The maternal mental health of Black women

By Lisa R. Rhodes

March 2023

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.

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 in Counseling Today do not necessarily represent the opinions of the editors or policies of the American Counseling Association.