International experiences help counseling students broaden their perspectives, which will influence their clinical practice in their careers.

During a Stetson University trip to Germany in 2012, master’s degree student Jessica Richardson presented a poster session on treating ADHD in adolescents with transcendental meditation at the European branch of the American Counseling Association conference. “I had a very limited view of counseling,” said Richardson. “Now I have a greater understanding of what it means to be a counselor. The job possibilities are endless—you aren’t limited to the state of Florida.” Indeed. Richardson plans to attend two international job fairs before she graduates in December.

Graduate mental health programs in the United States are increasingly finding value in offering their students just such international experiences, including courses at partner universities; community and service-learning projects; site visits; and conversations with local practitioners, clients, or patients.

Meghan Walter, an assistant professor of counselor education at Stetson and a former school counselor overseas, has led student trips to Germany and the United Kingdom. Careful attention to detail before, after, and during a trip is critical to providing personal and professional growth. Walter preferred leading a smaller group to Germany (11 students rather than 15) and making contact with hotels herself so she could insist on a private, designated meeting room for daily debriefing sessions. Ahead of any trip, Walter gathers students to discuss what excites them, what makes them nervous, and how they will handle tensions and challenges.

“We are training people to assertively communicate but they lack those skills themselves,” says Walter. “Communicating with each other becomes even more important than simply visiting a foreign place.” This was especially true for a student with cerebral palsy, who was accustomed to navigating independently in the United States. “She hadn’t thought of herself as a person with a disability,” recalled Walters, so the group helped her talk about being honest with people when they offered to help.

Those who lead international programs in mental health emphasize the critical importance of preparation. Professor Nataka Moore at Adler School of Professional Psychology in Chicago teaches students about the importance of entering foreign communities with respect, being aware of how they are perceived, and mindful of the consequences of their actions. In the essays she requires before students travel, she looks for students writing about what they need to learn rather than how they want to help.

Moore brings global concepts into her cognitive therapy class whether or not students will be traveling overseas. “The conversation that is missing from psychology programs,” says Moore, “is a discussion of human rights and globalization, and their impact on mental health…How do we look at an individual in their social context? We need to understand what fishbowl we are living in and how that fishbowl plays a huge part in resiliency and perception.” While traveling to South Africa, Moore’s students compare the different ways people address historical trauma—apartheid in South Africa, slavery in the United States—and how that broader understanding might inform the way they work with African American clients and communities. “What does another country do that we can learn from?” asks Moore. “Take that knowledge back to the communities where you work.”

The Adler School is also organizing a five-week summer program with UNIBE, Universidad de Iberoamérica, in Costa Rica for 2015. At least a dozen third- or fourth-year doctoral students are expected to participate in the cultural immersion, mental health shadowing experience. The shadowing will involve mental health professionals in a counseling center, regional hospital, private practice, and community-based health centers. In all cases, clients are to be notified that observers are on site. The ultimate goal, says Cecil Thomas, Adler’s director of global affairs, is enabling students to “take that cultural awareness and use it to work with different populations in a place like Chicago.” Seeking to give Adler School graduates a competitive advantage in the workplace, Thomas says newly trained counselors must be “nimble enough to work with different populations in a culturally competent manner and also have a better understanding of their own individual identity.”

Building self-awareness is a critical element to foreign travel, especially for young people who will be working professionally to expand that awareness in others. “Students learn they have to roll with the punches, which is what we have to teach our clients: there is parallel learning here,” says Stetson’s Meghan Walter. Brigid Noonan, chair of Stetson’s Department of Counselor Education, tells potential travelers, “I am not here to change your value system, but to help you put on different pairs of glasses to help you see the world that your client is viewing.” Stetson has engaged students in international travel since 2003, visiting England, France, Italy, Russia, and Greece. With few electives and many licensing requirements, travel must typically be scheduled during a break or incorporated into a credit-bearing course.

Noonan says she has many more personal connections in Europe than in Africa, so she is now working with the Global Engagement Institute to take Stetson students on a week-long program called “Mental Health in Botswana.” Second-year master’s students will visit a psychiatric hospital, a youth health organization, the Botswana Red Cross, and the Botswana Center for Human Rights. Stetson faculty will accompany the group of 15–20 students and create assignments for individual students based on their specific area of study.

Noonan’s assignments often have an air of profound whimsy. “When students have free time, I send them out in pairs and ask them to talk with people on the street. Engage in conversation for at least half an hour. Getting out of your comfort zones is really important as a counselor. This is what it’s like as a counselor talking to people you’ve never met before.” Which is precisely what one student discovered after telling Noonan he initially thought the assignment was bogus, “but this gentleman just wanted to talk about his life in Rome. I could see how this conversation would be like sitting across from a client saying, ‘what brings you here today?’” The student noted that the man’s English wasn’t that great, but “I enjoyed just sitting and listening to him.” Noonan added that students are not there to “fix problems, but to listen and experience what your client’s experiences are from an empathic standpoint.”

Getting Started

Initiating an international experience for students in mental health fields is not unlike other disciplines and typically involves networking and developing personal connections. Stetson’s Meghan Walter recommends attending an appropriate international conference as an interested faculty member. Make as many connections as possible and scope out the logistics at the first conference. Spend the time before the next conference building an itinerary, including opportunities for students to present posters or workshops individually or with a faculty member, meet with local professionals, visit clinics or other sites, or participate in a service-learning project. Walter also recommends investigating one- or two-day trainings offered by specialized institutes in such areas as clay therapy, expressive art, or working with trauma victims.

For Norman Epstein, director of the Couple and Family Therapy Program at the University of Maryland, a simple “yes” when a Chinese medical professor asked to visit Maryland as a visiting scholar led to two decades of student travel, conferences, and research collaboration. Fuguo Chen, MD, stayed in Maryland for 18 months. The two jointly researched the views of U.S. and Chinese couples on the characteristics that lead to satisfying relationships. Later, Epstein presented workshops for mental health professionals at Shanghai Second Medical University, including sessions for school counselors on treating depressing and anxiety. A Chinese student who earned a doctorate at Maryland introduced Epstein to her mentor at Beijing Normal University and another opportunity for international faculty and student collaboration was born.

In 2012 Epstein and Xiaoyi Fang, director of the Institute for Developmental Psychology in Beijing, organized the first Sino-American Forum on Marital and Family Therapy attended by 13 U.S. graduate students from the University of Maryland. In 2013 Fang and three colleagues spent a month in College Park, Maryland, seeing American family therapy firsthand and planning the second Beijing conference in 2014.

Epstein led his first students to Beijing in 2009 when he taught a study abroad course to U.S. and Chinese graduate students on cross-cultural applications of couple and family therapy models. China is a collectivist society valuing family ties and relationships, while Western cultures are much more individualistic. “We like to talk about everything, get our feelings on the table,” Epstein explains. “Communication in China is much more indirect—you don’t want anyone to lose face; there is a lot of reading between the lines. So you don’t say ‘no,’ you just don’t do what has been asked.” The adaptation? Go more slowly, be respectful, gradually form a trusting relationship, honor the family hierarchy. Couples therapy itself is still new in China. “A couple will say their child has problems, and we carefully try to get them to talk about the dynamics of their own relationship. We talk to them as two parents, not as a couple.”

How does all this benefit the U.S. graduate students? Not only have U.S. and Chinese students developed lasting friendships, “they learn a tremendous amount about cultural diversity,” says Epstein. “We teach cultural sensitivity but this is firsthand experience. Be sensitive to people’s communication styles. Meet people where they are.” Epstein says even his own therapy practice has changed because of his experiences in China. “I listen more to get a sense of the culture of a family. Every family has its own personal culture and traditions.”

Clio Le Zheng is a recent graduate of Epstein’s Couple and Family Therapy Program at the University of Maryland, and although she is choosing to stay in the United States for now, she hopes there will one day be good work opportunities in China. Beijing Normal University has a growing family therapy clinic even though Le Zheng said mental health counseling is not covered by insurance and still carries a stigma. “People who seek counseling might be viewed as being crazy because it is confused with psychiatric treatment.”

Epstein emphasizes the importance of having a good contact in the collaborating country to guarantee a good experience for students, and in the case of China, to arrange visits to mental health centers. He also noted the small challenge of participating in conferences overseas: he had to send his PowerPoint presentation early so it could be translated and he had to allow time for simultaneous translation during the sessions.

Spirituality and Counseling

Another serendipitous meeting coupled with a growing interest in spirituality led to a graduate elective at the University of Wisconsin-Oshkosh (UW-Oshkosh) called “Counseling, Culture, and Spirituality in India.” UW-Madison has offered an undergraduate study abroad program in Vernase, India, since 1961. In 2009 associate professor Charles Lindsey in the Department of Professional Counseling at UW-Oshkosh was invited to come along.

“I walked into this room and met this person I had known all my life, Tulsi Das.” The immediate personal connection they forged led to an evolving series of short (two-and-a-half-week) trips to India that come with three semester hours of graduate credit. Many of the 33 students Lindsey has taken on three separate trips to India had never been outside the United States. Before the trip, students prepare a presentation for their fellow travelers on a topic they want to know more about, perhaps Indian politics or Buddhism. Lindsey also lets students know that India can be a tough place to travel. “I can’t promise you hot water; you won’t always sleep well; you won’t always find things to eat that settle well.” In fact, one train ride to Vernase took 12 hours instead of the expected three. “In the U.S. we have a lot of control over getting what you want and it was difficult for people to lose that,” recalled graduate student Lisa Plonsky. “You have to have the mindset that things are going to go wrong and you have to be flexible.”

In addition to coming home with humorous stories of expectations torn asunder, the students “return with different ideas about exploring their own spirituality,” says Lindsey. “They want to be more in tune with themselves and understand how that is connected with being a mental health practitioner: if we aren’t taking care of ourselves and growing, how are we going to be most effective working with other people?”

Although the trip includes stops at world-renowned tourist destinations like the Taj Mahal, the real epicenter of each trip is Vernase, a sacred Hindu pilgrimage center on the Ganges River. Tulsi founded the nonprofit Diva International Society for Child Care, which operates a variety of programs around Vernase focused on people with leprosy and developmental disabilities, education, and an empowerment program for teenage girls. During the first trip, the Wisconsin travelers visited it all. “We overbooked,” said Lindsey. In subsequent trips, they did less and went deeper into the experience, interacting with residents at a Missionaries of Charity (Mother Teresa) home for people who were homeless or dying and also with the teens at the center for girl empowerment.

The experience “pushes students to think of how you connect with other people without using spoken language. We do art activities with kids and adults. We have them teach us games. Our students have to dig into those places where they establish connections. They have to be creative. It pushes them out of their comfort zone.”

But does it also create a problem of initiating relationships and then suddenly leaving? Less so for the Indians than the Americans, Lindsey believes. “Within Indian culture, there is more of a here-and-now perspective, more understanding that something may not be in place tomorrow that is here today. We live very futuristically in the United States. We are promised all these tomorrows.”

UW-Oshkosh graduate Carlyn Andrew, now a practicing counselor, believes these short-term exchanges overseas can be healthy and helpful. She said a day dancing, holding hands, and connecting with a group of teenagers in India was powerful and beautiful. “It parallels work we do in counseling. It is a time-limited relationship. It is a skill to be taught on how to engage in relationships and close it off when it comes to an end. You can walk away saying ‘I don’t know if I will see you again but this has been meaningful for me,’ rather than ‘see you again sometime.’” After meeting with the girls, Andrew said, “Based on the looks on their faces—big smiles with crows’ feet in the corners of their eyes—it was joyful in the moment.”

Three months after each trip, students gather to share presentations that demonstrate some reflection about the experience, such as art projects or a slide show set to music. One student made dal and chai for everyone. Another had the group singing songs. Both Andrew and Plonsky were struck by the pervasiveness of spirituality in Indian culture. There is religion “in every piece of what they do,” said Plonsky. “There are small prayer areas and meditation centers everywhere.” Exploring spirituality was an important motivator for Andrew’s participation in the trip in the first place. “Spirituality can be self-defined and very different from religion,” she explains. Americans often shy away from talking about politics and religion, yet spirituality “can be an important part of wellness—being present and mindful and living with intention.” Andrew now works with U.S. teens “who are just establishing their belief systems. I feel I can draw them out a little more, help them define what makes them feel connected, what makes them feel alive to the moment.”

Plonsky, now a middle school counselor, says she was “completely changed by my experience in India—how I relate to students, understanding the importance of culture. I make sure I understand the differences their world brings to their life.” Speaking with one student who had been traumatized by her experiences in Congo before her family escaped, Plonsky said, “We were able to talk about culture because I had things from India in my office. I felt okay asking if I didn’t understand something rather than assuming I understood.” Noting that “middle school students don’t get listened to enough,” Plonsky added that “when students say they celebrated an event at a family gathering, before I would have said, ‘that sounds wonderful.’ Now I would ask ‘what did that celebration mean to you?’”

A 2011 report from the American Counseling Association on Integrating Spirituality and Religion into Counseling: A Guide to Competent Practice recalls a time “when the realm of spirituality and religion was clearly separate from the counseling process.” Now, many consider “that spiritual and religious matters are therapeutically relevant, ethically appropriate, and potentially significant topics for the practice of counseling with diverse client populations in a variety of settings.” The UW-Oshkosh trips to India reflect this changing attitude. Time was set aside for students to participate in an evening of meditation. A leading expert on sacred Hindu texts discussed connections between the Hindu Bhagavad Gita and Ramayana and the profession of counseling.

Mission-Driven Travel

Not surprisingly in a profession that seeks to help people understand themselves and their purpose in life, some overseas programs in counseling and mental health are mission driven. The World Health Organization’s Comprehensive Mental Health Action Plan 2013–20 reports that up to 85 percent of people with severe mental disorders in low- and middle-income countries receive no treatment. The plan is a call to action, with psychologists expected to be among the prime movers. William Froming, provost at Palo Alto University (PAU), asked himself, “Can we do something with what we know and what we are good at to benefit people in other countries where there is a complete absence of mental health professionals and no infrastructure to train the next generation?”

Froming is working on several fronts with PAU’s Global Advancement of Counseling Excellence (GACE), which offers a master’s program in counseling psychology that combines long-distance online learning with on-the-ground clinical practice in the student’s home country. The most advanced program currently is in China, where there is mixed awareness of the need for counseling services. During the 2008 Sichuan earthquake, China suddenly “recognized the need for counseling,” says Froming. “The ways they used to deal with everything privately and in the family are breaking down.” PAU is building on this growing interest in the field. Froming says hundreds of thousands take a counselor licensing test in China, which requires book knowledge but no clinical experience. The GACE program enables students in Beijing to earn a master’s degree in counseling through online seminars and academic courses coupled with training sites on the ground such as the Beijing United Family Hospital. The first four Chinese students are expected to graduate in 2014. A similar program in Argentina enrolled its first students in 2011. There are also opportunities for U.S. doctoral students like Leighna Harrison to gain clinical training experience in Argentina. Harrison wanted to improve her clinical skills in Spanish but she said the experience also “reinforced for me the notion of being an ‘informed not-knower,’ reminding me that there is always something new to look for, always a different question to ask, or a different approach to conceptualizing cases.”

Froming found that he too was an “informed not-knower” in a place like Rwanda. “I have been in this business for 30–40 years and know about counseling and psychology. But I go to Rwanda and know nothing.” PAU offers an emphasis in cross-cultural training and trauma counseling, but “here in the United States we deal with individual trauma,” Froming explained. “In Rwanda you have to reach millions.” He has taken three groups of U.S. graduate students to Rwanda, where they have visited mental health agencies, families that have adopted children orphaned by genocide, the Kigali Genocide Memorial, and national survivors organizations. “Students see the resilience of people and the solutions they create.” They were introduced to a female drumming troupe of Hutu and Tutsi genocide survivors. “Why do you drum?” Froming asked the women, especially since drumming is traditionally a male activity in Rwanda. “It makes me feel good,” the women answered. While Americans might have been discussing all kinds of cognitive-based treatment for these women, Froming said the Rwandans themselves “found a solution we would never have thought of.” Now PAU associate faculty member Helena Young, an expert in crisis and trauma counseling, has received a Fulbright Fellowship to pilot a counselor training program in Rwanda.

PAU was also invited to the Philippines after Typhoon Hayan in November 2013. Professor Lynn Waelde provided disaster mental health consultation for a team of faculty and graduate students from Ateneo de Manila University, including mindfulness training for self-care by first responders. Currently, Waelde and two other PAU graduate students are evaluating the effectiveness of both this training and a newly published manual of workshops on resilience for Filipino survivors.

Personal growth is a significant element of any study abroad experience, but perhaps especially so in the fields of mental health, psychology, and counseling, whether a student is building professional skills, shadowing practitioners in a different culture, or providing crisis intervention. Charles Lindsey at UW-Oshkosh senses a growing interest in study abroad programs in the mental health field in part because “multicultural and social justice issues are hot topics right now,” he says. “In two-and-a-half weeks of being abroad, the things the students learn and come into contact with would be very difficult to replicate on our campus,” explains Lindsey, adding that he wants his students to “experience a vastly different way of life and world view…To be completely honest, that is the hallmark of a great mental health practitioner—a person who is willing to take risks, look at things with a broad perspective, a person willing to be uncomfortable at times as a professional. How are we going to ask our clients to do that if we don’t do it ourselves?”

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Karen Leggett is a freelance writer in Washington, D.C. Her last article for IE was “Influx From the Middle East,” which appeared in the November/December 2013 issue.