Sep 9, 2014 | Article, Volume 1 - Issue 1
Allison L. Smith, Craig S. Cashwell
Social distance towards adults with mental illness was explored among mental health and non-mental health trainees and professionals. Results suggested mental health trainees and professionals desired less social distance than non-mental health trainees and professionals, and that women desired less social distance than men, with male non-professionals demonstrating the greatest desire for social distance to individuals diagnosed with mental illness. Social distance also is related to attitudes towards adults with mental illness. Implications of such findings are presented.
Keywords: social distance, adult mental illness, mental health professionals, stigma, discriminatory behavior
Stigma has been defined as a product of disgrace that sets a person apart from others (Byrne, 2000). Stigma towards adults with mental illness, defined here as a serious medical condition such as schizophrenia, bipolar disorder, or major depression that disrupts a person’s thinking, feeling, mood, ability to relate to others, and daily functioning (National Alliance on Mental Illness [NAMI], 2009), is both a longstanding and widespread phenomenon (Byrne, 2000; Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). Researchers seem clear that stigma still exists as a detrimental occurrence in the lives of those diagnosed with a mental illness (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Link, Yang, Phelan, & Collins, 2004; Perlick et al., 2001). In fact, some have argued that the impact of mental illness stigma is so immense that the stigma can be as damaging as the symptoms (Feldman & Crandall, 2007). In the last decade, there have been attempts to highlight to the general population the topic of stigma towards adults with mental illness. For instance, Surgeon General David Satcher spoke in a recent report of the need to recognize stigma as a barrier within the field of mental health. He suggested that mental health care could not be improved without the eradication of mental health stigma (U.S. Department of Health and Human Services, 1999).
In the mental illness stigma literature, authors have used the construct of social distance (the proximity one desires between oneself and another person in a social situation) to assess expected discriminatory behavior towards adults with mental illness (Baumann, 2007; Link & Phelan, 2001; Marie & Miles, 2008). Scholars have described low social distance as characterized by a feeling of commonality, or belonging to a group, based on the idea of shared experiences. In contrast, high social distance implies that the person is separate, a stranger, or an outsider (Baumann, 2007). It has been suggested that social distance research can provide valuable insight into factors that influence mental illness stigma (Marie & Miles, 2008).
Social Distance and Non-Mental Health Professionals
Factors that are associated with social distance in the general population towards adults with mental illness have been discussed in the literature (Corrigan, Backs, Edwards, Green, Diwan, & Penn, 2001; Feldmann & Crandall, 2007; Hinkelman & Haag, 2003; Marie & Miles, 2008; Penn, Kohlmaier, & Corrigan, 2000; Phelan & Basow, 2007; Shumaker, Corrigan, & Dejong, 2003). One such factor that has been studied as it relates to social distance is gender, both of the target (person with the mental illness) (Phelan & Basow, 2007) and perceiver (person who desires social distance) (Hinkelman & Haag, 2003; Marie & Miles, 2008; Phelan & Basow, 2007).
Researchers (Marie & Miles, 2008; Phelan & Basow, 2007) have found that women tend to be more willing than men to engage in a relationship with someone diagnosed with depression. Marie and Miles (2008) investigated familiarity of the perceiver with various mental illnesses. A significant main effect was found for gender, with women perceivers rating the characters in vignettes as more dangerous than men participants (Marie & Miles, 2008). Phelan and Basow (2007) found that gender of the target character was a significant predictor of social distance, with female targets being more socially tolerated than male targets. This may be due to the fact that participants perceive male characters in vignettes as more dangerous than female characters. Hinkelman and Haag (2003) also have assessed how gender and adherence to strict gender roles impact attitudes toward mental illness. Interestingly, adherence to strict gender roles rather than gender was related to attitudes about mental illness. Those with strict gender roles were less likely to have positive attitudes. Thus, gender alone did not account for differences in attitudes; instead it was gender roles that related to attitudes towards mental illness.
Social Distance and Mental Health Professionals
Researchers have suggested that stigma also exists among mental health professionals (Lauber, Anthony, Ajdacic-Gross, & Rossler, 2004; Nordt, Rossler, & Lauber, 2006). Lauber et al. (2004) found no significant differences between psychiatrists and the general population on their preferred social distance from people with a mental illness. Both psychiatrists and the general population indicated that the closer the psychological proximity (e.g., allowing the person with mental illness to marry into their family compared to working with someone with a mental illness), the more social distance they desired. Similar results were found when comparing mental health professionals (i.e., psychiatrists, psychologists, nurses, social workers, and vocational workers) and the general population regarding social distance attitudes (Nordt et al., 2006). Both professionals and the general public reported many stereotypes about mental illness, and wanted an equal amount of social distance towards a mentally ill character in a vignette. Professionals, however, endorsed to a much lesser degree that adults with mental illness should have restrictions to rights such as voting or marriage. The public significantly accepted the restriction of the right to vote more than each professional group.
Professional Counselors and Social Distance
Although professional counselors might work in the same settings as other mental health professionals, the training background of this subgroup includes some noteworthy differences. Relative to other mental health disciplines, counselor training programs are largely, but not exclusively, grounded in developmental perspectives and strength-based orientations (Ivey & Ivey, 1998; Ivey, Ivey, Myers, & Sweeney, 2005; Ivey & Van Hesteren, 1990) as well as humanistic values and assumptions (Hansen 1999, 2000b, 2003), with a primary focus on the counseling relationship. Given these substantial differences as well as authors’ (Lauber et al. 2004; Nordt et al., 2006) suggestions that it is idealistic to assume that stigma does not exist among mental health professionals, it is important to consider counselors in comparison to other mental health professions and the general public. Further, particular types of counseling programs (clinical mental health counseling or school counseling) might differ when compared to each other on stigma towards adults with mental illness, given the variations of curriculum and clinical training associated with each.
Previous researchers have examined psychiatrists, psychologists, and social workers, but not professional counselors. Professional counselors should be included in this type of empirical examination, as professional counselors have reported that they are seeing more clients in severe distress (Ivey et al., 2005). Additionally, although attitudes towards mental illness and social distance have been examined in the literature, the relationship between these constructs has not been examined using the current study’s instruments. Further, researchers have not examined simultaneously the attitudes and desired social distance of students. Thus, the purpose of this study was to gain a more comprehensive understanding of social distance by including counselors and counseling students in addition to other mental health professionals and students, non-mental health professionals, and students outside of a mental health discipline.
The following research questions (RQ) were developed to organize this study:
(RQ1) What differences exist in social distance toward adults with mental illness between mental health professionals in-training, non-mental health professionals in-training, mental health professionals, and non- mental health professionals?
(RQ2) What differences exist in social distance toward adults with mental illness between mental health trainees and professionals based on professional orientation (i.e., counseling, social work, or psychology)?
(RQ3) What differences exist in social distance towards adults with mental illness between mental health trainees and professionals based on gender?
(RQ4) What is the relationship between social distance and other attitudes toward adults with mental illness?
Method
Participants: The total sample included 188 participants. Of these, 62.8% (n = 118) were female and 37.2% (n = 70) were male. The majority of respondents described themselves as Caucasian (89.4%, n = 168) with other participants identifying as African American (4.2%, n = 8), Asian Pacific Islander (2.1%, n = 4), Hispanic (2.1%, n = 4), Multiracial (1.1%, n = 2), and other (1.1%, n = 2). Age of participants ranged from 21 years to 65 years (M = 39.63, SD = 13.23). Response rate of the participants could not be determined, since participants responded to the survey online via a link provided in an email.
The total sample was divided into four subgroups. The first group, the non-mental health student group, included a sample of students (n = 20) who were enrolled in graduate programs in business administration at a mid-sized university in the southeast United States. Business students ranged from 21 to 53 years of age (M = 36.05, SD = 9.19).
A second subgroup included counseling students (n = 17), social work students (n = 20), and psychology students (n = 21). These students were enrolled in master’s level graduate training programs and were in at least their second year of graduate study. Counseling students ranged in age from 21 to 48 (M = 27.94, SD = 5.97). Social work students ranged in age from 22 to 31 (M = 30.45, SD = 8.56). Psychology students ranged in age from 21 to 32 (M = 24.29, SD = 2.72). Three programs of each discipline (counseling, social work, and psychology) at midsized universities in the Southeast United States were used to recruit volunteers. These students comprised the mental health student group.
The third subgroup included 76 mental health professionals who self-identified as counselors (n = 24), social workers (n = 20), or psychologists (n = 32) who were working in the mental health field and had been employed as such for a minimum of one year. Professional counselors ranged in age from 27 to 61 (M = 45.42, SD = 10.79), professional social workers ranged in age from 28 to 64 (M = 53.30, SD = 9.45), and professional psychologists ranged in age from 28 to 65 (M = 47.16, SD = 12.25). Mental health professionals ranged in years of mental health experience from one to 20 years (M = 14.32, SD = 6.25).
The fourth subgroup of interest included 34 non-mental health professionals. These were professionals who were working in a non-mental health field (business) in the southeast United States. Only professional level participants were included in this group to provide some control for education level as a potential confounding influence. Non-mental health professionals ranged in age from 25 to 64 (M = 43.76, SD = 10.62).
Instrumentation
Social Distance Scale. Social distance was measured by a modified version of a Social Distance Scale developed from the World Psychiatric Association Programme to Reduce Stigma and Discrimination Because of Schizophrenia (2001). Gureje, Lasebikan, Ephraim-Oluwanuga, Olley, and Kola (2005) modified this scale to assess social distance regarding attitudes toward mental illness, as the original scale was designed to measure social distance specifically towards adults with schizophrenia. Gureje et al.’s modified version was used in the current study. Six statements assess various levels of intimacy. For example, the first question asks, “Would you feel afraid to have a conversation with someone who has a mental illness?” Answers are given on a 4-point likert-type scale ranging from definitely (1) to definitely not (4). Item scores are added together to get a total social distance score, with high scores indicating less social distance and lower scores indicating more social distance. The Social Distance Scale had sufficient evidence of internal consistency (α= .81) with the current sample.
Community Attitudes Toward the Mentally Ill. The Community Attitudes Toward the Mentally Ill (CAMI; Taylor & Dear, 1981) was used to assess attitudes towards adults with mental illness. The CAMI was developed from the Opinions of Mental Illness Scale (OMI; Cohen & Struening, 1962) and is a 40-item self-report survey that uses a 5-point likert-type scale (5 = “Strongly agree” to 1 = “Strongly disagree”). Four scales are included on the CAMI: Authoritarianism, Benevolence, Social Restrictiveness, and Community Mental Health Ideology. Authoritarianism is defined by the belief that obedience to authority is necessary and people with mental illness are inferior and demand coercive handling by others. Benevolence is defined as being kind and sympathetic, supported by humanism rather than science. Social Restrictiveness involves beliefs about limiting activities and behaviors such as marriage, having children, and voting among people with a mental illness. Community Mental Health Ideology is defined as a “not in my backyard” attitude toward adults with mental illness, or the belief that adults with mental illness should get treatment, but not in close proximity to me (Taylor & Dear, 1981).
Evidence for internal consistency of the CAMI was clear for three of the four scales with the current sample: Community Mental Health Ideology (α= .86), Social Restrictiveness (α= .80), and Benevolence (α= .81). Only the Authoritarianism subscale (α= .62) was problematic in this research.
Marlowe-Crowne Social Desirability Scale. The Marlowe-Crowne Social Desirability Scale (MCSDS; Crowne & Marlowe, 1960) was included in order to assess the extent to which participants were answering in a socially desirable manner to further validate the attitudes captured by the CAMI and the Social Distance Scale. The MCSDS is the most commonly used social desirability assessment (Leite & Beretvas, 2005) and has demonstrated strong reliability. The original authors obtained a Kuder-Richardson reliability coefficient estimate of .88 (Crowne & Marlowe, 1960). A Cronbach’s alpha of .85 with the current sample provides evidence of reliability with this sample.
Procedure
Potential participants were invited to respond to the survey via electronic email. Email addresses of potential mental health professional participants were obtained from comprehensive statewide lists of the various subgroups of interest. To collect the sample of students, graduate students were contacted via various departmental listservs. Non-mental health professionals were reached through an alumni listserv obtained from a non-mental health training program. Participants were told that the following survey was designed to investigate attitudes towards adults with mental illness. Included in the email was a link to the survey, which was housed at a commercial online site for electronic survey research.
Results
As a preliminary analysis, scores on the Social Distance Scale and the CAMI were correlated with scores on the MCSDS to investigate whether participants were answering in a socially desirable manner. It has been suggested by authors (Leite & Beretvas, 2005) that a low correlation between the Marlowe-Crowne Desirability scale and the scale of interest indicates honest responses. No scores of interest correlated significantly at a .05 level with scores on the MCSDS. This provides evidence that social desirability did not have a substantive role in participant responses and that participants answered questions on the Social Distance Scale and the CAMI with a reasonable level of honesty.
To answer RQ1 and RQ3, a 2 X 2 X 2 ANOVA (professional level [trainee vs. professional] X status [mental health vs. non-mental health] X gender [female vs. male] X Social Distance) was used to investigate the desired social distance toward people with a mental illness. This analysis assessed for main effects based on professional level (trainee vs. professional), main effects based on status (mental health vs. non-mental health), main effects based on gender (female vs. male), and possible interaction effects between professional level, status, and gender. There was a significant main effect found for status F (1, 184) = 16.44, p < .05, η² = .08. Mental health trainees and professionals had higher mean scores on the Social Distance Scale (M = 3.4, SD = .38) than non-mental health trainees and professionals (M = 3.0, SD = .54). Results indicated a main effect for gender F (1, 184) = 6.63, p < .05, η²=.04. Women desired less social distance than men (M = 3.38, SD = .39 vs. M = 3.13, SD = .54) and an interaction effect for gender X mental health status F (1, 184) = 12.17, p < .05, η²=.07. Marginal means revealed that the non-mental health male sub-group was most important in separating the groups. There were no other significant main or interactive effects.
A 2 X 3 ANOVA (professional level [trainee or professional] X professional orientation [counseling, social work, psychology] X Social Distance) was used to investigate the differences in desired social distance. Results indicated that there was a main effect for professional orientation F (2, 184) = 17.67, p < .05, η² =.16. Univariate follow-up analyses indicated that participants with the professional orientation of counselor and psychologist desired significantly less social distance (M = 3.40, SD = .34; M = 3.40, SD = .4, respectively), than those who identified as social worker and non-mental health professional (M = 2.89, SD = .62; M = 3.06, SD = .49).
Finally, although attitudes towards mental illness and social distance have been discussed in the literature (Gureje et al., 2005; Taylor & Dear, 1981), the relationship between attitudes towards mental illness and social distance towards mental illness had not been explored using the CAMI and the Social Distance Scale. Therefore, bivariate correlations were calculated. Because multiple bivariate correlations were being conducted, a more stringent alpha level of .01 was used. There was a significant negative relationship between social distance and Authoritarianism (r (186) = -.52, p < .01) and social distance and Social Restrictiveness (r (186) = -.64, p < .01). There was a significant positive relationship between social distance and Benevolence (r (186) = .51, p < .01) and social distance and Community Mental Health Ideology (r (186) = .60, p < .01).
Discussion
Previous researchers have examined social distance attitudes of mental health professionals and trainees with samples of psychiatrists, psychologists, and social workers, but not professional counselors. In addition, researchers had not examined simultaneously the attitudes and desired social distance of students. Both the mental health professional group and the mental health trainee group included professional counselors, a group previously excluded from this research.
Authors had suggested that those associated with the mental health field hold the same social distance attitudes towards adults with mental illness as the general population (Lauber et al., 2004; Nordt et al., 2006). Results of the present study suggested that non-mental health trainees and professionals desired more social distance than those associated with the mental health field. This implies that members of the general population hold more negative attitudes toward those with mental illness than mental health professionals and trainees. These results are encouraging and imply that training programs and experience might have a positive effect on reducing social distance towards adults with mental illness. Regarding gender and social distance, a consistent finding in previous research (Marie & Miles, 2008; Phelan & Basow, 2007) suggested that women desired less social distance than men from those diagnosed with mental illness. Results from this study are consistent with those findings.
Since mental illness stigma can be as damaging as the symptoms (Feldman & Crandall, 2007), professional counselors can advocate for adults with mental illness in order to lessen stigma. These messages can be shared with the general population through national groups such as the National Alliance for the Mentally IlI and the National Mental Health Association, as well as through international programs such as the World Health Organization and NBCC International’s Mental Health Facilitator Program. Further, professional counselors might broach the topic of social distance with their clients, as sharing thoughts and feelings related to discrimination as a result of stigma might be therapeutic for those who are dealing with the phenomenon.
Professional orientation was of particular interest in this study. As counselors come from distinct training programs that largely, but not exclusively emphasize developmental perspectives and strength-based orientations (Ivey & Ivey, 1998; Ivey et al., 2005; Ivey & Van Hesteren, 1990), how this subgroup compared to other disciplines was of interest. If there were noteworthy differences in the ways in which professional counselors viewed adults with mental illness, for example, results could serve as an indication that counselor training is indeed unique in the way that professional counselors view clients, as the aforementioned literature has suggested.
Findings suggested that professional counselors and psychologists desired less social distance than both social workers and non-mental health professionals. Despite distinguishing aspects of counselor training (i.e., developmental, strength-based orientation), however, there were no significant differences in attitudes of professional counselors and counselor trainees when compared to those in the psychology field. The lack of difference between counselors and psychologists may be attributed to similarities in training. Alternatively, though, it may be that the types of people drawn to counseling and psychology programs are more similar than different, and that the similarities might not be based on training.
Social work trainees and professionals and non-mental health professionals desired significantly more social distance. This might imply that there are some fundamental differences in the training and coursework of social workers as compared to other professional orientations. For example, it is possible that the focus on macrosystems, more uniquely the purview of social work, leads to an external orientation to change relative to an individual or microsystem approach more common to counseling and psychology. Thus, this focus on larger systems might be a differentiating factor related to proximity to persons with mental illness. Conversely, training and coursework might not be differentiating factors related to social distance. Perhaps students already possess social distance preferences when they enter into mental health training programs.
Of particular interest was how the gender of mental health professionals impacted desired social distance towards adults with mental illness. There was a significant main effect found for status as well as for gender. This finding is consistent with previous literature (Marie & Miles, 2008; Phelan & Basow, 2007) that suggested that women desired less social distance than men from those diagnosed with mental illness. In addition, there was an interaction between the two variables. The social distance scores of women were highly similar between mental health professionals and non-mental health professionals. For men, however, there was a substantive gap based on status. Men who were not mental health professionals desired the highest level of social distance. Although there is a within-group difference, this suggests that targeted advocacy efforts might be tailored to men in the general population who seem to desire a greater social distance from people diagnosed with mental illness.
This study looked at social distance attitudes of participants as one group in order to explore the relationship social distance had with other attitudes towards mental illness. It seems that social distance and other attitudes towards mental illness are related. All correlations were in the hypothesized direction. There was a significant negative relationship between social distance and both Authoritarianism and Social Restrictiveness. There was a significant positive relationship between social distance and both Benevolence and Community Mental Health Ideology. This is because higher social distance scores indicate less social distance while higher mean scores on the CAMI indicate more of each attitude. Scores on the more negative attitude subscale of the CAMI, such as Authoritarianism and Social Restrictiveness were related to more social distance, while more positive attitudes on the CAMI such as Benevolence and Community Mental Health Ideology were related to less social distance.
This implies that social distance, or proximity to adults with mental illness, can be related to attitudes. People who hold more negative attitudes towards mental illness, such as Authoritarianism (belief that people with mental illness are inferior) and Social Restrictiveness (limiting the rights for people with mental illness) might manifest this in behavior such as the desire for more social distance. More positive attitudes towards mental illness such as Benevolence (a kindly or sympathetic attitude towards mental illness) and Mental Health Ideology (the belief that mental illness deserves treatment but “not in my back yard”) are related to the desire for less social distance. Those who hold a more positive attitude towards adults with mental illness will tend to be more comfortable with situations such as working at the same place of employment or maintaining a friendship with someone with a mental illness. Since the two constructs are related, perhaps advocacy efforts need to be geared towards both attitudes and social distance in order to combat mental illness stigma. For example, only focusing on attitudes might miss the proximity associated with stigma toward an adult with mental illness. These efforts might especially be geared towards those in the general population, since this study suggested that non-mental health professionals and students desired the most social distance.
Mental health professionals of any type can begin to consider social distance as it relates to attitudes towards adults with mental illness, since the construct of social distance can be used to assess expected discriminatory behavior towards adults with mental illness (Baumann, 2007; Link & Phelan, 2001; Marie & Miles, 2008). As well, professional counselors might begin to explore their own comfort level with proximity and closeness to adults with mental illness, since it relates to attitudes. Counselor educators might consider including people with mental illness as a marginalized group in multicultural training and challenging students to examine their knowledge and self-awareness related to mental illness. Although results of this study suggested that mental health professionals desired less social distance than those in the general population, other recent research has suggested that it would be too simplistic to assume that mental health professionals do not indeed hold stigmatizing attitudes (Nordt et al., 2006).
Limitations and Future Directions
As with all research, the current study has limitations that both contextualize the findings and provide direction for future research efforts. First, replication with larger and more diverse samples is warranted. It is unknown the extent to which respondents in this study differ from non-respondents. In particular, it is possible that there is a systematic bias (either positive or negative) among those who chose to respond to the study request. Future researchers should include a more racially diverse sample, as these findings are based on the responses of participants who largely identified as Caucasian.
Additionally, replication and extension efforts are warranted that use alternative methods of measuring social distance, which is important for at least two reasons. First, the current study relied solely on self-report and, although responses were not overly influenced by social desirability, it is unknown to what extent a mono-method bias exists. Future researchers could use other methods of assessing social distance to account for this potential bias. Furthermore, the present study is limited because of the cross-section scope of the data. Scholars interested in social distance might longitudinally examine mental health trainees before and after training to better understand the developmental nature of social distance and stigma towards adults with mental illness. Specifically, it would be useful to know what types of experiences impact one’s desired social distance and stigma. Such a longitudinal study also would provide information about whether mental health trainees enter their training program already desiring less social distance than the general population. While previous researchers explored attitudes towards mental illness before and after a single course during mental health training, thus assuming attitude changes were a result of the course, future research might survey students at the beginning of the training program, before starting any coursework, and at the end of training in order to investigate social distance over time. If desired proximity remains the same, this might imply that mental health students naturally possess less stigmatizing attitudes and are drawn to helping professions rather than assuming that low levels of desired social distance are an artifact of training. Further, future research could examine different types of counseling students, so that any differences related to particular types of counseling programs (i.e., clinical mental health counseling or school counseling) would be revealed. Given the variations of curriculum and clinical training associated with each, differences in attitudes might suggest attitude changes as a result of curriculum and training.
The topic of gender and social distance may be an area for continued study. Qualitative designs might assist researchers in gaining a deeper understanding of desired social distance of men and women, and whether gender is most important in understanding desired social distance with adults with mental illness. Depending on themes that might arise related to social distance, counselors can aim advocacy efforts and anti-stigma campaigns to assist with this.
Conclusion
Many people have attempted to highlight to the public that stigma towards adults with mental illness is as damaging to those diagnosed as the illness itself. Missing, however, is a comprehensive understanding of the stigma process. In this study, the focus was on social distance as it relates to stigma towards adults with mental illness. Factors such as mental health training, professional orientation, and gender seem to result in differences related to social distance. Individuals not associated with the mental health field continue to have mental illness stigma, as previous research suggested. Results of the current research can assist in a deeper understanding of the factors involved in the phenomenon. With a deeper understanding of social distance and stigma, practitioners can create advocacy efforts and targeted interventions with the overall goal of eradicating mental illness stigma.
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Allison L. Smith is an Assistant Professor of Clinical Mental Health Counseling at Antioch University New England. Craig S. Cashwell, NCC, is a Professor of Counseling and Educational Development at the University of North Carolina at Greensboro. Correspondence can be addressed to Allison L. Smith, Antioch University New England, 40 Avon Street, Keene, New Hampshire 03431, asmith3@antioch.edu.
Sep 8, 2014 | Article, Volume 2 - Issue 1
Keith A. Cates, Christopher Gunderson, Michael A. Keim
Counselors working in frontier communities may encounter unique challenges and experiences not regularly found in larger contexts. This paper explores the aspects of counseling significant to rural and frontier settings. It discusses the traditional attitudes of rural and frontier populations, the counselor’s place in these communities, boundaries of competence, and ethical concerns that are significant to these areas of counseling, such as confidentiality. It also offers potential ways to address related ethical issues. The cultural milieu in small communities, subcultural self-identification, frontier attitudes and beliefs, and multiple relationships are explored.
Keywords: rural, ethics, frontier, multiple relationships, confidentiality, boundaries of competence
Working in small and rural communities presents counselors with challenges and experiences not necessarily or often encountered in larger population centers. The geographic constraints of the area itself, the culture and behavior of the client population, as well as the attitudes and skills of the counselor, can combine to create significant difficulties in providing ethically competent mental health care. Even the term rural is difficult to define when attempting to describe the 16% (Nusca, 2011) of the total U.S. population and the 20% (Trading Economics, 2011) of the Canadian population that live in “rural” settings. Rural in this usage is generally defined in regards to low population density, population size and distance from larger population centers. Although governmental agencies vary in their exact definition and identification of rural locations and populations in the United States, urban is generally defined as an area having more than 100 people per square mile, rural areas generally comprise open country and settlements with fewer than 2,500 residents and are defined as having between 99 and 6 people per square mile, and frontier is an area having less than 6 people per square mile (Bushy & Carty, 1994; Helbok, 2003). Much of Alaska, the central United States, and central Canada are primarily designated as frontier areas.
“Rural” and “frontier” become increasingly difficult to define when viewed through the perceptions of those living in these areas. Individual life experiences and interpretations blend with considerations of distance between families and communities, self-sufficiency, access to resources, and support to and from the community to create a style of living centered on individual capacity and self-reliance, as well as increased community interdependence (Brownlee, 1996; Erickson, 2001). Small and rural community living, however, does tend to have some similarities across geographic areas including scarce resources, higher poverty rates, lack of access to employment opportunities, lack of higher formal education, higher illiteracy rates, limited health services, limited insurance coverage, higher rates of disability, greater environmental hazards, increased overall age-adjusted mortality, and fewer mental health resources (Helbok, 2003; Murray & Keller, 1991; Roberts, Battaglia, & Epstein, 1999; Wagenfeld, 1988; Wilcoxon, 1989). In addition to the concerns associated with rural living, frontier areas have to contend with even fewer mental health care resources due to populations spread over a large geographic area, reduced numbers of mental health care providers, limited access to crisis services, mental health services and general medical care, inaccessibility to remote geographic areas, and the increased hardship of living in isolated locations (Bushy & Carty, 1994; Roberts et al., 1999).
Alaska is illustrative of the difficulties of providing for mental health care needs and access to experienced practitioners in rural and frontier communities. Alaska is the largest state (656,424 square miles) with the lowest population density in the United States with 1.2 persons per square mile. Much of that population is concentrated in two metropolitan statistical areas that account for approximately 66% of the state’s total estimated population (U.S. Census Bureau, 2012). In 2007, it had the highest suicide rate in the nation, with 21.8 suicides per 100,000 residents as compared to 11.5 suicides per 100,000 for the rest of the U.S. For Alaska Natives, the suicide rate jumps to 35.1 per 100,000 people (State of Alaska Bureau of Vital Statistics, n.d.).
In 2006, a report on the prevalence of mental health concerns estimated that 4.6 percent (21,754) of Alaskan adults in households had a serious mental illness and that 7.2% (12,725) of Alaskan youth had a serious emotional disturbance. The estimates for adults only include those with a diagnosable disorder that had persisted for over one year and was associated with a significant impairment (State of Alaska, Health & Social Services, n.d.). In 2007, approximately 11.3% of the population (about 53,000) of Alaskan adults (age 18 years or older) experienced serious psychological distress and 7.6% (about 36,000) had at least one major depressive episode (SAMHSA, 2009).
Community hospitals are important healthcare contact locations in rural and frontier areas. In 2011, Alaska community hospitals had only one community hospital bed for every 433 people. Outside the primary population areas of the state, this number increased to one bed for every 792 people. Only two psychiatric hospitals exist in Alaska and both of these are located in the municipality of Anchorage; outside of this area the state has no public psychiatric treatment options (U.S. Census Bureau, Health & Nutrition, 2012: U.S. Hospital Finder, 2011).
Small Communities
Small communities can be seen as each possessing their own cultural milieu with a shared context, set of perceptions and understandings and a view of “how we do things around here” (Alegria, Atkins, Farmer, Slaton, & Stelk, 2010, p. 50). When rural and frontier issues are part of a small community, the communities’ concerns magnify through the restrictions of geography and scarcity of resources and all of the previously noted ways that distinguish rural and frontier populations. Even so, rural and frontier communities have common threads with other small communities in their methods of subcultural self-identification. Each of them can be defined as much by external forces (such as geographic setting, population density, available natural and economic resources) as internal motivators (desire for small community interactions, dislike of big cities, desire for support from those with similar values and outlooks), but each also has a shared context that encourages successful adaptation in that setting, including an appreciation and support for the cultural norms and values endemic to each setting (Alegria et al., 2010). Therefore, the life context of the people who live in these communities, whether they are in a geographically isolated village in Alaska, a group of military families living in and around a military base, or an alternative lifestyle community living in a larger city, have much in common. Each of them is a part of a culture that shapes attitudes, behaviors and values as well as perceptions of what is accepted as “normal” in their community (Schank, Helbok, Haldeman, & Gallardo, 2010). This perception is frequently in contrast, or opposition, to the majority culture and is continually evolving through member interactions, reaction to the environment and perceived self-identity.
Rural and Frontier Attitudes and Behaviors
Self-reliance, which includes self-care behaviors, is a characteristic traditionally associated with rural residents. Historically, this reliance on self and kinship ties helped people to survive in remote, isolated, and difficult environments (Bushy & Carty, 1994) and created a hesitancy to seek services. Current potential mental health clients still tend to turn to familiar people, friends and family as a first level of support (Bushy & Carty, 1994; Helbok, 2003). These services are informal, heavily steeped in a shared history or culture, and frequently follow a tacit understanding of reciprocity among participants. This informal level of healthcare can be very beneficial in its promotion of healthy living and self-care behaviors, for example, in a family’s care of a mentally ill family member or a community’s support of a person with a disability or developmental issue. It also can be highly detrimental as it can hide that person’s issue within the family or community and enable a person to take on or maintain a sick role or prevent a person from seeking or receiving mental health care that may improve their overall functioning (Bushy & Carty, 1994).
The second level of assistance includes community groups, church and religious groups, school services, community educational and outreach programs, and civic organizations. Group members (usually extended community members) often combine and/or contribute resources to provide assistance to individuals and families in need, particularly in times of emergency or crisis. This generally takes the form of volunteering time and services, and donating food, clothing, other non-monetary items, and financial contributions. It also can include taking in an individual or family who is lacking housing or needs more comprehensive support (Bushy & Carty, 1994; Murray & Keller, 1991). The third level of support covers formal services such as community mental health and hospital/clinic services, medical doctors, governmental programs and services, and for-profit commercial service providers (Bushy & Carty, 1994). Financial remuneration is expected for the services provided and may potentially be based on a sliding scale or reduced fee schedule (Bushy & Carty, 1994; Murray & Keller, 1991).
That residents of rural and frontier areas tend to initially rely on the two informal levels of social support may in part be due to their self-reliant tendencies aggravated by geographic location and/or isolation, inability to access or qualify for services, inability to pay for services and lack of service providers. This also may be due to cultural traditions regarding the accepted traditional method of handling mental health issues (or if the concern is even acknowledged as a significant issue), a shared belief that outsiders are not to be trusted, resentment of outsiders coming to “rescue” them, and/or negative perceptions of the value of formal services in addressing the issue (Bushy & Carty, 1994; Erickson, 2001).
Acceptability of services by rural and frontier residents also is influenced by the behavior and approach of mental health professionals. A provider’s attitude and training in relation to rural and frontier practice can be fundamental in relating to a specific environment and the people living there. If a service is offered with an understanding of the particular characteristics and needs of a population, and the provider has been accepted into the community, then the services may be viewed as a treatment option in the community structure. If, however, the provider has not been accepted as a trustable member of the community or exhibits attitudes and behaviors that are incongruent with local values, then locals needing assistance may not seek services, or may not accept services that are readily available and accessible (Bushy & Carty, 1994).
Rural and Frontier Mental Health Services
The U.S. Department of Health and Human Services’ Health Professional Shortage Areas, which are determined by the availability of mental health service providers in relation to population numbers for a defined area (HRSA, 2011), illustrates the lack of qualified mental health services and providers for rural and frontier populations. This lack of qualified mental health professionals translates directly to reduced services for a given area as well as professional practice concerns for those that provide services.
In the face of such scarcity, frontier mental health providers frequently assume multiple roles in order to function in a variety of situations. Counselors may take on many duties past their primary role as clinician including case manager, crisis intervention specialist, advocate for client services, and community outreach worker, just to name a few. This multiplicity of duties provides better generalized coverage for client care, but can place the counselor in the ethically dangerous position of potentially breaching client confidentiality, operating outside professional training and competence, managing multiple dual relationships and conflicting professional roles, limited or no professional support, and increased potential for professional burnout (Roberts et al., 1999; Schank, 1998; Werth, Hastings, & Riding-Malon, 2010).
Ethical Issues in Rural and Frontier Mental Health Services
Counselors frequently face serious ethical dilemmas as service delivery in rural and frontier communities presents them with ethical challenges distinctive to those environments (McDermott, 2007). These ethical dilemmas and potential violations are no less common in rural and frontier areas than in urban locations but according to studies are more difficult to resolve (Bolin, Mechler, Holcomb, & Williams, 2008) due to geographic and social isolation, scarce resources, limited population numbers, and the cultural expectations that characterize those communities (Roberts et al., 1999; Scopelliti et al., 2004).
These ethical issues are not limited to populations that are primarily defined or identified by geographic restrictions or population density. They also are particularly relevant to small communities that are identified by demographic variables such as age, race, culture, sexual orientation, disability, or spiritual orientation. Although there are some needs that are specific to certain populations, the determination of appropriate ethical practice guidelines also should include the needs and cultural values of other small community groups (Schank et al., 2010; Schank & Skovholt, 1997).
The needs and considerations of rural and frontier communities frequently cause professional codes and guidelines to be in opposition to prevailing small community standards and expectations (Schank, 1998). To address these concerns, rural and frontier clinicians may find it necessary to adopt a view of professional boundaries and ethical guidelines that places more importance on community values and professional roles in the community than on rules of behavior as defined by professional organizations.
Urban ethical orientation in mental health services. This necessity on the part of mental health providers is intensified by the fact that mental health training and much of the ethics literature and professional ethics codes appear to favor urban-based mental health practices. This could potentially lead to erroneous assumptions when it comes to distinguishing between ethical and unethical practices in small community environments (Helbok, 2003; Roberts et al., 1999; Werth et al., 2010).
Most mental health clinicians are trained at universities and colleges located in urban and suburban areas. Their practical experience takes place in urban and suburban clinical training sites that have adequate resources and readily available personnel. Later in their practice, clinicians tend to work within areas that have relatively easy access to referral resources at multiple levels of intervention (hospitals, psychiatric treatment centers, partial treatment and day treatment centers), public transportation, various community support and centers, self-help groups, and peer support including ongoing supervision and professional mentoring (Helbok, 2003; Schank et al., 2010). This exposure to training in an urban/suburban environment may not adequately prepare those clinicians that go forward to work with small community and rural populations and creates the general consensus in the literature that an urban model of mental health training and service delivery is inadequate to meet the needs of rural and frontier communities. With this in mind, mental health service providers often feel that ethics codes and other literature are so urban-biased that they are not helpful in a rural or frontier context (Helbok, 2003; Murray & Keller, 1991; Roberts et al., 1999; Schank, 1998; Werth et al., 2010).
Current ethical codes do not adequately address ethical concerns in rural settings. It is important to understand that while there may be significant differences between the ethical considerations of urban, rural and frontier mental health practices, this does not mean that ethical codes have no applicability in rural and frontier clinical settings; to the contrary, potential ethical concerns should be closely monitored precisely because of the inherent ethical dangers that come with working as a clinician in such areas (Helbok, 2003). The fact that such situations will occur in rural and frontier clinical settings and will influence mental health services encourages the need to develop and expand the ethical codes and ethical decision-making processes (Schank et al., 2010) to include an understanding that rural and frontier mental healthcare decision-making is “colored and shaded by values, beliefs, emotions, competencies, and resources” (Cook & Hoas, 2008, p. 52). It is only by understanding and working with this coloring and shading that mental health providers can develop awareness and skills needed to work effectively in rural and frontier communities. To do this, rural and frontier clinicians must do more than simply adhere to standards or rote application of rules—they must understand why those rules exist, at what point those rules may be a detriment to the development of clinical relationships, and what may constitute a severe enough ethical issue in regards to both ethical codes and community values to warrant concern. Rural and frontier clinicians need to understand that “ethics should not be static but rather constantly examined and evolving in order to be the most beneficial to clients and counselors” (Schank, 1998, p. 272).
Confidentiality
The limitations in both human and material resources in frontier areas can cause many seemingly obvious and standard professional practices to take on significant ethical aspects and primary among these is confidentiality. With fewer mental health professionals in a given area, fewer support mechanisms and services, and geographically large and sparsely populated areas, confidentiality can be more difficult to ensure in rural and frontier practice; while on the other hand a strict adherence to confidentiality can negatively impact important collaborative relationships in smaller communities (Scopelliti et al., 2004).
The close confines and small populations of many frontier areas and towns lend themselves to personal business being known by many people in the community and each person potentially being aware of many others’ behaviors (Helbok, 2003; Roberts et al., 1999). It is in this regard that confidentiality is difficult to control as the size of the community lends itself to many people knowing who is seeking and/or getting treatment at any time. The members of the community tend to collectively know those who are having difficulties with mental health, personal or addiction concerns. The stigma of receiving mental health services, particularly when the potential client knows that the community is aware of their actions, can cause many to avoid needed professional assistance. This is only compounded when the office or support staffs of a mental health service are longtime members of the community and are familiar with the client, or may even be related to the client. Potential clients may be reluctant to engage in services where they may personally know others, such as group counseling or outpatient addictions settings (Helbok, 2003; Solomon, Hiesbergr, & Winer, 1981). Office and support staffs, themselves not having to meet the ethical requirements of professional licensure, may be more apt to share confidential client information between themselves, friends and family members. This sharing of information between community members is a concern on a professional level as the lack of professional referral sources may mean involving people, groups and organizations that may not share a counselor’s view of confidentiality. These referral sources may include community, church, and volunteer organizations, and these organizations and their associated paraprofessionals may create confidentiality concerns for clients through the informal sharing of information which is common in small communities.
This sharing of confidential information across professional lines also is significant in the relations of the counselor to the broader array of professional services and agencies that may interact with their clientele. Law enforcement, medical, educational and social service professionals may expect the rural and frontier counselor to freely share information the counselor considers confidential to the client. Without an appropriate informed consent or release of information the counselor is obligated to not share any personal or treatment information, or to even tell if the client is receiving services. This ethical stance can be damaging to a counselor’s professional practice as it can distance them from the local professional community, reduce future client referrals and strain relations with other health and service professionals (Helbok, 2003; Solomon et al., 1981; Stockman, 1990). Hargrove (1986) maintained that confidentiality must be preserved unless there is consent to release information, or if there is a clear and present danger. At the same time, the counselor needs to be responsive to community standards and attempt to work in the best interests of their client even when most rural clients assume that information will be shared without their consent (Elkin & Boyer, 1987; Helbok, 2003). In frontier settings, it may be difficult to balance ethical obligations with community expectations, but the counselor can be the best agent of change in these situations by taking steps to educate referral sources and local professional organizations on the importance of confidentiality in counseling services and how confidentiality can reduce the client’s fear of being stigmatized. Counselors also should take steps beyond the development of a comprehensive informed consent to discuss with clients the professional requirements of confidentiality and promote clarity regarding what information will be shared and in what circumstances (Helbok, 2003).
Boundaries of Competence
A counselor’s boundaries of competence are defined as the “education, training, supervised experience, state and national professional credentials, and appropriate professional experience” (ACA Code of Ethics, C.2.a, 2005) that qualifies a counselor to work with a particular client, population, or mental health area. In rural or frontier areas the determination of professional boundaries of competence can be difficult to achieve (Helbok, 2003). As rural and frontier clinicians are called upon to serve a diverse range of client issues, they tend to work as generalists rather than specialists in order to provide the highest quality of service to the most clients within a given area (Werth et al., 2010). Within a small community they may be asked to address many issues including adjustment concerns, addictions, mental illness, trauma, crisis, marital issues, career development, developmental and learning issues, life-changing circumstances and/or end-of-life concerns. These concerns can surface in any of the situations that a frontier counselor may find themselves in including community outreach, educational training, professional consultation and individual or group counseling settings (Werth et al., 2010).
When such a situation arises it is the duty of the counselor to determine if the concerns of the potential client fall within or without their professional competence while also considering the availability of appropriate referrals and professional services that may be better suited to address this issue, the geographic availability of such referrals, if such exists, and the ability, resources and inclination of the client to access such services. The counselor may choose to deny a client services on the grounds of non-maleficence; namely, that by working outside their areas of experience they risk more potential harm to the client than they would by violating their boundaries of competence. On the other hand, the counselor may choose to uphold the principle of beneficence in regards to client care with the opinion that a potentially inappropriate treatment would be less harmful than no treatment, or when there are no reasonably available referral options (Remley & Herlihy, 2009). Both of these options can be untenable when judging the value of a person’s mental stability and ability to function against an ethical code that does not take into account the realities of small community life. In that regard, each of these options serves to highlight the position that determinations of boundaries of competence in frontier areas need to include an awareness of the needs of the community.
In areas where members of close-knit communities traditionally depend on each other in the face of adverse living conditions, and the problematic behavior of even a single person can disrupt a family and through that a community, it is imperative to be aware of the interdependence and needs of small communities. With this in mind, when a frontier counselor is faced with a client concern that they do not feel wholly qualified to treat, they may choose to work with the client knowing that referral services are too far removed or inaccessible and that professional action may be construed as a violation of competence on the part of the counselor, but also that working with the client may serve to maintain the client’s best functioning in the community, thus supporting the continued well-being of the community itself (Werth et al., 2010). In contrast, a counselor could deny services to a client based on the counselor’s perception of their own professional abilities in regards to a particular client concern. The counselor could then seek to augment the boundaries of competence through supervision, mentoring and continuing education, expanding understanding until more comfort working with a particular concern or population was achieved. This assumes, of course, that adequate supervision and continuing education opportunities are available and that the counselor is able to access these services. In this manner, the frontier counselor is in the same predicament as their clients with geographic location and distance determining availability of resources. While technologies (Internet, audio/visual conferencing, telephone) do create greater potential access to necessary resources, the reality of frontier life is that many areas do not have Internet or phone access, or have very limited access heavily dependent on weather conditions and other factors relating to location and available technical resources. While most licensing boards allow some continuing education units (CEU’s) to be obtained through distance means (Zur, 2006) and some allow distance supervision for licensure (McAdams & Wyatt, 2010), the actuality of frontier counseling frequently makes it difficult to readily obtain licensure CEU’s, timely mentoring, and collaborative resources when needed.
Multiple Relationships and Conflicting Professional Roles
“A dual relationship would be considered to exist when, in addition to the professional role and relationship, there exists a further meaningful relationship with clear role expectations and obligations, such as employer, friend, family member, or business partner” (Brownlee, 1996, p. 498). These dual and multiple relationships are the most pervasive ethical concern facing rural and frontier counselors and are the most complicated of all the ethical dilemmas encountered in daily professional practice (Helbok, 2003; McDermott, 2007; Scopelliti et al., 2004; Werth et al., 2010; Zur, 2006).
Perceived problems with multiple relationships in counseling. The relationships themselves are, of course, not the problem. The ethical concerns begin to arise when the boundaries of a therapeutic relationship become unclear through multiple relationships to the extent that the potential of client dependency, feelings of entitlement to special favors, and financial, emotional, or sexual exploitation can more readily occur (Nickel, 2004). That is why the traditional view of managing multiple relationships has been to avoid them (Ebert, 1997; Faulkner & Faulkner, 1997; Stockman, 1990) and in general, the ethical codes of mental health professional organizations have discouraged multiple relationships in an effort to avoid exploiting the trust and dependency of clients (Erickson, 2001).
In the American Counseling Association’s (ACA, 2005) ethics code, for example, counselors are encouraged to avoid all non-professional interactions or relationships with “clients, former clients, their romantic partners, or their family members…except when the interaction is potentially beneficial to the client” (A.5.c). If there is a potential benefit for a current or former client the counselor:
must document in case records, prior to the interaction (when feasible), the rationale for such an interaction, the potential benefit, and anticipated consequences for the client or former client and other individuals significantly involved with the client or former client. (A.5.d.)
This may be a reasonable course of action when the counselor has the justifiable belief that he or she can move around in an environment without the immediate concern of interacting with a current or former client (Schank & Skovholt, 1997). But when the constraints of geography, availability of mental health services, population density, and the distinct characteristics and expectations of frontier communities and their inhabitants are taken into account it is a much more sensible assumption on the part of the frontier counselor that non-professional contact with a client, former client, their romantic partners, or their family members is not only inevitable but imminent (Faulkner & Faulkner, 1997; Schank et al., 2010). It is this inevitable imminence that lies at the heart of the disparity between current ethical guidelines and practical mental health provision to rural and frontier populations.
While there are some clearly delineated ethical violations that apply across professions and work environments, such as sexual or romantic counselor-client relationships, the complexity of social values and human relationships makes it impossible to define clear directives for engaging in nonsexual multiple relationships, particularly for those who practice in rural and frontier communities (Faulkner & Faulkner, 1997; Nickel, 2004; Pope & Vetter, 1992). With these considerations in mind, the idea that all dual relationships are unethical “would seem to be unnecessarily restrictive and unrealistic in a rural context” (Brownlee, 1996, p. 500).
Place of multiple relationships in frontier counseling. Unfortunately for the frontier counselor, the very social structure of frontier life fosters multiple interdependent relationships between people as a way of adapting to the realities of living in remote and sometimes harsh and dangerous environments. The smaller and more remote a community is, the greater the interdependence between its members in regards to life necessities such as food, water and shelter, as well as other needs including health issues, education and companionship (Roberts et al., 1999). In frontier areas, the likelihood of multiple relationships between community members is even greater due to scant resources and professional services, reduced population density, and the fact that many of the community members will have family relations between them as well. As Roberts et al. (1999) stated, “in these naturally ‘enmeshed’ communities, there are few options for relationships other than overlapping ones” (p. 499). Multiple relationships between members are seen as normal and reflect expected and traditional cultural and social norms (Campbell & Gordon, 2003). They expect to interact with each other in significant social and personal endeavors so their social norms have more flexible and permeable boundaries (Nickel, 2004) than might be encountered in less interdependent and socially interwoven populations.
Utility of multiple relationships in frontier counseling. It is into this world of highly interconnected social and familial relationships that the frontier counselor strives to be accepted and trusted. Faced on the one side with the idea of the ethical slippery slope, where relatively minor ethical infractions tend to lead to more severe violations (Faulkner & Faulkner, 1997), and on the other with a populace that expects and in many cases demands social and interpersonal interactions, the frontier counselor must find ways to be embraced by the people that make up their communities (Schank & Skovholt, 2006). The most secure route to this acceptance is through involvement with the community as this promotes familiarity which may lessen suspicion and increase approachability (Campbell & Gordon, 2003), thereby fostering community approval and trust (Horst, 1989; Schank et al., 2010).
This approval may directly establish the counselor as a trusted resource regarding mental health concerns and allow the counselor to act as an advocate for the value of formal therapeutic services. It also may indirectly influence clinical effectiveness (Erickson, 2001; Scopelliti et al., 2004) as clients may mistrust a counselor who lives and operates outside of the community structure and isn’t available on social or personal levels. As Nickel (2004) stated, “No matter how warm and caring they may be during therapy, rural mental health care providers cannot be effective if they hold themselves distant and aloof in other situations” (p. 19). On a personal level, this aloofness may not be advisable as the frontier counselor, and potentially his or her family, is living in the community and as such, personal survival may depend on interactions and relationships with community members. This inherent dual relationship works against the potential of avoiding multiple relationships as it is acceptance into the community that helps ensure communal and personal survival in many frontier and remote areas. However, the deeper a counselor is accepted into a community the greater the probability of developing non-sexual multiple relationships with clients and their families (Werth et al., 2010). This, consequently, could lead to professional ethical concerns for all of the reasons mentioned previously and potentially lead to gross ethical violations and/or impairment on the part of the counselor (Faulkner & Faulkner, 1997; Stockman, 1990). It should be noted, however, that not all multiple relationships must lead to ethical violations. While some rural clinicians establish and maintain strict professional boundaries, discouraging multiple relationships due to a belief that clinicians who work in rural environments must make personal sacrifices (Faulkner & Faulkner, 1997), others believe that multiple relationships may enhance a clinician’s standing in the community (Schank et al., 2010) to the extent that chance meetings outside of therapy and routine social interactions are protected by the counselor’s investment in the community and the community’s trust in the counselor (Faulkner & Faulkner, 1997).
This emotional investment of the counselor in the community can become a positive ethical force as “dual relationships and familiarity with patients…tend to decrease the probability of exploitation—not increase it—as the power differential in a more egalitarian relationship is reduced” (Scopelliti et al., 2004, p. 955). Due to the counselor’s involvement in the community, the local clientele may choose the services of the frontier counselor because they may be seen as someone who would understand and have awareness of the client’s concerns (Schank et al., 2010). Thus the regard the counselor has for the community’s overall welfare can act as a monitor “warning that distancing through anonymity and neutrality is not only likely to be counter-therapeutic, but also to increase the likelihood of exploitation” (Scopelliti et al., 2004, p. 955). This of course assumes that the counselor is diligently aware of their relations with clients and community members because, as Reamer (2003) states, such relations “can be ethically appropriate and, in fact, therapeutically helpful as long as the clinical dynamics are handled skillfully” (p. 128). Conversely, lack of awareness can lead rural clinicians to consider that because multiple relationships can be expected they are free to engage in any type of relationship and excuse it as a natural result (Werth et al., 2010).
Considerations for Frontier Counselors
Certainly there are no easy answers to the ethical dilemmas that working in frontier areas presents. Limited by resources, bound by geography and distance, and confronted with issues that might seem tractable in more urbane environments, the awareness of a frontier counselor needs to be focused on many professional and ethical levels at any one time.
Define Clear Boundaries
Informed consent is paramount. Considering the potential for ethical violations in a frontier setting the counselor must clearly communicate to his or her clientele the parameters within which the counseling relationship can exist. This should include how the client wishes chance or social encounters with the counselor to be handled as well as how multiple relationships, to the extent that they can be pre-determined, should be addressed when they occur. In an environment where overlapping relationships are best viewed as a certainty the need for transparency in the client/counselor relationship is fundamental for a clinical relationship that can weather the ethical realities of frontier life.
The counselor also needs to consider his or her own professional boundaries and determine a level of comfort in regards to the potential ethical issues that shape frontier clinical practice. Clarifying one’s own understanding of where boundaries of competence are can help the counselor determine when he or she is entering an area of uncertainty regarding providing services in which the counselor may not be fully conversant. In this regard the counselor also needs to come to terms with his or her own acceptable level of multiple relationships with clients. Understanding one’s self-determined boundaries, be they ethical or personal, can help alert the counselor to behaviors that could lead to ethical violations.
Confidentiality. The counselor must communicate to the client the confidentiality issues that are common in frontier environments and establish an understanding of the counselor’s ethical and legal obligations. Even when the client expects the counselor to share information about the client with other services or professionals in the area, it is the responsibility of the counselor to foster an understanding on the part of the client as to the extent and obligation of counselor/client confidentiality. As with other aspects of counseling, the frontier counselor should also be prepared to define their professional boundary of confidentiality when dealing with other professional services or agencies in the area. To the extent that they are able, it is a counselor’s duty to protect their client’s confidentiality, even in the face of a cultural value that shares information as part of communal survival.
Professional Awareness
The journey from analyzing ethical case studies in training situations to personal involvement in potential ethical violations can be very short for the new frontier counselor (Schank & Skovholt, 2006). Counselors new to the frontier perspective need to find qualified supervision to help them establish their understanding of ethical decision-making in ethically challenging environments. This may include investigating state licensure regulations on distance supervision (via phone, Internet, etc.) to expand the supervision and mentorship possibilities. The counselor, new or experienced, should also strive to find supervision and peer-consultation that has experience in rural and frontier communities to better support an informed awareness of the necessities and realities of frontier life.
“Acts of everyday living are self-disclosures” (Schank et al., 2010, p. 503) and the frontier counselor needs to be aware of their behavior on professional, social, and personal levels. As so much of frontier counseling is inter-relational, this self-attention is significant as it can help foster an awareness of the ethical aspects of many facets of frontier counseling practices and alert the counselor to potential ethical concerns in the making. When concerns are identified it is then incumbent on the counselor to determine the nature and extent of the issue and take action when necessary. The nature of that action is dependent on the role the counselor has created for themselves in the community, the needs of the client and the community and the potential actions that can be taken within cultural and ethical guidelines.
Cultural Awareness
With their own traditions and attitudes, frontier communities are very much their own small community cultures with self-determined ways of behaving and interrelating. For the frontier counselor to be accepted into the community it is necessary for the counselor to understand the values the community is built upon and work to honor and foster those values through professional practices. While many of the cultural behaviors of a frontier community may seem at odds with professional counseling ethical practices, a merging of the two is possible with vigilance and understanding. It is not for the counselor to enter a frontier community and require that they follow a professional ethic designed on a divergent cultural model by a dissimilar people; rather, it is for the counselor to appreciate that an ethical code is based on accepted cultural and behavior ideals and that it is the counselor’s obligation to serve those ideals within the boundaries of accepted professional codes of ethics. Understanding the community needs and values in terms of desired ideals and expected behaviors will help the counselor to better become a part of and serve the community as an involved and invested member.
Future Investigation Directions for Frontier Ethics
As the work of rural and frontier counselors impacts a significant percentage of the U.S. population and that population experiences a higher lack of mental health provisions than urban clients, it is in our best interest to better understand the needs and practices of rural and frontier counselors so that we can then provide better services to rural and frontier communities. Primarily, research needs to explore the practices of small community, rural, and frontier counselors, which should include case studies of how clinicians approach and handle clinical issues. This investigation into counselor practices needs to focus on the ethical decision-making processes that counselors employ when managing the ethical concerns that are prevalent in these communities. It also needs to analyze the products of these processes in light of the professional counseling code of ethics to better determine at what level, if at all, rural and frontier counselors are experiencing ethical crossings or violations in their professional practices. Next, we need to gain an understanding of the extent to which counselor educators recognize and understand small community settings and their effect on counseling in such areas. This would include the training that may exist in counselor education regarding the preparation of counselors to work with small community, rural, and frontier populations and should include counseling program curriculum, professional development courses and continuing education opportunities. Understanding what counselors are being taught in relation to these populations will help to determine if their training is adequate and appropriate to the needs of these communities.
Conclusion
This paper seeks to illustrate the point that the ambiguity that makes a code of ethics a flexible set of guidelines of professional behavior also creates difficulties when the situations they caution against are an inherent part of the social fabric of the world that the counselor works within, particularly that of a rural or frontier community. It is clear that many ethical issues cannot be avoided when working with frontier communities and must be integrated into professional practice with due consideration. Counselors in these areas need to be conscientious in examining their relationships with clients and community members. This examination should lead to clear communication with clients on potential ethical issues and help define the roles and boundaries of the client and the counselor. It also requires the counselor to remain vigilant against potential boundary violations and to take action whenever an issue arises (Helbok, 2003; Kitchner, 1988; Remley & Herlihy, 2009).
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Keith A. Cates, NCC, is an Assistant Professor in the Department of Counseling and Special Education at the University of Alaska-Anchorage. Christopher Gunderson is the Director of Training and Development at Denali Family Services, Anchorage, Alaska. Michael A. Keim is an Assistant Professor in the College of Education at the University of West Georgia, Carrollton, GA, USA. Correspondence can be addressed to Keith A. Cates, University of Alaska–Anchorage, 3211 Providence Dr., UAA-COE-CASE, PSB 206K, Anchorage, AK 99508-4614, kcates@uaa.alaska.edu.
Sep 8, 2014 | Article, Volume 1 - Issue 1
James M. Benshoff, Melinda M. Gibbons
Recently, many counselor education programs have considered whether and how to offer courses online. Although online counselor education courses are becoming increasingly common, the use of synchronous (real-time) teaching approaches appears to be limited at best. In this article, we provide a context and rationale for incorporating online synchronous learning experiences, discuss the use of simple technologies to create meaningful educational experiences, and present one model for combining synchronous and asynchronous instructional approaches online. We also share our perspectives on the contributions of synchronous learning components, reflect on student and instructor experiences, and discuss issues to be considered in developing online counselor education courses.
Keywords: online teaching, counselor education, synchronous learning, implementation, technology
Use of technology in counselor education is commonplace today. Email, PowerPoint presentations, and online grading are accepted and utilized on a daily basis. In addition, many counselor educators use online teaching platforms such as Blackboard as a way of incorporating asynchronous communication, discussion, and resources to enhance face-to-face (F2F) courses. In this hybrid model of instruction, the asynchronous component is utilized but a significant part of the course is taught in a traditional (F2F) classroom. What is less prevalent, however, is the use of computer-mediated communication (CMC) in place of F2F classroom meetings. Online synchronous discussion (OSD) is one approach to CMC that includes a range of activities which occur online in real time, including chat and instant messaging. These technologies allow participants to have conversations much as they would if they were physically in the same space. The purpose of this article is to review the literature on the effectiveness of CMC, to provide an example of how online synchronous discussion (OSD) (combined with asynchronous use of Blackboard) has been used effectively in counselor education, and to discuss the possibilities and limitations of this approach. This article is intended for those with little or no experience in online teaching as well as for those who have primarily used asynchronous teaching approaches online.
Technology in Counselor Education
Although technology is not the primary focus of this paper, some introductory definitions of terms are necessary to approach this topic. Distance education is an overarching term used to describe teaching that includes the use of various technologies in order to serve students who are not physically present in the classroom. Often, this involves using audio- or videoconferencing tools to allow people from various locations to participate in a course. In video- or teleconferencing, students may report to various satellite classrooms in order to access the technology. Students in each classroom can then view both the instructor and other students (Woodford, Rokutani, Gressard, & Berg, 2001). Computer-mediated communication (CMC), which involves the use of computers and web-based technology as teaching tools, can be divided into two types. Online asynchronous discussion (OAD) involves learning that is not restricted to classroom time and that can be accessed at any time; often, this includes discussion boards, email, and postings of course materials on an Internet-accessible site (e.g., webpage or Blackboard course pages) (Jones & Karper, 2000). Alternatively, online synchronous discussion (OSD) involves audio, text, and/or video connections through the Internet for real-time communication (Slack, Beer, Armitt, & Green, 2003). Because the advantages of distance education often include the opportunity for students to attend class completely on their own schedule, many distance education courses depend on asynchronous approaches to instruction since these do not require that all students and the instructor be in the same space (physical or virtual) at the same time.
Two studies have examined the use of technology in counselor education programs. Wantz et al. (2003) surveyed CACREP-accredited counselor education programs on their use of distance learning and found that the majority of programs reported not using distance learning and that these programs had no current plans to implement these types of courses into their curriculum. A second group (Quinn, Hohenshil, & Fortune, 2002) examined the use of technology in general by CACREP-accredited programs. Although technology frequently was utilized within a traditional classroom setting, few respondents reported offering online courses in their programs. It appears that advancement in the use of CMC has been slow within the counselor education community.
A Conceptual Framework for Online Teaching
Garrison, Anderson, and Archer (2000) created a conceptual framework that includes the required components of what they considered to be a powerful online educational experience. Their model, termed a community of inquiry, included three aspects of the educational experience: Social Presence, Cognitive Presence, and Teaching Presence. Social Presence refers to the ability to bring student and instructor personalities into the learning community. Included in this social component are expression of emotion, open communication, and development of group cohesion. Cognitive Presence is the ability to construe meaning from the educational experience, with critical thinking or inquiry being the major focus. Finally, Teaching Presence refers to the design, delivery, and facilitation of the course content. This component includes three aspects: instructional management, creating understanding, and direct instruction. Garrison et al. suggested that all three components are necessary for a successful online course.
Research on OSD
Studies of online learning communities have been conducted in various realms. Shea (2006) surveyed students participating in various online courses and found that the stronger the Teaching Presence, the stronger the overall learning community. Students rated the classroom community higher when their instructors were more active facilitators, including keeping students on task, creating an open and accepting learning climate, and acknowledging student input and contributions. Results of another study (Perry & Edwards, 2004) revealed that effective online instructors both challenged and affirmed their students, and that high levels of Cognitive Presence and positive Social Presence directly added to students’ positive reactions to online learning. Clearly, research to date supports the potential for successfully creating a community of inquiry online.
Other researchers have conducted studies examining the effectiveness of synchronous learning experiences online (OSD). Wang (2005) found that the use of open-ended and comparison questions in a real-time online classroom was effective in engaging students and fostering cognitive development. Another study (Walker, 2004) helped identify those teaching strategies that could help develop critical thinking and debate in an OSD-based course. Participants in one debate course indicated that Socratic strategies such as open-ended responses, including challenges and probes, were most likely to elicit student response, and that encouragement and countering also were helpful. Slack et al. (2003) found that online discussions where group cohesion had occurred promoted cognitive development in students better than in classes that lacked cohesion. This suggests that instructors must give attention to rapport building in their OSD classes in order to increase levels of critical thinking and involvement. Finally, Levin, He, and Robbins (2006) surveyed preservice teachers before and after their participation in a series of OSDs. Prior to the online discussions, the majority of participants believed they would prefer asynchronous discussion; afterwards, however, the majority indicated that they actually preferred synchronous discussions online. Reasons given for this change in preference included the opportunity to receive immediate feedback, the real-time pace of the discussions, the convenience of having the entire chat completed in one sitting, and the challenge of having to think critically and learn from peers. In addition, participants in OSD demonstrated higher levels of critical reflection than did OAD participants. These studies demonstrate the potential effectiveness of OSD and point to the importance of appropriate facilitation in order to promote student growth.
Although Garrison et al. (2000) stated that “all three elements [Social Presence, Cognitive Presence, and Teaching Presence] are essential to a critical community of inquiry for educational purposes” (p. 92), they also noted challenges involved in developing such an online community of inquiry. These authors proposed that “… the elements of a community of inquiry can enhance or inhibit the quality of the educational experience and learning outcomes” (p. 92). In addition, they clarified that the kind of OAD they addressed, although collaborative, was quite different from F2F environments. It is this difference from traditional F2F learning that makes the obstacles in using online courses to train counselors unacceptable and virtually insurmountable. Because counseling is a person-to-person experience, it can be particularly difficult for counselor educators to envision how counseling students could be trained and evaluated effectively through a text-based, online experience where course participants cannot see and interact with each other in real time.
The online group course described in the following section was designed to address all three of Garrison et al.’s (2000) elements of a community of inquiry by combining synchronous and asynchronous experiences that much more closely simulate an F2F educational experience. Moreover, our experience has been that use of readily-available technology has allowed us not only to more closely simulate face-to-face classroom experiences, but also to take advantage of features unique to the online experience.
The Online Course: Group Counseling in Schools
To meet the needs of practicing school counselors for additional post-master’s degree training in school counseling, the counselor education program at one southeastern university created an online-only Post-Master’s Certificate (PMC) in Advanced School Counseling. This program was designed to provide working school counselors with 12 hours of additional training that also would qualify them for a significant salary increase in the state system. Over a two-year period, four graduate-level courses were developed for this program. The first of these courses, Group Counseling in Schools, was created and used to pilot test an instructional model for the remaining courses. To do this, the first author worked closely with university instructional technology consultants to create an online learning environment that could be process-based and provide a student-focused learning environment in which student participation was critical to the quality and success of the course itself. The result was an online course that incorporated both OAD and OSD components.
The Asynchronous Component (OAD)
Blackboard is well known and widely used as an educational platform “for delivering learning content, engaging learners, and measuring their performance” (http://www.Blackboard.com/Teaching-Learning/Learn-Platform.aspx) in higher education. Blackboard is primarily an asynchronous learning platform which offers a format that provides for easy posting of course information and a wide variety of course resources. Features include a discussion board with forums that provide opportunities for students to respond to prompts, discuss issues, and share ideas in an OAD where postings can be made and responded to at any time. Blackboard currently is used widely to supplement F2F instruction. In our online group course, Blackboard’s discussion board is used to allow students to take more time to reflect on their learning and encourages them to think more critically about online experiences and course material. Because instructors typically do not participate in these discussions, both responsibility and control are shifted to students for the quality and content of their postings. We have been very interested to see how learning conversations develop as students learn to respond not just to instructor-generated prompts, but also to each other, sharing support, differing perspectives, and experiences. Instructors’ review of the weekly postings is then used to help guide course content and discussion in the OSD component of the course.
The Synchronous Component (OSD)
LinguaMOO (MOO) is an interactive, synchronous learning platform that is available in its basic form for free (see http://www.ericdigests.org/1997-4/moo.htm), with technical support provided by each individual institution. MOO was developed as a community that is designed to simulate F2F environments in many ways using technology that is affordable and easily implemented. MOO is text-based and utilizes a very basic chat environment. More capable, commercial software packages that are now becoming widely used include Elluminate (a free, virtual, collaborative web-conferencing system; http://www.Elluminate.com) and Saba Centra Classroom (which offers a complete set of features for recreating interactive classroom learning experiences online; http://www.saba.com/products/centra/details.htm). Both of these packages add greatly enhanced capabilities for using audio, video, whiteboards, and graphics as part of online class meetings, providing a wide variety of tools to use in creating a virtual environment for learning.
In the online MOO class, when students come to class, they enter the instructor’s room, which is the virtual classroom. Each person who enters the online classroom is visible to everyone else already in the room. As with F2F classes, MOO meetings often begin and end with informal chatting among students and instructors. The visual format of MOO is simple and would be familiar to anyone who has participated in online chats. The computer screen is divided into three sections: two sections on the left display the ongoing discussion and provide a place for students and instructors to compose their comments. In addition to text, MOO also provides an emote feature that can be used to add nonverbals and emotions (similar to text-based emoticons) to the discussion, giving participants a different way to express themselves or add expression to their comments. The right half of the screen is used to present PowerPoint slides that support, guide, and facilitate online discussion, as well as provide structure and content for the class meetings. In addition, MOO allows for recording the transcription (complete with links to PowerPoint slides) for each class, permitting students to review what occurred in class if they missed a class or wanted to revisit a discussion topic. This feature also frees students from having to take notes during class.
Class meets for two hours per week during the regular semester. Like F2F courses, class is scheduled for a particular day and time. Thus, students must commit to being able to attend the online class meetings at the same designated time each week; just like F2F, everyone has to attend class at the same time. Unlike F2F classes, however, students do not have to travel, search for parking, and arrive at a physical classroom on time. Both instructors and students have the flexibility to log into class from any location with an Internet connection. Although the same faculty member has taught this course from its inception, different advanced doctoral students, typically with strong background and expertise in school counseling, have been assigned to co-teach each time the course was offered.
Implementation of the Course
A required F2F meeting is scheduled on campus prior to the beginning of the group counseling course. Although the primary purpose of this meeting is to train students in use of the technology to be used in the course, additional benefits include: making social connections with students and instructors; developing a basis for social presence; and getting a feel for the instructors’ teaching style. Starting in a familiar F2F format and using a standard classroom environment to acquaint students with new technology, a new learning format, and each other seems to work well. In addition, students frequently comment on the importance of this first F2F session for having a successful experience in the course; their F2F experiences help reduce anxiety and create a basis for group cohesion and support throughout the PMC program.
Combining Synchronous and Asynchronous Modes of Learning
In this online course, OAD and OSD approaches are combined to create the total learning environment. Blackboard tends to elicit more formal, traditionally academic, and reflective responses as students reply to instructor prompts (and each other) on the Blackboard discussion board. Prompts typically come from readings and OSD discussions. By contrast, MOO has the vitality more characteristic of a F2F class meeting, with more social and informal discussions and responses. Use of PowerPoint slides online helps structure class and provides content to supplement required reading. Like F2F, synchronous online class meetings have immediacy and are fast-paced. The chat aspect of class means that comments, responses, and interactions can move very quickly, challenging students (and instructors) to pay attention. The quick back-and-forth in the chat format requires that traditional academic expectations about such details as spelling and grammar be suspended, helping to create a more relaxed climate online. Also, active participation online requires much shorter comments and responses than in F2F classes because the faster pace requires faster posting of responses and shorter amounts of text for others to read. Thus, online class sessions are reading- and writing-intensive.
Cognitive Presence
In discussing the cognitive presence component, Garrison et al. (2000) emphasized the “potential for facilitating deep and meaningful learning in a [virtual learning] environment” (p. 93). We use MOO to provide opportunities for high levels of in-depth interaction during class. The nature of the OSD component is that it requires verbal participation online in order to be actively engaged in class. Students who are not actively posting in the discussion are invisible in class. This is unlike F2F experiences where students can contribute minimally or choose to be passive learners. In MOO, all students contribute very actively to discussions. In interactions with instructors online, students are encouraged to take responsibility for their own learning, share their knowledge with others in the class, and combine what they know from practice with new or revisited concepts in class. Thus, instructors strive to address the teaching elements proposed by Newman et al. (1996), including actively encouraging and inviting new ideas and perspectives as well as helping link together theories, facts, applications, and professional experiences.
With this expectation of active verbal participation online, many students are challenged to modify their usual classroom style. For example, introverts who might be hesitant to share comments in an F2F class often shine online. Conversely, strong extraverts can feel constrained online by having to compose their comments and keep them shorter and more focused. Students quickly adapt to this change and most tend to be active in every class meeting.
Throughout the course, we utilize various techniques to promote critical thinking. Similar to F2F classes, open-ended questions are frequently posed to students. Often, probes are used to stimulate further discussion on a topic. In addition, we frequently make encouraging comments such as “interesting idea” or “well put” to let students know that their ideas are important to the discussion and highlight these contributions for other students. These encouragers reinforce student contributions to class, help promote additional conversation, and help highlight important points in the transcript. Even more than in an F2F class, it is vital that instructors plan for how to use their teaching skills to promote cognitive presence online. In the synchronous online learning environment, critical thinking results from instructors’ intentional encouragement, supportive comments, and challenging questions.
Social Presence
Garrison et al. (2000) hypothesized that “high levels of Social Presence with accompanying high degrees of commitment and participation are necessary for the development of higher order thinking skills and collaborative work” (p. 93). To create a community of inquiry, students must feel they can be “real” people in the virtual classroom. As noted earlier, we use the on-campus training to help students feel comfortable and competent with the technology. Then, in the first class online, instructors ask students to reflect on their own professional experiences, modeling use of humor, restatement, encouragement, and positive reinforcement along the way. These techniques help build a level of social presence in the online classroom.
As students have successful experiences in the online environment, they find ways to contribute their personalities, ideas, and expertise in the virtual classroom. As that happens, the technology becomes just another tool for learning and sharing information, ideas, and resources with each other. The shared experience of doing something new and the commonalities students have as school counselors also help to foster social connections and relationships online. One strong indicator of success in developing the social component online is that students frequently share both professional and personal issues with each other, at the beginning and end of class as well as (appropriately) throughout discussions. Students typically develop strong connections with the group and its members that provide a working foundation for their ongoing development as a group during the PMC program. As Garrison et al. (2000) have observed, “Social Presence marks a qualitative difference between a collaborative community of inquiry and a simple process of downloading information” (p. 96).
Teaching Presence
Clearly, there is a critical need to establish a strong teaching presence online, since this has been described as “the binding element in creating a community of inquiry for educational purposes” (Garrison et al., 2000, p. 96). One challenge for counselor educators is to provide familiar kinds of structure, leadership, and facilitation online. We have found that the synchronous learning environment lends itself very well to using group facilitation and process skills to stimulate and involve students in very active ways. We present prompts, share selected information, encourage students to think critically about material, and help students relate course material to their own experiences and work settings. For teaching that is more instructor-centered and more lecture-based, MOO is limited and somewhat lacking. As a platform for process-based learning experiences, however, MOO provides the basic elements to create an online experience that can offer a viable alternative to F2F instruction. In fact, what actually takes place in an online class is largely the same as what would happen in an F2F version of the class; the primary adaptations have to do with effectively using technology to do these things online.
Garrison et al. (2000) noted the importance of students having time to reflect on information as a critical part of the learning process. In our course, students have built-in time to reflect and discuss during online meetings. This reflection time, however, is limited, and must be intentionally included in the class structure by the instructors. Enhanced reflection can occur through Blackboard discussion board postings (OAD) and by requiring students to review and comment on transcripts from online class meetings following online class sessions. With co-instructors for this course, there typically are two instructor/facilitators online in the class. As with co-leading groups, this allows one instructor to serve as lead facilitator to guide the process and cover content while the other instructor keeps a closer eye on student responses and responds to their questions and comments, often playing a major role in supporting and reinforcing student contributions. Because the lead instructor role often shifts midway through a class, each instructor has the chance to be more upfront and facilitative in one part of the class and more of the active listener and supporter in another.
Some examples can illustrate how we create a strong teaching presence. First, class size is limited to 12 students. This small number helps the instructors keep track of the students in the class; since students cannot be seen, it is important to watch users’ screen names to ensure that everyone participates. In addition, the smaller class size allows activities to be completed without consuming the entire class time. Activities also are used to engage students and model facilitation skills. For example, in one class students are asked to design a tattoo for themselves and discuss its meaning. The instructors use this activity to demonstrate group processing skills by modeling reflections, open-ended questions, and facilitative comments. This type of activity helps lead to cognitive presence through strong teaching presence. Finally, everything done in the class is purposeful, just as in an F2F classroom. This attention to goals and purpose helps maintain students’ interest, keeps students focused and involved during the class, and helps us maintain a strong teaching presence.
Reflections on Course Format and Learning Experiences
Benefits to Students and Instructors
Surprisingly, one of the benefits for students is a much higher level of consistent, ongoing participation than would be possible in an F2F classroom. One reason is that in a chat (MOO) format, everyone can essentially be talking at the same time, something that can be managed in an online environment, but would create total chaos F2F. In addition, the chat format allows students to address instructors and each other directly to ask questions, share observations, or make suggestions. In many ways, students can have much more contact and interaction with instructors and their peers in the virtual classroom, and we see this as a major benefit of this online learning environment.
Because of the ongoing dialogue in class, students can more readily affect the pacing and depth of material covered in class by having ongoing input into the educational process. We also encourage students to bring their real-life experiences to bear on the material (and vice-versa). This is particularly appropriate for working adult students who consistently have been found to value opportunities to blend experience with new information in the classroom. Many other benefits to students have been mentioned previously, including the opportunity for everyone to participate, availability of class transcriptions, easy access to the class on the Internet, and the ability to use PowerPoint slides to both guide discussion and inject instructors’ personalities into the class (e.g., through selective use of photos, images, or quotes).
Instructors share many of the benefits noted above for students. The most obvious instructor benefit may be the flexibility of being able to teach from any location with reliable Internet connections (e.g., the lead author has taught this class from New Zealand and Italy). Also, guest presenters can easily participate in the class no matter where they are located geographically. One class featured a guest presenter from India who shared information about her culture and responded to students’ lively questions. Additionally, the simple format of MOO allows instructors the opportunity to exercise their creativity by adding color, graphics, photos, and design elements to visually enhance and enliven the online experience. These creative elements also can help to stimulate and harness the live energy and the excitement of collaborative learning experiences. Graduate student co-instructors have found that teaching online has given them additional teaching skills they can market as new counselor educators, in addition to influencing how they view both online and F2F teaching. Even for the experienced faculty member, the online teaching experiences have positively affected how he plans for and conducts F2F classes.
Student Feedback on Online Experiences
As we reviewed student evaluations from several semesters of this online course, the most striking thing was how similar ratings and feedback were to student evaluations of F2F classes taught by the counselor educators. In addition, very little mention was made about the technology used for class; the few comments that were made were positive. The vast majority of student comments focused on instructor effectiveness, skills, and knowledge. Related to teaching presence, students commented positively on organization of the course, group leadership/facilitation, clear communication, and instructors’ knowledge. In the area of cognitive presence, key themes were instructors’ ability to stimulate interest in course content and stimulation of critical inquiry. Finally, students addressed social presence in the course with comments about instructors’ approachability and helpfulness, respectfulness, and ability to foster group cohesion.
Precautions and Practical Considerations
We believe there are three keys to success with online learning: (1) incorporate an energetic and well-planned interactive component; (2) keep things as technically uncomplicated as possible; and, (3) provide necessary training and tech support (e.g., backup) upfront. Students regularly cite the importance of the initial F2F technology training and the comfort of knowing they can contact university tech support if they experience difficulties. As noted above, the MOO platform provides basic tools for creating live classes online without many of the frills that can make things unnecessarily complicated and intimidating to students. Classes really come alive with the interactive component that MOO offers, due in no small part to instructors’ establishing a norm for active and enthusiastic participation in online sessions. Instructors also act as if these classes are F2F, using familiar language (e.g., “see you next week,” “see you in class”) and familiar structures (agendas for class, balance of information-giving and discussion, even having a break midway through class) that subtly replicate familiar F2F instruction experiences.
To be able to accomplish all three areas of presence (teaching, cognitive, and social) identified by Garrison et al. (2000), instructors must be very intentional in designing and conducting the OSD component. For example, to teach effectively in this environment, instructors need to closely monitor student participation so that they can see those who are sitting quietly in the online classroom and encourage or call on them to bring their voices to class discussions. We have found it very helpful to have co-instructors to help keep up with the flow of discussion, maintain energy in the online classroom, and reach out to quieter or less involved students. To create and maintain cognitive presence, instructors need to be very intentional in cultivating an environment of critical inquiry, including asking good, critical questions and encouraging constructive dialogue among students and instructors. Social presence primarily involves encouraging students to connect with their peers and with instructors in class, and can include appropriate use of humor, liberal use of names, and attention to time for socializing at different points in class (beginning, end, break).
Conclusion
Numerous approaches exist for offering and teaching online graduate courses. If the primary goal is communication of large amounts of information, the approach described in this article likely will not be the most effective or efficient option. Counselors and counseling students, however, like to be able to interact with each other—whether F2F or online—and the MOO/Blackboard (OSD/OAD) approach to teaching and learning online allows for much discussion and processing of course material. Over the past several years, we have found that student responses to this online format have been overwhelmingly positive. Even students fearful or skeptical at the beginning, readily become active and engaged class members. This approach has worked particularly well with more advanced students where their F2F coursework prepared them with fundamental counseling knowledge and skills. It is our belief that a community of inquiry can be established effectively in an OSD format and that the elements of teaching that counselor educators hold dear—social contact and interaction—can be created successfully in an online environment. The increasing availability of more sophisticated platforms for synchronous online class meetings (e.g., Elluminate and Saba Centra Classroom) should make it even easier for counselor educators to use OSD for online only or hybrid courses in their programs. For us, the ability to interact with students online in real time has been a key to making online instruction come alive in ways that rival what we do in our F2F classes.
References
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James M. Benshoff, NCC, and Melinda M. Gibbons, NCC, are professors at the University of North Carolina at Greensboro and the University of Tennessee, Knoxville, respectively. Correspondence should be addressed to James M. Benshoff, University of North Carolina at Greensboro. Department of Counseling and Educational Development, P.O. Box 26170, Greensboro, NC 27402-6170, benshoff@uncg.edu.
Sep 7, 2014 | Article, Volume 1 - Issue 3
E. Heather Thompson, Melodie H. Frick, Shannon Trice-Black
Counselors-in-training face the challenges of balancing academic, professional, and personal obligations. Many counselors-in-training, however, report a lack of instruction regarding personal wellness and prevention of personal counselor burnout. The present study used CQR methodology with 14 counseling graduate students to investigate counselor-in-training perceptions of self-care, burnout, and supervision practices related to promoting counselor resilience. The majority of participants in this study perceived that they experienced some degree of burnout in their experiences as counselors-in-training. Findings from this study highlight the importance of the role of supervision in promoting resilience as a protective factor against burnout among counselors-in-training and provide information for counselor supervisors about wellness and burnout prevention within supervision practice
Keywords: counselors-in-training, wellness, burnout, supervision, resilience
Professional counselors, due to often overwhelming needs of clients and heavy caseloads, are at high risk for burnout. Research indicates that burnout among mental health practitioners is a common phenomenon (Jenaro, Flores, & Arias, 2007). Burnout is often experienced as “a state of physical, mental, and emotional exhaustion caused by long-term involvement in emotionally demanding situations” (Gilliland & James, 2001, p. 610). Self-care and recognition of burnout symptoms are necessary for counselors to effectively care for their clients as well as themselves. Counselors struggling with burnout can experience diminished morale, job dissatisfaction (Koeske & Kelly, 1995), negative self-concept, and loss of concern for clients (Rosenberg & Pace, 2006). Clients working with counselors experiencing burnout are at serious risk, as they may not receive proper care and attention to often severe and complicated problems.
The potential hazards for counselor distress in practicum and internship are many. Counselors-in-training often begin their professional journeys with a certain degree of idealism and unrealistic expectations about their roles. Many assume that hard work and efforts will translate to meaningful work with clients who are eager to change and who are appreciative of the counselor’s efforts (Leiter, 1991). However, clients often have complex problems that are not always easily rectified and which contribute to diminished job-related self-efficacy for beginning counselors (Jenaro et al., 2007). In addition, counselor trainees often experience difficulties as they balance their own personal growth as counselors while working with clients with immense struggles and needs (Skovholt, 2001). Furthermore, elusive measures for success in counseling can undermine a new counselor’s sense of professional competence (Kestnbaum, 1984; Skovholt, Grier, & Hanson, 2001). Client progress is often difficult to concretely monitor and define. The “readiness gap,” or the lack of reciprocity of attentiveness, giving, and responsibility between the counselor-in-training and the client, are an additional job-related stressor that may increase the likelihood of burnout (Kestnbaum, 1984; Skovholt et al., 2001; Truchot, Keirsebilck, & Meyer, 2000).
Counselors-in-training are exposed to emotionally demanding stories (Canfield, 2005) and situations which may come as a surprise to them and challenge their ideas about humanity. The emotional demands of counseling entail “constant empathy and one-way caring” (Skovholt et al., 2001, p. 170) which may further drain a counselor’s reservoir of resilience. Yet, mental health practitioners have a tendency to present themselves as caregivers who are less vulnerable to emotional distress, thereby hindering their ability to focus on their own needs and concerns (Barnett, Baker, Elman, & Schoener, 2007; Sherman, 1996). Counselors who do not recognize and address their diminished capacity when stressed are likely to be operating with impaired professional competence, which violates ethical responsibilities to do no harm.
Counselor supervision is designed to facilitate the ethical, academic, personal, and professional development of counselors-in-training (CACREP, 2009). Bolstering counselor resilience in an effort to prevent burnout is one aspect of facilitating ethical, personal, and professional development. Supervisors who work closely with counselors-in-training during their practicum and internship can promote the hardiness and sustainability of counselors-in-training by helping them learn to self-assess in order to recognize personal needs and assert themselves accordingly. This may include learning to say “no” to the demands that exceed their capacity or learning to actively create and maintain rejuvenating relationships and interests outside of counseling (Skovholt et al., 2001). Supervisors also can teach and model self-care and positive coping strategies for stress, which may influence supervisees’ practice of self-care (Aten, Madson, Rice, & Chamberlain, 2008). In an effort to bolster counselor resilience, supervisors can facilitate counselor self-understanding about overextending oneself to prove professional competency to achieve a sense of self-worth (Rosenburg & Pace, 2006). Supervisors can help counselors-in-training come to terms with the need for immediate positive reinforcement related to work or employment, which is limited in the counseling profession as change rarely occurs quickly (Skovholt et al., 2001). Counselor resiliency also may be bolstered by helping counselors-in-training establish realistic measures of success and focus on the aspects of counseling that they can control such as their knowledge and ability to create strong therapeutic alliances rather than client outcomes. In sum, distressing issues in counseling, warning signs of burnout, and coping strategies for dealing with stress should be discussed and the seeds of self-care should be planted so they may grow and hopefully sustain counselors-in-training over the course of their careers.
Method
The purpose of this exploratory study was to investigate counselor-in-training perceptions of self-care, burnout, and supervision practices related to promoting counselor resilience. The primary research questions that guided this qualitative study included: (a) What are master’s-level counselors-in-training’s perceptions of counselor burnout? (b) What are the perceptions of self-care among master’s-level counselors-in-training? (c) What, if anything, have master’s-level counselors-in-training learned about counselor burnout in their supervision experiences? And (d) what, if anything, have master’s level counselors-in-training learned about self-care in their supervision experiences?
The consensual qualitative research method (CQR) was used to explore the supervision experiences of master’s-level counselors-in-training. CQR works from a constructivist-post-positivist paradigm that uses open-ended semi-structured interviews to collect data from individuals, and reaches consensus on domains, core ideas, and cross-analyses by using a research team and an external auditor (Hill, Knox, Thompson, Williams, Hess, & Ladany, 2005; Ponterotto, 2005). Using the CQR method, the research team examined commonalities and arrived at a consensus of themes within and across participants’ descriptions of the promotion of self-care and burnout prevention within their supervision experiences (Hill et al., 2005; Hill, Thompson, & Nutt Williams, 1997).
Participants
Interviewees. CQR methodologists recommend a sample size of 8–15 participants (Hill et al., 2005). The participants in this sample included 14 individuals; 13 females and 1 male, who were graduate students in master’s-level counseling programs and enrolled in practicum or internship courses. The participants attended one of three universities in the United States (one in the Midwest and two in the Southeast). The sample consisted of 10 participants in school counseling programs and 4 participants in clinical mental health counseling programs. Thirteen participants identified as Caucasian, and one participant identified as Hispanic. The ages of participants ranged from 24 to 52 years of age (mean = 28).
Researchers. An informed understanding of the researchers’ attempt to make meaning of participant narratives about supervision, counselor burnout, and self-care necessitates a discussion of potential biases. This research team consisted of three Caucasian female faculty members from three different graduate-level counseling programs. All three researchers are proficient in supervision practices and passionate about facilitating counselor growth and development through supervision. All members of the research team facilitate individual and group supervision for counselors-in-training in graduate programs. The three researchers adhere to varying degrees of humanistic, feminist, and constructivist theoretical leanings. All members of the research team believe that supervision is an appropriate venue for bolstering both personal and professional protective factors that may serve as buffers against counselor burnout. It also is worth noting that the three members of the research team believed they had experienced varying degrees of burnout over the course of their careers. The researchers acknowledge these shared biases and attempted to maintain objectivity with an awareness of their personal experiences with burnout, approaches to supervision, and beliefs regarding the importance of addressing protective factors, wellness and burnout prevention in supervision. This study also was influenced by an external auditor who is a former counselor educator with more than 20 years of experience in qualitative research methods and supervision practice. As colleagues in the field of counselor education and supervision, the research team and the auditor were able to openly and respectfully discuss their differing perspectives throughout the data analysis process, which permitted them to arrive at consensus without being stifled by power struggles.
Procedures for Data Collection
Criterion sampling was used to select participants in an intentional manner to understand specified counseling students’ experiences in supervision. Criteria for participation in this study included enrollment as a graduate student in a master’s-level counseling program and completion of a practicum experience or participation in a counseling internship in a school or mental health counseling agency. Researchers disseminated information about this study by email to master’s-level students in counseling programs at three different universities. Interested students were instructed to contact, by email or phone, a designated member of the research team, who was not a faculty member at their university. All participants were provided with an oral explanation of informed consent and all participants signed the informed consent documents. All procedures followed those established by the Institutional Review Board of the three universities associated with this study.
Within the research team, researchers were designated to conduct all communication, contact, and interviews with participants not affiliated with their respective universities, in order to foster a confidential and non-coercive environment for the participants. Interviews were conducted on one occasion, in person or via telephone, in a semi-structured format. Participants in both face-to-face and telephone interviews were invited to respond to questions from the standard interview protocol (see Appendix A) about their experiences and perceptions of supervision practices that addressed counselor self-care and burnout prevention. Participants were encouraged to elaborate on their perceptions and experiences in order to foster the emergence of a rich and thorough understanding. The transferability of this study was promoted by the rich, thick descriptions provided by an in-depth look at the experiences and perceptions of this sample of counselors-in-training. Interviews lasted approximately 50–70 minutes. The interview protocol was generated after a thorough review of the literature and lengthy discussions about researcher experiences as a supervisee and a supervisor. Follow-up surveys (see Appendix B) were administered electronically to participants six weeks after the interview to capture additional thoughts and experiences of the participants.
Data Analysis
All interviews were audio-taped and transcribed verbatim for data analysis. Transcripts were checked for accuracy by comparing them to the audio-recordings after the transcription process. Participant names were changed to pseudonyms to protect participant anonymity. Participants’ real names and contact information were only used for scheduling purposes. Information linking participants to their pseudonyms was not kept.
Coding of domains. Prior to beginning the data analysis process, researchers generated a general list of broad domain codes based on the interview protocol, a thorough understanding of the extant literature, and a review of the transcripts. Once consensus was achieved, each researcher independently coded blocks of data into each domain code for seven of the 14 cases. Next, as a team, the researchers worked together to generate consensus on the domain codes for the seven cases. The remaining cases were analyzed by pairs of the researchers. The third team member reviewed the work of the pair who generated the domain coding for the remaining seven cases. Throughout the coding process, domains were modified to best capture the data.
Abstracting the core ideas within each domain. Each researcher worked independently to capture the core idea for each domain by re-examining each transcript. Core ideas consisted of concise statements of the data that illuminated the essence of the participant’s expressed perspectives and experiences. As a group, the researchers discussed the wording of core ideas for each case until consensus was achieved.
Cross analysis. The researchers worked independently to identify commonalities of core ideas within domains across cases. Next, as a group, the research team worked to find consensus on the identified categories across cases. Aggregated core ideas were placed into categories and frequency labels were applied to indicate how general, typical, or variant the results were across cases. General frequencies refer to findings that are true for all but one of the cases (Hill et al., 2005). Typical frequencies refer to findings that are present in more than half of the cases. Variant frequencies refer to finding in at least two cases, but less than half.
Audit. An external auditor was invited to question the data analysis process and conclusions. She was not actively engaged in the conceptualization and implementation of this study, which gave the research team the benefit of having an objective perspective. The external auditor reviewed and offered suggestions about the generation of domains and core ideas, and the cross-case categories. Most feedback was given in writing. At times, feedback was discussed via telephone. The research team reviewed all auditor comments, looked for evidence supporting the suggested change, and made adjustments based on team member consensus.
Stability check. For the purpose of determining consistency, two of the 14 transcripts were randomly selected and set aside for cross-case analysis until after the remaining 12 transcripts were analyzed. This process indicated no significant changes in core domains and categories, which suggested consistency among the findings.
Results
A final consensus identified five domains: counselor burnout, counselor self-care, faculty supervision, site supervision, and improvements (see Table 1). Cross-case categories and subcategories were developed to capture the core ideas. Following CQR procedures (Hill et al., 1997, 2005), a general category represented all or all but one of the cases (n = 13–14); a typical category represented at least half of the cases (n = 7–12); and a variant category represented less than half but more than two of the cases (n = 3 – 6). Categories with fewer than three cases were excluded from further analysis. General categories were not identified from the data.
Counselor Burnout
Experiencing burnout. Most participants reported knowledge of or having experiences with burnout. Participants identified stressors leading to burnout as a loss of enthusiasm and compassion, the struggle to balance school, work, and personal responsibilities and relationships, and difficulty delineating and separating personal and professional boundaries.
Participants described counselor burnout as no longer having compassion or enthusiasm for counseling clients. One participant defined counselor burnout as, “it seems routine or [counselors] feel like they’ve dealt with so many situations over time that they’re just kind of losing some compassion for the field or the profession.” Another participant described counselor burnout as no longer seeing the unique qualities of individuals seen in counseling:
I wouldn’t see [clients] as individuals anymore…and that’s where I get so much of it coming at me, or so many clients coming at me, that they’re no longer an individual they’re just someone that’s sitting in front of me, and when they leave they write me a check….they are not people anymore, they’re clients.
Participants often discussed a continual struggle to balance personal and professional responsibilities. One participant described burnout as foregoing pleasurable activities to focus on work-related tasks:
I can tell when I am starting to get burned out when I am focusing so much on those things that I forgo all of those things that are fun for me. So I am not working out anymore, I am not reading for fun, and I am putting off hanging out with my friends because of my school work. There’s school work that maybe doesn’t have to get done at that moment, but if I don’t work on it I’m going to be thinking about it and not having fun.
Another participant described burnout as having a hard time balancing professional and personal responsibilities stating, “I think I don’t look forward to…working with…people. I’m just kind of glad when they don’t show up. And this kind of sense that I’m losing the battle to keep things in balance.”
Boundary issues were commonly cited by participants. Several participants reported that they struggled to be assertive, set limits, maintain realistic expectations, and not assume personal responsibility for client outcomes. One participant described taking ownership of a client’s outcome and wanting to meet all the needs of her clients:
I believe part of it is internalizing the problem on myself, feeling responsible. Maybe loosing sight of my counseling skills and feeling responsible for the situation. Or feeling helpless. Also, in school counseling there tends to be a larger load of students. And this is frustrating to not meet all the needs that are out there.
Participants reported experiences with burnout and multiple stressors that lead to burnout. Participants defined counselor burnout as a loss of compassion for clients, diminished enthusiasm, difficulty maintaining a life-work balance, and struggles to maintain boundaries.
Counselor Self-Care
Self-care is purposeful and proactive. Participants were asked to describe self-care for counselors and reported that self-care requires purposeful efforts to set time aside to engage in activities outside of work that replenish energy and confidence. Most participants identified having and relying on supportive people, such as family, friends, and significant others to help them cope with stressors. Participants also identified healthy eating and individualized activities such as exercise, reading, meditation, and watching movies as important aspects of their self-care. One participant described self-care as:
Anything that can help you reenergize and refill that bucket that’s being dipped into every day. If that’s going for a walk in the park…so be it. If that’s going to Starbucks…go do it….Or something that makes you feel good about yourself, something that makes you feel confident, or making someone else feel confident….Whatever it is, something that makes you feel good about yourself and knowing that you’re doing what you need to be doing.
Participants reported that self-care requires proactive efforts to consult with supervisors and colleagues; one of the first steps is recognizing when one needs consultation. One participant explained:
I think in our program, [the faculty] were very good about letting us know that if you can’t handle something, refer out, consult. Consult was the theme. And then if you feel you really can’t handle it before you get in over your head, make sure you refer out to someone you feel is qualified.
Participants described self-care as individualized and intentional, and included activities and supportive people outside of school or work settings that replenished their energy levels. Participants also discussed the importance of identifying when counselor self-care is necessary and seeking consultation for difficult client situations.
Faculty Supervision
Faculty supervisors directly promote counselor resiliency. More than half of the participants reported that faculty supervisors directly initiated conversations about self-care. A participant explained, “Every week when we meet for practicum, [the faculty supervisor] is very adamant, ‘is everyone taking care of themselves, is anyone having trouble?’ She is very open to listening to any kind of self-care situation we might have.” Similarly, another participant stated, “Our professors have told us about the importance of self-care and they have tried to help us understand which situations are likely to cause us the most stress and fatigue.” One participant identified preventive measures discussed in supervision:
In supervision, counselor burnout is addressed from the perspective of prevention. We develop personal wellness plans, and discuss how well we live by them during supervision….Self-care is addressed in the same conversation as counselor burnout. In supervision, the mantra is good self-care is vital to avoiding burnout.
Faculty supervisors indirectly promote counselor resiliency. Participants also reported that faculty supervisors indirectly addressed counselor self-care by being flexible and supportive of participants’ efforts with clients. Participants repeatedly expressed appreciation for supervisors who processed cases and provided positive feedback and practical suggestions. One participant explained, “I know that [my supervisor] is advocating for me, on my side, and allowing me to vent, and listening and offering advice if I need it….giving me positive feedback in a very uncomfortable time.”
Further, participants stated they appreciated supervisors who actively created a safe space for personal exploration. One participant explained:
[Supervision] was really a place for us to explore all of ourselves, holistically. The forum existed for us for that purpose. [The supervisors] hold the space for us to explore whatever needs to be explored. That was the great part about internship with the professor I had. He sort of created the space, and we took it. It took him allowing it, and us stepping into the space.
Modeling self-care also is an indirect means of addressing counselor burnout and self-care. Half of the participants reported that their faculty supervisors modeled self-care. For example, faculty supervisors demonstrated boundaries with personal and professional obligations, practiced meditation, performed musically, and exercised. Conversely, participants reported that a few supervisors demonstrated a lack of personal self-care by working overtime, sacrificing time with their families for job obligations, and/or having poor diet and exercise habits.
Participants reported that faculty supervisors directly and indirectly addressed counselor burnout and self-care in supervision. Supervisors who intentionally checked in with the supervisees and used specific techniques such as wellness plans were seen as directly affecting the participants’ perspective on counselor self-care. Supervisors who were present and available, created safe environments for supervision, provided positive feedback and suggestions, and modeled self-care were seen as indirectly addressing counselor self-care. Both direct and indirect means of addressing counselor burnout and self-care were seen as influential by participants.
Site Supervision
Site supervisors did not directly address burnout or self-care. Participants reported that site supervisors rarely initiated conversations about counselor burnout or self-care. One participant reported that counselor burnout was not addressed and as a result she felt a lack of support from the supervisor:
[Site Supervisors] don’t ask about burnout though. Every time I’m bringing it up, the answers I’m getting are ‘well, when you’re in grad school you don’t get a life.’ You know, yeah, I get that, but that’s not really true, so I get a lot of those responses, ‘well, you know, welcome to the club.’
One participant stated that her site supervisor did not specifically address counselor burnout or self-care, stating “I think that is less addressed in a school setting than it is in the mental health field….I think that because we see such a small picture of our students, I think it is not as predominantly addressed.” Some participants, however, reported that their site supervisors indirectly addressed self-care by modeling positive behaviors. One participant stated:
[My site supervisor] has either structured her day or her life in such a way that no one cuts into that time unless she allows it. In that sense, she’s great at modeling what’s important…She just made a choice….She was protective. She made her priorities. Her family was a priority. Her walk was a priority, getting a little activity. Other things, house chores, may have fallen by the wayside. She had a good sense of priorities, I thought. That was good to watch.
In summary, participants reported that counselor burnout and self-care were not directly addressed in site supervision. Indeed, some participants felt a lack of support when feeling overwhelmed by counseling duties, and that school sites may address burnout and self-care less than at mental health sites. At best, self-care was indirectly modeled by site supervisors with positive coping mechanisms.
Improvements for Counselor Supervision and Training
Improvements for counselor supervision. More than half of the participants reported wanting more understanding and empathy from their supervisors. One participant complained:
A lot of my class mates have a lot on their plates, like I do, and our supervisors don’t have as much on their plate as we do. And it seems like they don’t quite get where we are coming from. They are not balancing all the things that we are balancing….a lot of the responses you get demonstrate their lack of understanding.
Another participant suggested:
I think just hearing what the person is saying. If the person is saying, I need a break, just the flexibility. Not to expect miracles, and just remember how it felt when you were in training. Just be relatable to the supervisees and try to understand what they are going through, and their point of view. You don’t have to lower your expectations to understand where we’re at…and to be honest about your expectations…flexible, honest, and understanding. If [supervisors] are those three things, it’ll be great.
Participants also suggested having counselor burnout and self-care more thoroughly addressed in supervision, including more discussions on balancing personal and professional responsibilities, roles, and stressors. One participant explained:
What would be really helpful when the semester first begins is one-on-one time that is direct about ‘how are you approaching this internship in balance with the rest of your life?’ ‘What are any issues that it would be worthwhile for me to know about?’ How sweet for the supervisor to see you as a whole person. And then to put out the invitation: the door’s always open.
Improvements for counselor training programs. More than half of the participants wanted a comprehensive and developmentally appropriate approach to self-care interwoven throughout their counselor training, with actual practice of self-care skills rather than “face talk.” One participant commented:
Acknowledge the reality that a graduate-level program is going to be a challenge, talking about that on the front end….[faculty] can’t just say you need to have self-care and expect [students] to be able to take that to the next level if we don’t learn it in a graduate program….how much better would it be for us to have learned how to manage that while we were in our program and gotten practice and feedback about that, and then that is so important of a skill to transfer and teach to our clients.
Most of the participants suggested the inclusion of concrete approaches to counselor self-care. Participants provided examples such as preparing students for their work as counselors-in-training by giving them an overview of program expectations at the beginning of their programs, and providing students with self-care strategies to deal with the added stressors of graduate school such as handling administrative duties during internship, searching for employment prior to graduation, and preparing for comprehensive exams.
Discussion
Findings from this study highlight the importance of the role of supervision in promoting resilience as a protective factor against burnout among counselors-in-training. The majority of participants in this study perceived that they experienced some degree of burnout in their experiences as counselors-in-training. Participants’ perceptions of experiencing burnout are a particularly meaningful finding because it indicates that these counselors-in-training see themselves as over-taxed during their education and training. If, during their master’s programs, counselors-in-training are creating professional identities based on cognitive schemas for being a counselor, then perhaps these counselors-in-training have developed schemas for counseling that include a loss of compassion for clients, diminished enthusiasm for counseling, a lopsided balance of personal and professional responsibilities, and struggles to maintain boundaries. Counselors-in-training should be aware of these potential pitfalls as these counselors-in-training reported experiencing symptoms of burnout which were rarely addressed in supervision.
In contrast to recent literature, which suggests that counselor burnout is related to overcommitment to client outcomes (Kestnbaum, 1984; Leiter, 1991; Shovholt et al., 2001), many counselor trainees in this study did not perceive that their supervisors directly addressed their degree of personal commitment to their clients’ success in counseling. Similarly, emotional exhaustion is commonly identified as a potential hazard for burnout (Barnett et al., 2007); yet, few participants believed that their supervisors directly inquired about the degree of emotional investment in their clients. Finally, elusive measures of success in counseling are often indicated as a potential factor for burnout (Kestnbaum, 1984; Skovholt, et al., 2001). The vast majority of participants interviewed for this study did not perceive that these elusive measures of success were addressed in their supervision experiences. Supervisors who are interested in thwarting counselor burnout early in the training experiences of counselors may want to consider incorporating conversations about overcommitment to client outcomes, emotional exhaustion, degree of emotional investment, and elusive measures of success into their supervision with counselors-in-training. In an effort to promote more resilient schemas and expectations for counseling work, supervisors can take an active role in helping counselors-in-training understand the importance of awareness and protective factors to protect against a lack of compassion, enthusiasm, life-work balance, and professional boundaries, similar to the way a pilot is aware that a plane crash is possible and therefore employs purposeful and effective methods of prevention and protection.
Participants in this study conceptualized self-care as purposeful behavioral efforts. Proactive behavioral choices such as reaching out to support others are ways that many counselors engage in self-care. However, self-care cannot be solely limited to engagement in specific behaviors. Self-care also should include discussions about cognitive, emotional, and spiritual coping skills. Supervisors can help counselors-in-training create a personal framework for finding meaning in their work in order to promote hardiness, resilience, and the potential for transformation (Carswell, 2011). Because of the nature of counseling, it is necessary for counselors to be open and have the courage to be transformed. Growth and transformation are often perceived as scary and something to be avoided. Yet, growth and transformation can be embraced and understood as part of each counselor’s unique professional and personal process. Supervisors can normalize and validate these experiences and help counselors-in-training narrate their inspirations and incorporate their personal, spiritual, and philosophical frameworks in their counseling. In addition, supervisors can directly address misperceptions about counseling, which often include: “I can fix the problem,” “I am responsible for client outcomes,” “Caring more will make it better,” and “My clients will always appreciate me” (Carswell, 2011). While these approaches to supervision are personal in nature, counselors-in-training in this study reported an appreciation for time spent discussing how the personal informs the professional. This finding is consistent with Bernard & Goodyear’s (1998) model of supervision which emphasizes personal development as an essential part of supervision. Models for personal development in counselor education programs have been proposed by many professionals in the field of counseling (Myers, 1991; Myers & Williard, 2003; Witmer & Granello, 2005).
Counselors-in-training in this study reported an appreciation for supervision experiences in which their supervisors provided direct feedback and positive reinforcement. Counselors-in-training often experience performance anxiety and self-doubt (Aten et al., 2008). In an effort to diminish counselor-in-training anxiety, supervisors may provide additional structure and feedback in the early stages of supervision. Once the counselor-in-training becomes more secure, the supervisor may facilitate a supervisory relationship that promotes supervisee autonomy and higher-level thinking.
The majority of participants interviewed reported a desire for supervisors to place a greater emphasis on life-work balance and learning to cope with stress. These findings suggest the importance of counselor supervisors examining their level of expressed empathy and emphasis on preventive, as well as remedial, measures to ameliorate symptoms and stressors that lead to counselor burnout. Participants expressed a need to be more informed about additional stressors in graduate school such as administrative tasks in internship, preparing for comprehensive exams, and how to search for employment. These findings suggest the need for counselor educators and supervisors to examine how they indoctrinate counselors-in-training into training programs in order to help provide realistic expectations of work and personal sacrifice during graduate school and in the counseling field. Moreover, counselor educators and supervisors should strive to provide ongoing discussions on self-care throughout the program, specifically when students in internship are experiencing expanding roles between school, site placement, and searching for future employment. As mental health professionals, counselor educators and supervisors may also struggle with their own issues of burnout; thus, attentiveness to self-care also is recommended for those who teach and supervise counselors in training.
Limitations
Findings from this study will benefit counselor educators, supervisors, and counselors-in-training; however, some limitations exist. One limitation is the lack of diversity in the sample of participants. The majority of the participants identified as Caucasian females, which is representative of the high number of enrolled females in the counseling programs approached for this study. The purpose for this study, however, was not to generalize to all counselor trainees’ experiences, but rather to shed light on how counselor perceptions of burnout and self-care are being addressed, or not, in counselor supervision.
Participant bias and recall is a second limitation of this study. Recall is affected by a participant’s ability to describe events and may be influenced by emotions or misinterpretations. This limitation was addressed by triangulating sources, including a follow-up questionnaire, reinforcing internal stability with researcher consensus on domains, core ideas, and categories, and by using an auditor to evaluate analysis and prevent researcher biases.
Conclusion
Counselors should be holders of hope for their clients, but one cannot give away what one does not possess (Corey, 2000). Counselors who lack enthusiasm for their work and compassion for their clients are not only missing a critical element of their therapeutic work, but also may cause harm to their clients. Counseling is challenging and can tax even the most “well” counselors. A lack of life-work balance and boundaries can add to the already stressful nature of being a counselor. Discussions in supervision about the potential for emotional exhaustion, the counselor-in-training’s degree of emotional investment in client outcomes, elusive measures of success in counseling, coping skills for managing stress, meaning-making and sources of inspiration, and personalized self-care activities are several ways supervisors can promote counselor resilience and sustainability. Supervisors should discuss the definitions of burnout, how burnout is different from stress, how to identify early signs of burnout, and how to address burnout symptoms in order to promote wellness and prevent burnout in counselors-in-training. Counselor educators and supervisors have the privilege and responsibility of teaching counselors-in-training how to take care of themselves in addition to their clients.
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E. Heather Thompson is an Assistant Professor in the Department of Counseling Western Carolina University. Melodie H. Frick is an Assistant Professor in the Department of Counseling at West Texas A & M University. Shannon Trice-Black is an Assistant Professor at the College of William and Mary. Correspondence can be addressed to Shannon Trice-Black, College of William and Mary, School of Education, PO Box 8795, Williamsburg, VA, 23187-8795, stblack@wm.edu.
Appendix A
Interview Protocol
1. What do you know about counselor burnout or how would you define counselor burnout?
2. What do you think are possible causes of counselor burnout?
3. As counselors we often are overloaded with administrative duties which may include treatment planning, session notes, and working on treatment teams. What has this experience been like for you?
4. Counseling requires a tremendous amount of empathy which can be emotionally exhausting. What are your experiences with empathy and emotional exhaustion? Can you give a specific example?
5. How do you distinguish between feeling tired and the early signs of burnout?
6. As counselors, we sometimes become overcommitted to clients who are not as ready, motivated, or willing to engage in the counseling process. Not all of our clients will succeed in the way that we want them to. How do you feel when your clients don’t grow in the way you want them to? How has this issue been addressed in supervision?
7. What is your perception of how your supervisors have dealt with stress?
8. How has counselor burnout been addressed in supervision?
prompt: asked about, evaluated, provided reading materials, and how often
9. How have specific issues related to burnout been addressed in supervision such as: (a) over-commitment to clients who seem less motivated to change, (b) emotional exhaustion, and (c) elusive measures of success?
10. How could supervision be improved in addressing counselor burnout?
prompt: asked about, evaluated, provided reading materials, modeled by supervisor
11. What do you know about self-care or how would you define self-care for counselors?
12. What are examples of self-care, specifically ones that you use as counselors-in-training?
13. How has counselor self-care been addressed in supervision?
14. Sometimes we have to say “no.” How would you characterize your ability to say “no?” What have you learned in supervision about setting personal and professional boundaries?
15. What, if any, discussions have you had in supervision about your social, emotional, spiritual, and/or physical wellbeing? What is a specific example?
16. How could supervision be improved in addressing counselor self-care?
prompt: asked about, provided reading materials, modeled by supervisor
17. How could your overall counselor training be improved in addressing counselor burnout and counselor self-care?
Appendix B
Follow-Up Questionnaire
How would you describe counselor burnout?
How has counselor burnout been addressed in supervision?
How could supervision be improved in addressing counselor burnout?
How would you describe self-care for counselors?
How has counselor self-care been addressed in supervision?
How could supervision be improved in addressing counselor self-care?
How could your overall counselor training be improved in addressing counselor burnout and counselor self-care?
Sep 7, 2014 | Article, Volume 2 - Issue 1
Michael W. Firmin, Richard A. Wantz, Ruth L. Firmin, Courtney B. Johnson
Using qualitative research methods, interviews were conducted with college students regarding the sources they
used in generating perceptions of professional counselors. Respondents believed that information sources such as word of mouth, media sources and personal experiences were responsible for their understandings of professional counselors. The findings have applications for leaders in professional counseling organizations. Common knowledge characteristics, public perceptions, counselor identity and advocacy are discussed.
Keywords: perceptions, professional counselors, information sources, counselor identity, advocacy
Perceptions do not equal reality. However, perceptions eventually can lead to what reality becomes in time. All professions possess public perception. When someone refers to doctors, lawyers, dentists, and other specialized occupational groups, images are created in our minds. These percepts possess varying degrees of reality, of course, but the effects of such images are cogent nonetheless. Of particular interest to the present study is the perception of human service personnel, including professional counselors.
As a whole, the human service profession has landed itself on the positive side of the public’s opinion spectrum (Nunnally & Kittross, 1958). McGuire and Borowy’s (1979) research showed a continuum of perceptions held by the lay public regarding a wide range of professionals who worked with mental illness. Those occupying the fields of nursing, physicians, counseling psychologists, social workers, psychiatric nurses, psychiatrists, and clinical psychologists received the highest rankings.
Undergraduate students’ opinions regarding effectiveness of various human service providers for helping mental health consumers were reported by Tse, Wantz, and Firmin (2010) and Wantz and Firmin (2011). Participants in these studies rated human service providers’ effectiveness more positive than negative. Professional counselors and psychologists were rated more effective with providing mental health services than other human service providers.
Richardson and Handal (1995) found the general public viewed psychotherapy as a reasonably effective means of treatment for between 25 and 50% of all cases. Most people also recognized that services of less traditional human service providers, such as marriage and family therapists, also could be used effectively in relation to particular disorders. Psychiatrists and psychologists, however, were perceived as having higher levels of competence when addressing mental health issues (Schindler, Berren, Hannah, Beigel, & Santiago, 1987). Educational attainment (Dotson-Blake, Know, & Holman, 2010), chronological maturity (Erikson, 1963; Oliver, Reed, & Smith, 1998), and psychosocial development (Tinsley, Hinson, Holt, & Tinsley, 1990) have been reported to be positively correlated with perceived benefits of counseling.
Murstein and Fontaine (1993) found familiarity of the general public to be greater concerning physicians, clergypersons, and psychiatrists than it was in their knowledge of psychotherapists and psychologists. Consequently, of the two, psychologists were the source the general public was most likely to use when recommending a human service provider. Also reported, the most common reasons for which clients sought mental health professionals were mild depression, marital problems, and child-rearing issues. A generation ago, Gelso, Brooks, and Karl (1975) reported mental health consumers’ overall preferences to be for counseling psychologists and psychiatrists.
Sharpley (1986) purported a tendency for mental health consumers to separate human service professionals into two categories, each entailing distinct perspectives. First, private practice and fee-for-service providers, psychologists and psychiatrists being the most prominent, were viewed as those who were most competent in treating mental illnesses. Second, public-utility and non-fee-demanding professionals, of which social workers and counselors prominently emerged, were perceived as being more practical and apt in providing service to the average person when addressing emotional problems.
Among the various human service professionals, counselors are of particular interest to the present study. Sharpley, Bond, and Agnew (2004) indicated that the public views counselors’ roles to be primarily listening, supporting, and helping to solve problems. While 79% said counselors were needed, and the same number indicated a willingness to pay for services provided, survey respondents personally were likely to consult a counselor concerning only 13–20% of the problems they faced. Participants also reported benefits of counseling to include having an impartial person to listen and help clarify, as well as having a facilitator for problem-solving, and meeting in a safe, confidential environment.
Fall, Levitov, Jennings, and Eberts (2000) described the public’s expressed general confidence in professional counselors’ abilities to treat “less serious” cases, but less confidence when treating cases which were perceived to be at higher levels of seriousness (e.g., psychopathology). These findings are congruent with those found by Fall, Levitov, Anderson, and Clay (2005) specifically studying the perceptions of the African-American population. In both studies, the participants expressed significantly greater levels of confidence in the abilities of psychiatrists when addressing severe issues, such as psychotic depression or post-traumatic stress disorder. Findings further showed that doctoral-level counselors were perceived similarly to clinical psychologists, while both studies showed that in every case professional counselors with doctorates were preferred over those with only master’s-level education. Wantz, Firmin, Johnson, and Firmin (2006) reported on university student perceptions of high school counselors. This qualitative study found college students reported high school counselors as having similar empathic and desire to help skills as licensed professional counselors.
Dixon, Vrochopoulos, and Burton (1997) reported the underrepresentation of counseling psychologists in introductory psychology textbooks, showing counseling to have significantly fewer references than clinical, school, and industrial psychologists. Likewise, Firmin, Johnson, and Winkler’s (2005) research showed almost no references to professional counselors in general psychology texts. Consequently, we conclude that while the public generally possesses positive perceptions of professional counselors, their presence is kept somewhat cryptic by the gatekeepers. College-educated students depend on introductory psychology texts to frame for them professional domains and functions among human service professionals.
As counselors have achieved professional status through licensure over the last two decades, identity confusion has been demonstrated by the practitioners within the field (King, 2006). Inevitably, this perplexity has trickled down to the minds of mental health practice consumers regarding distinctions and roles of professional counselors. Consequently, while the public generally likes the construct of who they think of as counselors, they also are unsure of these professionals’ roles (Butterfield, 1989).
Decades ago, Dahlem (1969) called for the vital need to research the general publics’ perception of counselors’ images and role perceptions, compared to counselors’ self-perceptions. He stressed the importance of clarifying consumers’ understandings and perceptions in relation to the success of the providers. Gelso and McKenzie (1973) followed up, studying ways in which students were informed of counselors’ available assistance. Students receiving only written information about hypothetical problems appropriate for counseling were less likely to experience changes of perceptions. This suggested that the most effective way to impact students’ impressions concerning counselors would be the presentation of written and oral information.
Narrowing the scope, the present study updates this important research inquiry. Specifically, our interests were to explore how college students, as potential consumers of mental health services, came to their understandings of counselors’ professional competence. That is, how effective do students perceive professional counselors to be? Obviously, since such perceptions are tied to students’ ultimate use of counselors’ services, the answers to the research question have significant implications for personnel working in college counseling settings.
Method
In accomplishing the study’s aim of assessing how college students generate their perceptions of professional counselors, we considered a number of potential research designs. While quantitative methods such as surveys would provide us with a relative breadth of understanding in this area (Patten, 1998) and this would be valuable, we believed such an approach would not be as apt as a qualitative design. Generally, quantitative approaches answer “what” or “how many” types of questions (Sarafino, 2005). However, we were more interested in knowing answers to “how” and “why” types of questions. These, by and large, are best answered via qualitative designs (Atkinson, Coffey, & Delamont, 2003).
At the outset, we are explicit regarding our decision in using an atheoretical approach to the qualitative method. Significant and heated debate presently exists in qualitative circles regarding whether one should or should not use theory—and if so, what that role should be. Originally Glaser and Strauss (1967) advocated that atheoretic, inductive approaches were the only means of generating a grounded theory. Later, Strauss and Corbin (2008) purported that theory was legitimate and useable for some qualitative research designs. Glaser (1992), however, vehemently opposed this departure from the classical approach indicating that researchers must exercise disciplined restraint in holding back theory when generating or interpreting results.
Obviously, we are not going to abate the controversy in this article, but we do wish to be explicit in reporting our commitment to classical grounded theory. That is, philosophically we believe that phenomenological studies such as the present one should be conducted inductively—holding theory at bay. While we understand the implications and even potential limitations of this approach, we believe it to be most apt, nonetheless.
A sample of 26 students was drawn from a general psychology course (16 females and 10 males). The institution was a selective, private comprehensive university located in the Midwest. Departing from traditional criterion or purposeful sampling most often used with qualitative research (Seidman, 2006), we used random sampling for this study because we wished to enhance the external validity of our findings as much as feasible. That is, the trade-off of expanded generalizability was believed to be worth the expense of potentially less rich descriptions through specifically selected students. Since the general psychology course was part of the liberal arts core curriculum at the institution, our sample reflected a relatively wide cross-section of majors, included students who were freshmen through seniors, and participants’ ages ranged from 18 to 22 years of age. Interviews were tape recorded and later transcribed for analysis. In writing the present article, we used respondent pseudonyms for reading clarity.
We utilized a semi-structure method in conducting the in-depth interviews. We used staple constructs for generating questions, but also allowed students to deviate in their replies, enabling them to tell their own stories and share perceptions inductively. Following Firmin (2006a), two waves of interviews were conducted. That is, all participants were interviewed twice—with transcription and coding occurring in between the interviews. This allowed for constant comparison of the data and dialogue among the researchers for generating potential codes.
When analyzing the interviews, we used an open (Maxwell, 2005) coding, inductive process (Marshall, 1999). Since we located no studies published on this topic, axial coding was not practical and open coding was more consistent with the study’s exploratory aim. Frequent meetings among the article’s authors occurred and this process facilitated coding, providing verifications for consistency of analysis. When generating potential codes, we read through the transcripts, utilizing constant comparison methods (Bogdan & Biklen, 2007). This involved continuously comparing the transcripts to one another, looking for any repeating words, phrases, or constructs that were common among the participants. In order to keep the data manageable, some similar categories were collapsed into major categories. NVIVO qualitative research software also was used to help analyze data. This program helps to manage relatively large amounts of transcript documentation as well as aid in the generation of reliable themes across multiple participant data sets. This technology enhanced human capability, and it did not replace the role of subjective judgments required to conduct intuitive work (Lewins & Siver, 2007). Following Gay, Mills, and Airasian (2009), the process of transitioning from codes to themes involved asking key questions, conducting organizational review, visually displaying the findings, and concept mapping.
The research team’s dialogue regarding potential thematic outcomes enhanced the study’s internal validity. Naturally, one researcher can appropriately analyze data and provide apt findings. Nonetheless, the assurance of valid findings often is enhanced when multiple qualitative researchers participate in the analysis process (Ryan & Bernard, 2003). We included in this article only those themes on which the entire research team concurred. The study’s internal validity also was strengthened through generating a data trail (Daytner, 2006). This involved generating direct connections between each reported theme in our transcripts through identifying specific paragraphs within the interview conversations. Data trails can be useful to those who wish to check the validity of our reported findings or who hope to someday replicate or advance our present study (Firmin, 2006b).
Third, member checks (Merriam, 2002) were applied with various research participants. This is a qualitative research technique whereby we shared our findings with research subjects, garnering their feedback regarding how reported results aptly reflected their reported perceptions during the interview process. Each of the individuals with whom we checked commonly agreed with our reported results. Fourth, we strengthened the study’s internal validity by including participation from an independent researcher with renowned expertise in qualitative methodology (Flick, 2006). This expert appraised the steps at each stage of the study, the legitimacy of our process, assessed our data audit, and provided analysis regarding linking the transcripts data with the results. Fifth, saturation (Silverman, 2006) occurred when analyzing the transcript data. Specifically, after approximately 24 interviews, our participants generally shared similar sentiments, with few fresh insights added as subsequent interviews were added to the sample. In the qualitative tradition of experts such as Guest, Bunce, and Johnson (2006) and Neuman (2006), we believe our sample size was both ample and appropriate for the context of this specific study.
In summary, internal validity is a critical component in delineating appropriate qualitative research (Cope, 2004). Weightier confidence may be placed in the reported themes, that they adequately represent the general sentiments of the research participants when particular, deliberate steps are taken. Both in the study’s design and its implementation, we believe this project demonstrates rigor by established qualitative research standards (DeWet & Erasmus, 2005) and an apt grounded theory of the data collected (Lundberg & Young, 2005).
Results
Upon examination of the interviews, several themes emerged from the coded transcripts. Primarily, respondents discussed their awareness of sources such as the media, word of mouth, and personal experience in the development of opinions regarding professional counselors. Further, respondents discussed characteristics of a “common knowledge” upon which consumers draw in their utilization or hesitancy of seeking counseling services. Finally, responses delineated the perceived effects of this common knowledge on the reputation of counseling.
Three Sources
Repeatedly, respondents spoke of three main sources on which they depended in generating their opinions of professional counselors’ effectiveness. Respondents particularly mentioned the contribution of media sources such as radio, newspapers, television, and movies, along with the more personal and implicative sources of word of mouth and personal experience. Considered holistically, this amalgamated into a nebulous resource of common knowledge. One respondent defined common knowledge as “general sources,” implying the prevalent accessibility of this information.
Consistent with the sample’s generational factors, responses repeatedly indicated the role of the media in their concept formation of who professional counselors are and what they do. Janet explained that “common knowledge would probably be just things they’ve heard on TV or seen on TV,” revealing the expectation of what a professional counseling session should theoretically cover and how a session should appear. Media also sharply influenced perceptions of what a counselor and client should look like (i.e., personal dress and hygiene) and even where these services are located (e.g., in a swanky hospital wing or in urban city slums). Pete specifically mentioned the impact Hollywood had on the formation of his own perceptions, indicating no coincidence in the congruity of college students’ expectations with media depictions.
Fortunately, respondents spoke with a voice of relative discernment, aware of the possible slants injected into information relayed by the media. Injecting a sense of humor, Jason admitted: “I know I was watching TV the other day, I think it was Growing Pains, or something like that, and they were talking about it [counseling] so that’s how I know.” Not credulous to the media portrayal, he continued: “Like they have no problems in life, everything’s going smooth for them . . . people that have no problems and are like happy all the time . . . that’s not true.” While not all respondents explicitly expressed this intuition, they generally did note the connotations associated with counseling by the media. For example, Coleen noticed the subliminal messages as she watched movies or television shows: “It’s usually like TV and movies just have different characters in them and it usually seems like a negative type thing. . . I think that they make it seem like it’s [counseling] a weird place to go and it’s not a fun thing.” Clearly, the media is not a bias-free information source, but requires active examination on the part of the viewer.
Numerous respondents mentioned the place that word of mouth had in the formation of their perceptions about counselors. Where personal experience waned and media fell short of credibility, respondents turned to testimonies of people they know who were counseled first-hand and held credence. When asked to describe sources of common knowledge regarding her perceptions of counselors, Barb offered: “I think a lot of people would be, maybe from people they know, who have been to one, who are one [professional counselor].” Respondents feel that no matter the strength of the connection, be it from a friend-of-a-friend or from the mouth of a professional counselor, hearing of others’ encounters considerably influences perception formation. Making judgments on topics with which respondents are personally unfamiliar (i.e., no personal experience in counseling) is alleviated when backed by the testimony of personal references.
Dan mentioned the input of “the whole movies and TV and media” in passing, but pointed to word of mouth as the primary information hub about how he developed his percepts regarding counselors. His assertion that word of mouth is the primary means rests on another assumption, “I’m sure probably the majority of the people don’t go to counseling,” highlighting that where personal experience lacks, the information network through word of mouth becomes prominent in concept formations. Dan concluded: “I think that in general it’s the word of mouth because you always know someone who’s been through something or doing something and has had to go to counseling.” Respondents believed that personal encounters with counselors by their friends were a rarity, and in a sense a commodity, taking what they heard at face value. As such, their collections of personal testimonies were typically sparse. Johanna considered word of mouth to be the prominent common knowledge source when thinking about counselors, as she stated: “I haven’t really read up on them or anything, but just based on what people have said, that’s where I’ve gotten my perspective from.” Even more, Johanna looked to her immediate context: “For me it would be more of adults, like parents, parents’ friends, stuff like that.” Speaking from the periphery, students gain perspective based on other’s comments.
When accessible, respondents relied on personal experience and interactions of acquaintances as their main contributors to their knowledge base about professional counselors. No matter how insignificant the interaction, respondents preferred personal encounters or those of close friends, more so than media or other sources, in their concept formations. For example, Emma drew on memories from elementary school: “Just like experiences in elementary school where counselors came around and talked like ‘don’t do drugs and things like that.” Respondents readily admitted their recollections may be somewhat “fuzzy,” but nonetheless preferred these to more broad sources.
The context of “home” was imperative for perception formation about counselors among respondents in our sample. Specifically, respondents heavily relied on past experiences to formulate opinions about new concepts or in discussing unfamiliar territory. Carla offered this insight: “I suppose it could be something that has come from their background or their family life.” Familial beliefs are known to possess cogent influences in multiple life domains such as politics, religion, prejudice, etc. In the present context, our students suggested that generational influences play a moderating role in perceptions of professional counseling.
As the majority of respondents could not draw from personal experience, the testimony of friends often was their closest connection to professional counselors. Stephanie mentioned that common knowledge was a salient influence in how she came to think of counselors. Later, she elaborated this could be from talking with “friends that went to go see a counselor” and who could fill in the gaps of her understanding. Randy affirmed the power generated when he will “hear other people’s experiences.” Obviously, respondents in our sample could not judge the relative quality of their friends’ experiences or the degree of truth represented by their friends’ accounts. But hearing what their friends told them left indelible impressions, nonetheless.
Common Knowledge Characteristics
Upon examination of their information sources, respondents reflected on the characteristics of their sources. Specifically, respondents mentioned that their knowledge about unfamiliar topics such as professional counselors may have little-to-no factual basis or may be unreliable. Mandy shared that respondents evaluate counselors by “just what they think they know. It might not necessarily come off of anything.” Respondents often were aware of this vulnerable reasoning, but when asked to offer their opinions, they drew on the ambiguous common knowledge anyhow. Linda stated her perception that this concept was “possibly general statistics or people’s assumptions about professional counselors, not necessarily what’s true.” In consideration of the often inaccurate portrayal of counselors through movies, magazines, and additional sources of media, these assumptions may differ widely from reality. Kevin offered this reasoning about how common knowledge affects perceptions about counselors: “People . . . think they know stuff about stuff, and really don’t. . . . So that’s why the majority of people don’t even know much about counselors and stuff like that. They hear one thing, and generalize it about everybody.” The tendency to generalize can be potently beneficial, depending on the accuracy of the source, of course. This principle has important ramifications for the development of counseling as a potential profession.
A second characteristic of common knowledge in our study is an inability of participants to recall the sources from which the information comes. Clearly, when making decisions such as choosing counseling services, knowing potential sources behind the motivation for utilizing them are important. Lori mentioned that students often rely on “things from a long time ago that they may not remember specifically” in order to evaluate the positive or negative effects of seeking professional counseling services. Similar to Rob’s tendency to generalize, our subjects’ distant recollections were said to be formative in their perceptions, however accurate they may or may not be. Steve elucidated that this source of common knowledge may be far removed from the true source: “Like second and third hand information about people who have gone to counselors, again television and movies, the joke from the Sunday newspaper, you know.” Perceptions for these students are formulated from a conglomeration of sources, credible or not, evidently even from the comics section of the Sunday newspaper.
While respondents relied heavily on word of mouth, Jordan did speak of the possible flaws in this resource: “I guess from other people talking to them about it. You can’t just know, obviously, but obviously they don’t remember where they’ve heard it from.” While acquaintances and peers may be eager to share their opinions, our subjects evidently often were unable to support their opinions with factual sources. Cathy concurred in stating that common knowledge of counselors is generated by “probably a little bit of what they fill in, what they assume.” Not only are their potential sources emitting their own assumptions, but the respondents fall prey to the same tendency in order to compensate for lack of information. Sandy further clarified, “it may just be, I assume they’re this way, but they really didn’t base that off of anything,” again revealing the flaws in their apt perception formation.
Effects of Common Knowledge
Without doubt, the lack of verifiable validity found in common knowledge about counselors creates powerful effects for the advancement of counseling as a profession. Namely, not only is the reputation of services potentially marred, but respondents also may be less likely to seek out counseling when needed due to their incorrect assumptions and faulty sources. Respondents reported feeling that the media, through movies, magazines or books, too often generates negative connotations with professional counseling images. Rachel noted: “I think that it [media] negatively affects their perception of professional counselors.” When prodded to share more, she continued: “A lot of times in TV and in movies they’re portrayed as odd people so I guess that’s the image that a lot of people have, because going back to their philosophy in the way they conduct their counseling.” Most definitely, “odd” is not a positive connotation to associate with professional counseling. In times of need, respondents likely will not seek out a source they consider to be odd. Larry offered a similar insight in his comment: “Probably that they’re just people who sit there and they try and make you talk to them even though you don’t want to and, I don’t know, probably the same thing that they would be with a psychologist.” This statement is loaded with several faulty assumptions, ubiquitous in other students’ comments. First, respondents tend to believe counselors force their clients to talk about issues when they do not wish to receive counsel, or that their sessions consist more of passive listening, where clients ramble as the counselor nods occasionally and interjects the expected empathetic reflection. Second, this respondent offhandedly equated counselors with psychologists, illuminating the lack of public awareness in deciphering services offered by counselors compared to psychologists.
Students indicated that the connotations afforded by common knowledge sources of professional counselors sometimes are positive and sometimes negative, depending on the source. Molly used media news as a concrete example: “Well, usually if they hear it in the news it will be negative, if the counselor screws up, they’ll hear that, and it might give them a bad image.” She continued that one negative news report could be potent enough to prevent her or others from ever seeking a professional counselor, regardless of the intensity of the personal need. Similarly, Kim thinks that movies could “go either way” and the audience “can either think of a positive image of counselors that they really do help someone, or they can portray them as people who are out of touch with reality and don’t really help the person necessarily.” This phenomenon follows the similar vein relative to the equivocal nature of these sources. Clearly, the common knowledge phenomenon affects the realm of professional counseling by impacting not only expectations of a session on the part of the counselor or the client, but also regarding the tendency to seek professional counseling services.
Discussion
We believe that due deliberation of our findings are warranted on two levels: macro and micro. On the macro level, professional organizations must become more aggressive in advocating for the profession in media and other “common knowledge sources.” Specifically, we interpret our results as a clarion call to the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), and the National Board for Certified Counselors (NBCC).
In the past decade, how many times has a major motion picture made central references to a Licensed Professional Counselor (LPC)? A systematic assessment in answering this important question is warranted elsewhere. However, the authors of the present article are unaware of a single time when this has occurred. We do recall, of course, main characters visiting psychiatrists, psychologists, social workers, and even marriage & family therapists. But, it is completely unacceptable for Hollywood to ignore licensed professional counselors.
Our findings suggest that movies are powerful sources by which the public come to generate their perceptions of professional counselors. When movies ignore the profession, then it follows that counselors become vulnerable to unhealthy stereotypes, negative perceptions, or simply empty perceptions. The role of professional counseling organizations is to advance the profession—and our data suggests that much more needs to be done in this domain.
To be more specific, every time a major motion picture is released where main characters interact with human service professionals that are not counselors—advocacy must occur. That is, leaders of ACA, AMHCA, NBCC, state counseling organizations, and others need to issue united statements of protest. Media such as the Associated Press need to pick up on these protests, carrying complaints of professional counselors’ lack of Hollywood notice.
To proactively accomplish this, the professional organizations must make permanent connections with producers, directors, writers, and other influential individuals in Hollywood as scripts are generated. Hollywood needs to be aware that if they ignore professional counselors as potential sources of human service provision, then the professional counseling organizations will become active. It should be worth their while to ensure that an apt, positive representation of counselors occurs.
On the micro level, individual counselors must be more active when advertising their services to the public. Specifically, the local media should be utilized to portray positive messages about professional counselors and benefits of service utilization. Local news media frequently look for short stories or opinions from human service professionals on various topics. This particularly is true around holidays or other special occasions—or even traumatic events—when media generate special interest stories. Local television specials can be powerful mediums for perception formation among families and potential clients. Universities with communication arts programs can budget monies for student and/or professionally generated DVDs that highlight and promote professional counselors as quality options during times of personal need.
The same advocacy can occur with school newspapers, web sites, circulars, and other sources of “common knowledge.” Respondents from the present study indicated that media is a powerful source and influences their perceptions. Professional counselors, therefore, should seize this medium—using it to generate reoccurring positive messages.
Respondents also told us that parental opinions, former clients, information from friends, and other word of mouth sources were important in how they came to think of professional counselors. There is little that counselors can do to encourage positive word of mouth advertising for professional counselors. However, they can utilize the media to its fullest.
On both macro and micro levels, we are concerned about professional counselors’ general tendencies towards passivity. That is, counselors presently are at the mercy of how happenstance may occur in clients’ lives to formulate perceptions of counselors. Rather, counselors should architect how they want potential clients to think about them. Draft the message and then market it through public service announcements, movies, the media, and other sources that consumers say are important to their concept formations. In short, be proactive rather than laissez-faire on this important matter.
Limitations and Future Research
We believe the present research study provided an apt representation of the students interviewed. However, as with all qualitative research, external validity is a limitation. That is, while replication is important for quantitative research (Cumming, 2005), qualitative research is particularly context dependent, relying on replication ultimately to prove its generalizability (Firmin, 2006b). In this light, we are limited in our ability to apply the present findings to all students at all universities in the United States or the public in general. Further research should replicate this study, assessing students and potential clients in varying parts of the country. Further, national survey data should be collected—providing more breadth to our present findings—although, of course, breadth and depth acquisitions tend to be methodological tradeoffs.
No minority representation was included in the present sample. Of course they were not deliberately excluded; rather, the general psychology class from which the sample was drawn contained only a few minority students. By random sample chance they were not included. As previously indicated, we used random sampling of the students in the study in order to enhance external validity as much as possible. The university from which the sample was taken contains only a 6% total minority population. Consequently, further research should be conducted in this area, possessing greater numbers of minority students in those samples. Also, replicating the present qualitative study with all minority students would provide an interesting comparison to the present findings from a Caucasian sample.
In sum, we believe that the present study has powerful heuristic value. Researchers should take this concept and develop it much further than what we were able to do in the present design. Assuming that professional counseling is going to develop and flourish in the upcoming decades, then the call we make for proactive advocacy must be heard. Students and the public have perceptions of professional counselors. That simply is a fact of human nature. It behooves the professional counselor leaders as well as individual counselors to craft what they wish those perceptions to be.
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Michael W. Firmin is a Professor at Cedarville University. Richard A. Wantz is a Professor at Wright State University. Ruth L. Firmin and Courtney B. Johnson are doctoral students at Indiana University-Purdue University, Indianapolis. Correspondence can be addressed to Richard A. Wantz, Wright State University, Human Services, 3640 Colonel Glenn Highway, Dayton, OH 45435-0001, rick.wantz@right.edu.
