need to rediscover sadness or anger and realize that it’s OK to feel those emotions, or even that it’s OK to be happy. They often don’t know what to do with being happy,” Hipke says. “From there, we identify why it’s so difficult. What has led to the place where feeling sad or angry isn’t OK? And then we begin to dismantle that. Just labeling it, identifying it, is helpful — and then they can match coping skills to the emotion they are feeling.”

Preparing for relapse

When doing counseling work with women who are addicted to or dependent on alcohol, it is important to be prepared for the possibility of relapse.

It can be helpful to talk frequently about relapse prevention skills, both in group and individual counseling, Hipke says. This includes being able to recognize the signs that an individual might be headed toward relapse. She also listens for instances when clients mention going through a stressor. This presents an opportunity to offer extra support and check on how the client is coping, including asking gentle questions about the possibility of the client feeling an urge to return to substance use.

Once again, it is important for counselors to provide nonjudgmental responses, Hipke stresses. If a client relapses, counselors should normalize the experience and celebrate that the client recognized it and shared it with the therapist, she says. Women are often afraid to tell their counselor about a relapse. So, when they do, Hipke recommends that clinicians assure them that it’s not a sign of “failure,” either on the part of the client or the counselor.

Hipke also emphasizes that counselors should not take client relapses personally. “For a lot of the women [in our program], they struggle with balance in different areas of their lives. They’re not just stopping drinking, they’re making a lot of behavioral changes in their lives,” Hipke explains.

She often talks with clients about how it’s normal for relapses to occur during any kind of behavioral change. “It’s not the relapse that we want to focus on but what to do after,” Hipke says. “What can we do differently to make sure it doesn’t continue happening, [and how can we] keep [clients] from beating themselves up, because that can lead to more relapses.”

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How much is too much?

Counselors shouldn’t take a one-size-fits-all approach to assessment questions about a client’s alcohol use because women form dependency on alcohol for different reasons — and in different ways — than men. Practitioners should focus more on the context and reasons why a female client drinks alcohol rather than on the quantity, says Holly Wilson, the founder and chief empowerment officer of Women’s Recovery, an outpatient substance abuse treatment program for women in Denver.

Questions about the number of drinks a client consumes also have the potential to spark countertransference issues, notes Wilson, a licensed professional counselor candidate. Counselors will have personal feelings about how many drinks are acceptable, and they must be careful not to project those assumptions onto clients.

“It doesn’t matter if you would have a problem doing what they’re doing … or [if] the quantity or frequency of the client’s drinking may be something you’re fine with, but they’re not,” Wilson says. “It doesn’t have to be according to your own personal standards of drinking or substance use.”

Instead, she advises counselors to focus on exploring the client’s relationship with alcohol. The CAGE questionnaire can be a helpful tool to use with female clients, Wilson says, because it focuses on how a person feels about their drinking. CAGE poses four questions that can prompt further dialogue with the client:

Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

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Recommended titles

Here are some books that Sarah Moore uses with individual and group clients:

“Can I Keep Drinking?: How You Can Decide When Enough is Enough” by Cyndi Turner
“Between Breaths: A Memoir of Panic and Addiction” by Elizabeth Vargas
“The Sober Diaries: How one woman stopped drinking and started living” by Claire Pooley
“This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness & Change Your Life” by Annie Grace
“Quit Like a Woman: The Radical Choice to Not Drink in a Culture Obsessed with Alcohol” by Elizabeth Whitaker

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Restoring relationships with survivors of human trafficking

By Lindsey Phillips August 4, 2021

Jenna Hershberger, a licensed associate professional counselor, was working on a crisis response team for a regional human service center in North Dakota when she received a call from a young woman reporting physical abuse. The woman was forthcoming about her medical complaints but not the state of her mental and emotional health. Hershberger could tell there was more to the woman’s story, so she asked to meet her in real life to discuss things further. The woman agreed.

During their in-person meeting, Hershberger, a therapist at the Village Family Service Center in Fargo, North Dakota, noted signs of potential sex trafficking. “Her presentation was really concerning. She was very tearful,” Hershberger recalls. The woman also kept mentioning how her “friends” had forced her to do things while she was under the influence of substances. The more the woman shared, the more convinced Hershberger grew that the people being referenced were human traffickers, not friends. When Hershberger asked where the woman was staying, she revealed that she was currently homeless.

After talking for a while, the woman finally acknowledged that she had been forced into sex trafficking and wanted to get out. She was scared and didn’t know what to do. Fortunately, Hershberger did. She found the woman a safe shelter for the night and helped her locate mental and physical health services.

“I’m in North Dakota … [where] prevalence rates [of human trafficking] are lower, yet it’s still happening,” says Hershberger, a member of the American Counseling Association. “The tragedy where I am and in Midwestern, rural areas is that people just seem to say, ‘Well, this doesn’t happen here.’”

Jared Rose, a licensed professional clinical counselor and supervisor with a private practice, Moose Counseling and Consulting LLC, in Toledo, Ohio, has also encountered a “that doesn’t happen in my community” mentality when it comes to human trafficking. He began working in anti-trafficking about 15 years ago when someone involved in an anti-trafficking organization in Toledo approached him because of his work with the LGBTQ+ community and with people infected with, affected by or at risk for contracting HIV, both of which often intersect with trafficking. When conducting trainings in rural Ohio counties, Rose has heard law enforcement say, “That’s not happening here.” This statement makes Rose cringe because he knows firsthand from his work with individuals who have been trafficked that it is happening.

Human trafficking, in fact, is more common than we think. The International Labour Organization reported that approximately 40.3 million people were in modern slavery globally in 2016. Sometimes people incorrectly assume that human trafficking is a problem only in developing countries, but the National Human Trafficking Hotline identified 63,380 survivors of human trafficking in the United States from 2007 to 2019.

Rose, an ACA member who wrote an ACA fact sheet on human trafficking awareness for school counselors in 2019, finds that too many counselor clinicians also remain unaware of the definition and signs of trafficking. “You could have the epitome case sitting in front of you,” Rose says. “And if you don’t even know what trafficking is, you’re going to miss it.”

Recognizing the Signs

The U.S. Department of Homeland Security defines human trafficking as the use of force, fraud or coercion to obtain some type of labor or commercial sex act. Rose, an assistant professor of counseling at Bowling Green State University, advises counselors to stay alert to signs of force, fraud or coercion with clients. “Take note of who they are with and where the power and control lie,” he says. For example, is someone else benefiting — often financially — from the client’s actions? Does someone else seem to be in charge or making all the client’s decisions for them?

Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, also looks for visual signs such as bruising, scarring or branding. Individuals who are being or have been trafficked are often branded with “ownership” tattoos with the name of their trafficker or with symbols such as a star or cowboy hat. Because sex acts place a lot of strain on the body, survivors often discuss medical complaints such as dental issues, migraines or urinary tract infections, she adds.

Clients who have been trafficked “may appear overly compliant and submissive, or they might appear really abrasive and abrupt,” Hershberger points out. Counselors must recognize “that those strategies were adaptive at one time but they’re not right now.”

As it relates to falling victim to trafficking, Rose notes that the No. 1 risk factor for children is being unhoused. He prefers the term unhoused to runaway, he explains, because children are often abandoned or “thrown out” by their families. “Within a matter of two to three days of being out of the home, kids are approached [by traffickers], and one-third of those [unhoused] kids are going to get trafficked,” he says. “So, that piece of being unhoused — couch surfing, staying at a shelter, living on the street or whatever the case may be — puts them at significantly higher risk.” Children who are already vulnerable may easily fall prey to an adult who shows them attention or what they initially perceive as support, he adds.

Other risk factors include lower socioeconomic status, past trauma (sexual, physical, emotional, verbal or spiritual), being differently abled, substance use, and belonging to a racial or sexual minority group, Hershberger says. Given the complex trauma that these individuals experience, they often present with comorbid disorders such as substance use, bipolar and severe depression, she notes.

Counselors may overlook or miss signs of trafficking when they take the client’s circumstances or presenting issues at face value, notes Paige Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University. For example, if a client is homeless or doesn’t have any identification, counselors may start to talk about the emotions, behaviors and social systems surrounding the client’s chronic homelessness and help them come up with a plan to find a more stable environment. But in doing this, clinicians may miss the larger picture, stresses Dunlap, a licensed clinical mental health counselor with a private practice in Greensboro, North Carolina. Perhaps the client was forced into sex trafficking after being taken from their home or fleeing an unsafe environment.

“There’s a lot of different risk factors. There’s a lot of different things to look for. There’s a number of populations that we are particularly concerned about, but at end of day, it all boils down to vulnerability,” Rose says. For that reason, he stresses that counselors need to be cognizant of that vulnerability piece in connection with their clients.

Sometimes counselor practitioners worry that they won’t be able to recognize the signs that someone has been trafficked, Rose says, but he reassures them they know how to read interpersonal reactions. They know when someone is looking to another person for answers. They notice when people’s stories do not match up.

Counselors also need to consider what a trafficking survivor might look like in their particular clinical setting, Hershberger says. For example, if a counselor is doing crisis work, they might have someone who is in denial about being trafficked or confront a situation that appears to be domestic violence.

The office setting may determine the likelihood of a practitioner encountering an individual who is currently being trafficked or who has gotten out. Counselors who work in public health settings or hospitals are more likely to see individuals who are currently being victimized when these individuals come in for a medical issue such as testing for a sexually transmitted disease or injury from abuse, Rose notes. Counselors working in private practice or at a community agency will typically see these clients after they have been extricated, he says.

Establishing trust and safety

People who have been trafficked may find it difficult to trust others. Before thinking about clinical treatment plans, counselors need to establish a sense of safety and a healthy therapeutic rapport with these clients, Hershberger stresses. These individuals have experienced “complex trauma in the sense that it’s repeated for long duration and often comes from people who should be caregivers,” she explains, “so it makes it really hard for survivors of trafficking to trust us. We need to be really authentic because survivors will pick up on it if [we’re] not.”

Hershberger, president of the North Dakota Association for Counselor Education and Supervision, advises clinicians to maintain an open-door policy with survivors of human trafficking, especially when they are working on engagement with the client. People who are dealing with significant trauma may be more prone to canceling sessions, so adhering to a policy of termination after two missed sessions will not help build engagement and rapport with these clients, she cautions.

Counselors’ innate desire to help clients heal can sometimes be an impediment to build-ing this relationship. Rose sees counselors who want to dive right into the trauma work before first building strong therapeutic and strategic foundations, which can take a long time. “The minute we try to push too much — even if our best intentions are there — is when someone can have [a negative] reaction” and feel that the counselor is forcing them to do something they don’t want or are not yet ready to do, he says.

Rose has also witnessed the inverse: clients who get frustrated when counselors don’t jump straight into the trauma work. When this happens, he explains to clients that although they may feel ready, their whole system may not be. To further illustrate the point, he compares trauma work to a physical wound: “If I start poking around at a wound and you don’t trust me yet or your entire system isn’t ready to allow that yet, you’ll immediately pull back and you’re not going to want me to go near it,” he tells clients. “And the same [thing] is happening cognitively and emotionally with trauma. If we start poking around and you’re not ready, then it’s going to fall apart on us.”

The need for clinical trauma care

Rose asserts that counselors are in a prime position to provide clinical psychotherapy and trauma-focused work. Rose is an executive member of the Lucas County Human Trafficking Coalition, and he was awarded the Social Justice Leader Award from the Human Trafficking and Social Justice Institute in 2017.

Mental health services geared toward survivors of trafficking are great at managing clients’ symptoms through art or expressive therapy or group work, but Rose finds this is often where their treatment ends. “It has to be more. It has to be evidence-based trauma work,” he stresses. “We can’t just treat symptoms. We have to treat the whole person, and we have to treat the trauma.”

“Folx that have been labor trafficked have all sorts of layers of trauma damage. … Sex traffic victims have all of the symptoms of domestic violence, emotional abuse, physical abuse, sexual abuse — all rolled into one very unpleasant package,” he continues. “And expressive therapy is not going to treat that trauma; it’s going to treat the symptoms. If we really want to help folx, we have to go deeper, and that’s where counselors really need to come into play.”

Rose, a certified therapist in eye movement desensitization and reprocessing (EMDR), recommends that counselors use an evidence-based trauma treatment that follows a triphasic approach that a) establishes a foundation, b) reprocesses and works through the trauma and c) plans for the future. Rose often uses EMDR when he’s working with this population because he finds it helpful to treat the root cause of the trauma. He also recommends trauma-focused cognitive behavior therapy, especially when working with children and adolescents.

Take the relational approach

Hershberger points out that traffickers differ from other sexual offenders (who are often described as socially awkward and desire a sense of belonging) in that they are often socially intelligent, charismatic and good at forming relationships. They gain the trust of vulnerable individuals by initially fulfilling their need for love, connection and belonging, she explains. For example, the trafficker could be the first person in the individual’s life to recognize and celebrate their birthday or give them special attention, such as taking them to get a manicure.

These acts can cause some survivors to form bonds with and defend their traffickers — a condition often referred to as Stockholm syndrome. Hershberger and Dunlap point out that something similar sometimes happens with individuals who experience domestic violence. “Survivors will often defend their trafficker because they didn’t have that sense of belonging or that family growing up. So, this is the first time they’re experiencing that — along with horrible kinds of trauma — but it’s hard for them to differentiate that,” Hershberger explains.

According to Hershberger, these trauma bonds illustrate survivors’ desire for human connection. Traffickers thwart this connection by exploiting this desire for their own gain.

“Human sex trafficking is the ultimate anti-relationship,” argues Hershberger, who recently presented on this topic at ACA’s Virtual Conference Experience. Survivors of sex trafficking have been forced “to exist in a world absent of authentic, growth-fostering relationships,” she explains. Thus, she recommends that counselors use a relational-cultural approach with this client population to foster an authentic growth-fostering connection.

To explain this approach, Hershberger presents Marie, a fictional client: When she was 14 years old, Marie lived in an abusive home where her mother’s boyfriend molested her. So, Marie was excited when Jake, a 24-year-old man, approached her and promised a better life as his “girlfriend.” He bought her nice things and told her she was “amazing in bed.” One day, he told Marie some money hadn’t come through at work and asked if she would help him by having sex with a few guys. When she resisted, he beat her until she complied. He forced her into sex trafficking, and she was having sex with as many as 10-15 men a night. (See Hershberger’s 2020 article, “A relational-cultural theory approach to work with survivors of sex trafficking,” published in the Journal of Creativity in Mental Health, for a more detailed discussion of this case study.)

Following a relational-cultural framework, Marie’s counselor first establishes a sense of safety and trust, and they are authentic, empathetic and consistent in their interpersonal interactions, Hershberger says. So, if the counselor makes a mistake by showing up late for session, they own that mistake, apologize and ask Marie how they can make up for it.

Marie may have internalized negative beliefs or self-blame such as “I’m only good for my body and others’ use” or “I’m not worthy of being loved.” The counselor can help Marie first identify and name these beliefs, and then they can work together to challenge these negative beliefs. The therapeutic relationship further challenges Marie’s distorted thinking about herself and relationships, Hershberger notes, and models what a healthy relationship entails.

To challenge Marie’s belief, the counselor could use self-disclosure and tell Marie, “I experience you as a creative, confident individual who is worthy of being loved.” Hershberger recommends that counselors use the client’s own words when reflecting positive attributes to help the client identify and own their strengths.

As Hershberger points out, traffickers try to keep victims in a constant state of uncertainty about their environment, safety or identity. So, the counselor’s role is to identify moments or thoughts that are unclear, such as Marie’s negative perception of her self-worth, and help her add clarity to them.

Hershberger names bibliotherapy and narrative therapy as useful approaches for empowering survivors of trafficking and helping them find their own voice. For example, the counselor could ask Marie what name her trafficker gave her and the name she wants to use moving forward. Then, Marie could journal about this new identity and the qualities associated with it.

The counselor could also add in creative techniques such as collage or relational imagery. For example, Hershberger once had a client who identified with the image of a wounded deer because they too had been hurt and abandoned. The wounding paralleled their own trauma around the physical abuse they had experienced while being trafficked. Later, Hershberger used this image to help the client think about what they wanted their future identity to be and to create a collage of their strengths.

The therapeutic relationship becomes a healthy relationship — one that is safe, dependable and empowering and that counters the disconnection and uncertainty survivors experienced when they were trafficked, Hershberger says.

Preparing to work with this population

The best way to understand what is going on with human trafficking in a specific area is to get involved and volunteer in the community, Rose says. One place to start is joining or attending meetings of local, regional or state trafficking coalitions and task forces. “You can learn more about what agencies are providing services for this population,” he says. “They need to know where mental health providers are, and you need to know where additional services are for survivors.”

Rose advises counselors to approach these partnerships with an attitude of wanting to learn and help. Communities don’t respond well to people who think they know what is best or have all the right answers, he says. Instead, inform these organizations of the crucial skills they may be missing. Counselors have “the clinical piece that a lot of these places need and strive for,” Rose notes. “There’s a lot of social workers, nurses and different helping professionals, but clinical mental health treatment may not be what they have.”

In addition to attending monthly meetings of North Dakota’s trafficking task force, Hershberger prepared to work with this population by reading case examples and familiarizing herself with these tough stories. She also reached out to other clinicians in the field to hear about their experiences. As she points out, “It’s one thing to hear terminology, but it’s another thing to hear somebody’s story.”

Rose and Dunlap recommend that counselors limit their caseloads (if they have that option) when working with this population. “You can’t hear the thing of nightmares for three, four or eight hours a day and expect to be OK by 6 or 7 o’clock at night,” Rose says. Both he and Dunlap, an ACA member who researches and works with youth with disabilities, survivors of human trafficking and criminal populations, have had to learn how to balance their clinical schedules better. They intentionally leave time between these difficult sessions so they can reflect, reenergize and regroup before seeing their next client.

Counselors must also remember that not every client-counselor relationship is the right fit, Rose says. For example, someone may refer a female survivor of sex trafficking to him because of his expertise in EMDR, but if she has been abused by men her entire life, she may not want to work with Rose regardless of his qualifications and reputation as a counselor.

“These clients have had people treat them really poorly their entire lives,” he points out. “Part of that therapeutic relationship is recognizing maybe I’m not the best counselor for every person I want to help, and that’s OK. Just giving [clients] that freedom and autonomy will help them along in their journey. They don’t have to work with me to fix the problem.”

Rose reminds counselors there are other ways to help serve this population without working directly with clients. Counselors can get involved in local agencies that work on human trafficking, provide education and trainings, or work on prevention, he says.

Hershberger understands how difficult it can be when counselors must refer a client. Because she was part of a crisis response team when she met the woman who was a survivor of human trafficking, she wasn’t able to continue working with her. The woman was referred to another clinician who worked for the human service center. “That was hard,” she recalls. “I couldn’t stay with her, and having that continuity of care would have been nice.”

Hershberger did have a chance to meet with the woman a few months later. With the help of her new counselors, she was making progress toward creating healthier relationships.

fizkes/Shutterstock.com

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Working with perpetrators of human trafficking

Paige Dunlap, a licensed clinical mental health counselor in Greensboro, North Carolina, once worked with an agency in Detroit that assisted individuals who no longer wanted to be engaged in gang activity. In sharing their stories, some of the group members disclosed that they had been directly or indirectly involved in trafficking other individuals. After recovering from the initial shock of hearing that, Dunlap started to think and educate herself about ways counselors could help perpetrators of trafficking.

“We as counselors don’t really talk about this hidden population” of perpetrators, she says. “We don’t know too much about them.”

Often people’s biases can cloud their judgment about these individuals. The more Jenna Hershberger, a licensed associate professional counselor in Fargo, North Dakota, researched and worked with cases of sex trafficking, the more she discovered the dichotomous thinking attached to it: People consider traffickers to be “bad” and survivors to be “good.” But it’s more complicated than that, she says.

“In the literature, we see that traffickers and survivors experience the same kinds of childhood traumas, such as sexual, emotional, physical and spiritual abuse,” she explains. But for individuals who become traffickers, “there is a distortion that happens in the way that they respond to the trauma.” Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, acknowledges this is an area of research that mental health professionals do not fully understand yet. But initial clinical findings, as well as Hershberger’s own professional experience, indicate that traffickers often seem to have empathy deficits and endorse trafficking myths such as “people like this way of life.”

Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University, says that traffickers and victims of trafficking often get enmeshed in that world for similar reasons. “There is a need for belonging in all of these individuals,” she says. Both groups often lack support systems, have limited work opportunities and are tempted by the promise of a “better” life, she explains.

Once individuals get involved in trafficking, it becomes difficult for them to leave, Dunlap points out. “It becomes almost an institutionalization for them too. … They don’t know how to function outside of that.”

“Getting those individuals into your office to do this hard work is really going to be tough,” she admits. “If you’re a counselor and you do happen to have these clients, the last thing they need is for your own biases to be stopping them from getting help, because they’re doing good just to be there.”

Hershberger hopes counselors continue to research ways to better help both the survivors and perpetrators of human trafficking. In doing so, she encourages counselors to consider a larger question: How as a society are we creating spaces in which people don’t know what a healthy relationship looks like so that they’re seeking out this subculture for a sense of belonging?

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.