Jun 3, 2026 | Volume 16 - Issue 2
Shadin Atiyeh, Tahani Dari
Currently, 200,000 Afghans live in the United States, including the 76,000 Afghan nationals who arrived in 2021 under Operation Allies Welcome. Afghan refugees have often lived their entire lives under strife and occupation, presenting specific concerns unique to this population. To demonstrate how mental health and social and economic factors can manifest traumatic responses in children from migrant backgrounds, the article presents a case study involving a school-aged child and recommendations for how a counselor would work with this client in the school setting. The article also presents practical applications and interventions that could be beneficial in these cases while also considering the limitations that exist in the current case study regarding relevant issues for immigrants in counseling.
Keywords: counseling, Afghan refugees, case study, children, migrant
Afghan migration to the United States started to increase significantly in the late 20th century, growing from 4,000 in 1980 to 45,000 by 2000 (Saydee & Saydee, 2025). Currently, about 200,000 Afghans are living in the United States (Saydee & Saydee, 2025). The Afghan immigrant population in the United States has a lower median age than other immigrant and native-born groups in the United States, and 30% of Afghan immigrants are under 18 years old (Montalvo & Batalova, 2024). We present historical and contextual information related to the experiences of Afghan parolees in the United States and how counselors may work with a school-aged Afghan parolee and their family through a case study. Parole in this context refers to a temporary, discretionary immigration status allowing admission to the United States for humanitarian concerns or significant public benefit (Immigration and Nationality Act, 2025, 8 U.S.C 212(d)(5)).We demonstrate counseling using an integrative ecological approach with an Afghan child who arrived in the United States with humanitarian parole status through the case study. For this case study, we define children as school-aged (6–18). The case study is hypothetical, incorporating elements based on our experiences working with Afghan parolees in community and school settings in the United States post-evacuation in 2021. We illustrate through the case study of a school-aged child an integrative approach relevant for both school and mental health counselors.
Operation Allies Welcome
In August 2021, 76,000 Afghan nationals arrived in the United States under Operation Allies Welcome, an emergency evacuation effort after the American withdrawal from Afghanistan and subsequent takeover by the Taliban (U.S. Department of Homeland Security, 2022). Before arrival, these Afghans completed a rigorous health and security screening process and were granted humanitarian parole to enter the United States (U.S. Department of Homeland Security, 2022). This parole status allows individuals to enter the country without a visa in cases of humanitarian concern or benefit to the United States (National Immigration Forum [NIF], 2021), such as requiring protection from harm, seeking critical medical treatment within the United States, caring for a sick relative living in the United States, attending a funeral, or participating in a legal proceeding. Under this status, Afghan evacuees were allowed to remain in the country and to work legally for a period of 2 years. Similar past evacuation efforts occurred after the Hungarian Revolution in 1957, the withdrawal from Vietnam in 1975, the withdrawal from Iraq in 1996, and the evacuation of interpreters from Iraq in 2007 (NIF, 2021).
The recent exodus of displaced persons from Afghanistan after the U.S. withdrawal joined refugees fleeing the country in response to decades of conflict and hardship, including the Soviet invasion in the 1980s, civil war in the 1990s, the Taliban takeover in 1996, and the American invasion in 2001 (Montalvo & Batalova, 2024). Once in the United States, Afghan parolees were initially housed at Army base camps across the country (which closed by February 19, 2022), until referred to a refugee resettlement agency for permanent resettlement. Parolees had 2 years to apply for an immigration status that allows for a pathway to citizenship, such as asylum or a special immigrant visa (SIV; Bruno, 2023). This process differs from the typical refugee resettlement process, in which refugees must have fled their country because of persecution, been granted refugee status, and been referred to the U.S. resettlement screening process, which can take 5 to 8 years. Refugees who arrive under this process are eligible to work from the day of arrival in the United States and have a pathway toward citizenship.
Although Afghan parolees were deemed eligible for public benefits, resettlement, and other integration services benefits upon arrival to the United States, and were spared the long waiting process for refugee resettlement (Bruno, 2023), they were required to apply for work authorization as well as an immigration status that would allow them to stay in the country permanently (Bruno, 2023). The influx of Afghan migrants also overwhelmed resettlement agencies, many of whom were already operating under limited capacity because of COVID-19 and years of low arrivals (Office of the Inspector General, 2023). Because of the urgency of the evacuation, many of these migrants had little time to prepare or consider the implications of the decision to leave Afghanistan. Some had to leave behind family members, even spouses and children, with no pathway toward family reunification (until the family reunification initiative launched almost 2 years later; Rush, 2023).
Contextual Considerations for Counseling
It is important for counselors not to regard any country as a monolith and to assess the individual ethnic and cultural background of their clients. Afghanistan is diverse, made up of more than 19 different ethnic groups with distinct languages and cultures (Saydee & Saydee, 2025). The two primary languages are Dari and Pashto, and the primary ethnic groups include Pashtuns, Tajiks, Hazaras, and Uzbeks (Saydee & Saydee, 2025). Three-fourths of children in Afghanistan report experiencing violence at home, and children are at risk for child labor, early marriages, sexual violence, military recruitment, and honor killings (Saydee & Saydee, 2025). Although exposure to violence may be prevalent, counselors should never assume that a client is abusive or being abused solely because of ethnicity nor label the culture as inherently violent. Symptoms of trauma, such as hypervigilance and avoidance symptoms, can be exacerbated by honor values in Afghan culture (Missmahl, 2018). For example, an Afghan woman may lean heavily on cultural expectations that she serves as homemaker and caretaker to avoid uncomfortable experiences in a new country. A counselor may not question her behavior out of respect for her cultural beliefs, further enabling her isolation. Alternatively, a counselor may perceive culturally appropriate behavior, such as refusing to be in a room alone with a man, as indicative of paranoia, social phobia, or another pathological symptom.
Socioeconomic circumstances can contribute to psychological distress in children (Golberstein et al., 2019). Counselors may expect that a person who has experienced trauma such as war and sudden flight from their country must be traumatized. They might attribute symptoms of distress to traumatic experiences from overseas, and therefore miss that possible present unemployment, social isolation, homelessness, and/or food insecurity might be responsible for these symptoms (Im et al., 2021). In these cases, counselors should be prepared to investigate and address the socioeconomic circumstances that contribute to psychological distress (Missmahl, 2018).
Uncertain legal status complicates the daily life and integration of Afghan parolees resettled in 2021 and can contribute to symptoms of traumatic distress (Drožđek et al., 2013). The traditional refugee resettlement process includes coordination between several federal agencies, nonprofit organizations, and local communities that includes security and health screenings and clearance overseas, placement and travel, and reception and connection to services (Office of Refugee Resettlement, 2015). Although the initial parole status granted them legal presence for 2 years, they had to apply for employment authorization cards and wait for approval before starting work. Their only pathway toward permanent residency in the United States was to apply for asylum, which can also be an expensive and lengthy legal process, or to apply for an SIV, if they were eligible, by being able to prove that they worked with Americans in Afghanistan for at least 1 year. Asylum involves demonstrating evidence of persecution in the country of origin based on race, religion, nationality, membership in a particular social group, or political opinion (Bruno, 2023). Receiving an SIV involves demonstrating evidence that the Afghan individual assisted the U.S. government in the fight against the Taliban or eligible employment by or on behalf of the U.S government in Afghanistan (Bruno, 2023). Those who left behind immediate family members in Afghanistan had no pathway toward applying for them to join them in the United States.
Grief over separation from family and fear for their safety can be a major source of distress (Bryant et al., 2021), as can fear of discrimination in the United States (Yang et al., 2025). A young person coming to the United States from Afghanistan in 2021 is likely to have lived their whole life under American foreign occupation. Additionally, this person may feel a sense of betrayal for abandoning their country, and that sense of betrayal may color each decision, either to acculturate to American life or to cling to traditional Afghan ways. Afghan evacuees left behind their hometowns and the social structures inherent in them. Hence, practicing their cultural or religious beliefs may be difficult in a new country when these practices involve community, because this new community needs to be rebuilt.
In addressing the psychosocial needs of Afghan children resettled from the evacuation effort, counselors need to provide a comprehensive approach that considers the legal, physical, emotional, and social needs to begin the reconstruction of a new community structure for these children. Miller et al. (2006) conducted a study exploring Afghan conceptualizations of mental health and distress and found that well-being was made up of three areas: community (honor), family (respect, harmony), and the individual (hope, faith, calm). Young refugees, in general, benefit from a multidisciplinary approach (Stammel et al., 2017). Family can be a source of protection, belonging, and strength for immigrant children (Burgos et al., 2017). In Afghanistan, families are often tight-knit, and each contributes to the extended family unit. Although it can be a source of stress, children of immigrants often become involved in caring for parents as adults struggle to navigate new systems (Burgos et al., 2017). At the same time, contributing to the family can increase self-esteem for youth (Burgos et al., 2017). For Afghans, this can be a way of honoring culture, building social support, and promoting self-esteem.
Maintaining ethnic identity, religious practices, and family cohesion can lead to well-being among immigrant children (Burgos et al., 2017). Reimagining ethnic identity in the process of immigration can be a crucial step in integration and identity development. For example, an Afghan child can identify with other refugees from different countries who have experienced a similar process of flight from war and resettlement in a new country. This can be balanced against maintaining other important aspects, such as religious identity. Using religious practices and tenets to resolve family and internal distress can be useful, such as increasing tolerance and patience, practicing listening and respect, and using various relaxation techniques like prayer or aromatherapy (Faqiri, 2018). Children arriving from Afghanistan with humanitarian status are unique from other refugee groups because of the nature of their evacuation directly to the United States and the differences in their immigration status and its implications for long-term integration (Saydee & Saydee, 2025). We highlight these dynamics in the following case study.
Case Study: Aaisha
Ten-year-old Aaisha recalls the dangers of her home country, Afghanistan, and the limitations she experienced growing up in a war-torn country. These dangers forced her family to seek asylum in the United States. During her escape, her immediate family—her mother, father, and younger sister—were unable to stay with other close family members with whom she had grown up, such as her grandparents, aunts, uncles, and cousins. The separation from extended family and subsequent immigration to a new country disrupted her life and continues to affect the life her family is trying to build in the United States, where she now lives and attends elementary school.
While Aashia was still living in Afghanistan, the parents tell the school counselor, she was unable to play outside or attend school because of the danger of sniper and missile attacks. She reports that she even learned to identify what type of weapon was being used based only on the sound it made. Her mother tells the school counselor that they were able to get on a plane out of Afghanistan, during which her younger sister almost died because of the heat and crowded conditions. The family lived on an Army base in Texas for 2 months until they were assigned to a resettlement agency in another state. They have been staying at a local hotel for 2 months since then and are waiting for employment authorization and permanent housing.
Aaisha is struggling to adjust. She fears she is too far behind the other students in her grade at school, and the language barrier prevents her from connecting to classmates or fully expressing herself. She remembers the violence of her home country and, despite the new environment, thinks often about her past, in which she needed to hide. She still misses her extended family and her home in Afghanistan deeply. Leaving her family each day to go to school makes her feel nervous, and when at home, she suffers from restless sleep, further adding to her stress at school. She struggles to pay attention, and her teacher complains that she is distracted and often excuses herself to the restroom, which prevents her from engaging fully in the lessons. She does not want to complain and worry her parents, but the teacher assigned her to sit with two Afghan male students in class who have been in the country longer. They do not speak her language and ignore her when she tries to ask them for help. The girls in the class also seem to laugh at her and make fun of her clothes. At home after school, she procrastinates doing homework, often complaining that she has a headache. She also changes the subject when asked about her school day, frequently reporting that she does not feel well. The school counselor is concerned about Aaisha’s psychological well-being and has approached her and her parents about possible therapy options. The school counselor has suggested that her parents explore art therapy as a constructive way for their daughter to creatively express and process her emotions and trauma. Her parents like this idea but cannot afford therapy or even art classes. The school counselor refers the student to an on-site school-based clinic staffed by clinical mental health interns. The school counselor meets with the intern to discuss her concerns before the clinical mental health intern meets with the client. School-based mental health clinics can be effective and bridge gaps in accessibility for counseling services (Solomon et al., 2020).
An ecological approach can help school counselors promote equity for students like Aaisha (Savitz-Romer & Nicola, 2022). Children develop within and are influenced by multiple levels of society, including the immediate family, school environment, community, and wider sociological forces (Bronfenbrenner, 1979). The ecological approach can be useful in understanding the dynamic factors involved in refugee children’s development and potential areas of intervention (Yoon et al., 2023). Below, we show how an ecological approach can help us understand the case and provide a productive starting point for intervening to help Aaisha.
Ecological Approach
Case conceptualization and treatment planning with refugees should take an ecological approach that considers all relevant factors, highlighting areas of challenge and strength (Yoon et al., 2023). The ecological model attends to different spheres of the child’s life pre- and post-migration. The model includes any education, trauma, information, coping skills, and medical support the child would have received before immigration to a new country (Minhas et al., 2017). Assessing a child’s needs using an ecological approach can provide useful information to important individuals in the child’s life (Minhas et al., 2017), including caregivers, medical teams, pediatricians, physicians, and school staff who can help support successful acculturation. Minhas et al. (2017) developed an ecological approach to assessing risk factors among refugee children. This approach is represented by the acronym EMPOWER: Education, Migration, Parents and family, Outlook, Words, Experiences of trauma, and Resources (Minhas et al., 2017). Using this model, the school counselor and clinical mental health intern meet and discuss the possible ecological factors relevant to Aaisha’s case, applying the EMPOWER model, to coordinate her care. For her educational background, they know that she’s currently in an English as a Second Language (ESL) class and is perceived by her instructor as struggling with attention and focus. She is proficient in both spoken and written Dari and has some proficiency with English. She also experienced an interruption in her formal education because of her migration experience. Her migration experience included a forced migration from her home country to the United States, one that she did not have time to plan or prepare for. Her family was evacuated from Afghanistan and held in a temporary shelter in Texas at a military base for 2 months until they were referred to the local nonprofit agency for 3 months of resettlement services. Her family is now living on a temporary parole status and has to pay a lawyer to help with processing an application for asylum, leading to a more permanent pathway to staying in the United States. For her family, she lives with her mother, father, and sister who serve as a resource and source of strength for her. She is experiencing grief over the loss of her family and social network in Afghanistan. For her outlook, she is motivated to do well in school and to feel a sense of belonging and safety in a community. She worries about her extended family overseas and is troubled by loneliness. Related to words, she speaks Dari and some English. For resources, she can seek support from the local nonprofit that resettled the family and that offers additional social services such as a food pantry, after-school tutoring, and assistance navigating public benefits. She has limited support from the local Afghan community because they were also resettled recently and many of them came from a different ethnic group.
Evidence-Based Treatments
Counselors can help in a variety of ways by addressing grief related to the loss of friends and family, the effects of being a minority, perceived discrimination and acculturation, exposure to trauma and harassment, and the effects of social issues (Beehler et al., 2011; Beiser et al., 2015; Goh et al., 2007; Kopala et al., 1994). To meet the unique needs of children and families, practitioners must use evidence-based interventions, such as cognitive behavioral therapy (Sullivan & Simonson, 2016), while making appropriate adaptations to render them logistically and culturally accessible. Counselors using an integrative approach can utilize evidence-based interventions to address various aspects of the mental health challenges a child is facing. Counselors can focus on grieving the loss of family and friends (Goh et al., 2007), the effect of being a minority (Kopala et al., 1994), perceived discrimination (Beiser et al., 2015) and acculturation (Beehler et al., 2011; Beiser et al., 2015), exposure to trauma (Beehler et al., 2011), harassment, and social issues (Goh et al., 2007). With Aashia, these elements are all involved. She is experiencing migratory grief, which is often unnamed and unrecognized (Yoon et al., 2023), as well as the loss of family, friends, and the comfort of living in a familiar climate, environment, and surrounded by a familiar language. The experience of being perceived as a religious and racial minority in a different social system in the United States is also distressing. Aaisha was exposed to trauma overseas before migration, and the experience of migration and resettlement was further traumatizing. Evidence-based interventions are needed to assist with the processing of trauma associated with these experiences.
School-based mental health professionals can play an important role in offering mental health services for migrant children. Two-thirds of students surveyed said they preferred to seek counseling at school (Fazel et al., 2016; Sullivan & Simonson, 2016). Because of their ability to identify distress, address psychosocial functioning, and implement creative expression (Goh et al., 2007; McNeely et al., 2020), schools are well-situated to support student wellness, offering an opportunity to provide mental health services for migrant children in an acceptable and accessible manner (Sullivan & Simonson, 2016). For Aaisha, the school could be an accessible place to receive these services. The school counselors would not be able to provide the individual treatment themselves, but they can support the on-site clinics and coordinate with the individual practitioners. The school counselors would also be able to organize and offer group sessions to build peer psychosocial support. By providing referrals to individualized services, offering group sessions, and facilitating advocacy to build a welcoming and supportive school environment, the school counselor is meeting ethical responsibilities through a holistic approach (Harrichand et al., 2022).
Art Therapy
Creative expression through evidence-based art therapy provides an outlet for children, such as refugees struggling with traumatic past experiences, and can be an effective way for them to begin to process their complex emotions and trauma (Rowe et al., 2017; Sullivan & Simonson, 2016). In the absence of a shared common language, art provides a mechanism for communication and expression among peers (St. Thomas & Johnson, 2001). Rowe and colleagues (2017) reported that the use of assessment tools like the Diagnostic Drawing Series can be helpful as a baseline because art therapy can initially cause depressive symptoms as the trauma surfaces but ultimately leads to decreased anxiety and depression. If working with Aaisha, the school-based clinical mental health counselor could use art therapy to help reduce her anxiety and depression through either structured drawing or the Diagnostic Drawing Series. Art therapy could also offer Aashia a way to communicate her emotions in a safe environment.
Peer Support and Groups
It is up to counselors to develop an encouraging environment for students to address and process their present and past feelings (St. Thomas & Johnson, 2001). St. Thomas and Johnson (2001) investigated a 12-week program to help children process their feelings through puppetry in a supportive peer group setting. Panter-Brick et al. (2018) found that high levels of traumatic distress can be managed using psychosocial groups. They found that small peer groups help adolescents develop trusting relationships with individuals from different cultures. Groups also have the benefit of supporting acculturation for refugees and immigrants through rebuilding communities and offering opportunities to practice interpersonal skills (Atiyeh et al., 2020). As Aaisha is navigating life in a new country and rebuilding community, the school counselor can provide a group intervention that could assist her in learning new skills and reducing isolation. The school counselor would lead a peer support group for Aaisha and other new students to offer support in acclimating to the school environment, address social skills, and develop peer support. A group intervention can offer an opportunity for the school counselor to address Aaisha’s social needs, facilitating her connection with peers in a supportive environment. The school counselor would also be able to identify shared barriers or concerns new students face in the school and advocate more effectively for a welcoming environment among school faculty, staff, students, and families.
Cognitive Behavioral Therapy (CBT) and Trauma-Focused CBT
Interventions that focus on helping refugees and immigrants through trauma can be very therapeutic (Im et al., 2021). Cognitive behavioral therapy (CBT) interventions like narrative exposure therapy, creative exercises, cognitive restructuring, trauma-focused therapy, and psychoeducation are effective for children with post-traumatic stress disorder (PTSD), anxiety, and depression (Kangaslampi et al., 2015). The clinical mental health counselor working with Aaisha could implement these techniques to treat symptoms of trauma and facilitate adaptive coping techniques for acculturative stress. Trauma-focused cognitive behavioral therapy (TF-CBT) can be used to process and understand trauma (de Arellano et al., 2014). TF-CBT focuses on helping children with processing trauma and working through PTSD, depression, anxiety, and behavioral issues. TF-CBT has also helped counselors work with children who have struggled with depression, PTSD (de Arellano et al., 2014; Scheeringa et al., 2011), and behavioral issues (de Arellano et al., 2014). Scheeringa et al. (2011) completed a 12-session model for reducing PTSD and depression in children. TF-CBT could be productive with a client like Aaisha, who witnessed the danger of sniper and missile attacks. Addressing and focusing on her trauma could help reduce PTSD symptoms over time. The counseling intern working in the school-based clinic would offer TF-CBT to support with art therapy techniques to help Aaisha process grief and past trauma, and to strengthen coping skills to manage worries and anxiety. The counseling intern starts with a thorough informed consent process with both Aaisha and her parents, with an interpreter present to discuss the counseling process, the time limitation of her internship, and the plan for ongoing services after the end of the TF-CBT protocol. The intern develops a treatment plan that identifies manageable goals important to Aaisha for the timeframe they have to work together.
Integrative Approach
Using an integrative, school-based approach that addresses the logistical and cultural needs of the client in treating trauma and adjustment-based concerns, the school counselor working with Aaisha would need to hire a trained contractual interpreter to assist with co-facilitating an integrative group intervention. The school counselor could work with her teachers to identify other girls within her age bracket who might share similar concerns. The group sessions could follow the general protocol of TF-CBT, including psychoeducation, relaxation, affect regulation skills, integration of the trauma narrative, communication skills, and parenting skills. Art therapy techniques at each stage will make activities more accessible and meaningful. These techniques might include creating group murals or collages with coping techniques. While the clinical mental health counselor is working with the students, the school counselor could lead parenting skills and psychoeducation sessions with the parents so that they can be brought into the group sessions to support their children effectively.
Limitations/Considerations
While we offer an integrative approach in this case study, school counselors must account for their school contexts and resource limitations. Within those limitations, we advocate for an approach that honors the client’s cultural background, family and community involvement, and holistic needs for well-being. School and clinical mental health counselors must work in partnership with each other, students, interpreters, families, and wider school communities to meet these needs ethically. The ASCA National Model (2025a) and the ASCA School Counselor Professional Standards & Competencies (2025b) outline school counselors’ responsibility to build partnerships among schools, families, and communities. Seeking supervision and consultation can support creative advocacy efforts to address migration-related trauma and acculturation concerns within resource constraints.
Conclusion
Equipped with background knowledge of migration issues, cultural norms, and relevant social systems as well as skills in evidence-based interventions, advocacy, and cultural brokering, counselors can successfully support refugee and immigrant children in their pursuit of wellness. An ecological approach that includes consideration for poverty, trauma, and culture is best suited to facilitate understanding of both the pressing challenges and areas of strength and resilience among refugee and immigrant children. Counselors are well-positioned in the community and school settings to help facilitate psychosocial adjustment in collaboration with schools, service providers, health care providers, and families.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Shadin Atiyeh, PhD, NCC, ACS, LPC, CCC, CRC, is an assistant professor at Wayne State University. Tahani Dari, PhD, NCC, LPC, is an associate professor at the University of Detroit Mercy. Correspondence may be addressed to Shadin Atiyeh, 5424 Gullen Mall, Detroit, MI 48202, shadin.atiyeh@wayne.edu.
Jun 3, 2026 | Volume 16 - Issue 2
Matthew C. Fullen, Jonathan D. Wiley, Paul M. Delaughter, Connie C. Tomlin, Jordan B. Westcott, Nick Gowen
Older adult living communities (OALCs; i.e., continuing care retirement communities, assisted living facilities, and long-term care settings) are growing in number and complexity, and industry leaders are recognizing that promoting wellness among their residents is a top priority. Although OALCs offer services to keep their residents engaged and active, residents’ emotional needs often go unmet. Adults who reside in OALCs are likely to benefit from counseling services, especially when delivered within a wellness framework; however, there is inconsistent availability of wellness counseling within OALCs. Our article describes how wellness approaches can be utilized, addresses the unique counseling needs of OALC residents, and considers the importance of multicultural competence when serving older adults. The included case study highlights the promise of wellness counseling in OALCs.
Keywords: older adults, counseling, wellness, living communities, assisted living
Older adult living communities (OALCs) play an essential role in promoting multidimensional wellness among older adults (Hettler, 1976). OALCs are growing in number and complexity, and industry leaders suggest that promoting wellness among residents is a top priority (Johnson, 2025). Although OALCs offer services that engage residents’ multidimensional wellness, their mental health needs often go unmet (Fullen, Wiley, et al., 2020). Adults who reside in these communities are likely to benefit from counseling services; however, counseling is not consistently available within OALCs (Fullen, Wiley, et al., 2020).
Concurrent with the population increases of older adults, the number of OALCs, such as continuing care retirement communities, assisted living facilities, and long-term care settings, is increasing across the United States (Christman, 2025). According to the U.S. Census Bureau, by 2060 almost a quarter of all U.S. residents will be over age 65 and life expectancy will reach 85 years (Medina et al., 2020). It is estimated that OALCs will need to hire 1.2 million new employees across professional domains in order to meet residents’ needs and account for this growth in the older adult population (Argentum, 2016).
Demographic and industry trends point to counselors being well-positioned to meet the mental health and emotional wellness needs within OALCs. This is a timely development in the counseling profession, as licensed counselors recently became eligible to enroll as Medicare-eligible providers (Consolidated Appropriations Act, 2023). However, counselors face the challenges of understanding the counseling needs of older adults, practicing culturally competent care, and overcoming the obstacles related to providing professional counseling services within OALCs (Fullen, Wiley, et al., 2020). Therefore, we describe the unique counseling needs of residents of OALCs, as well as specific challenges to providing counseling services within OALCs related to mental health services integration, payment and reimbursement, and counselor education, training, and supervision. Because OALCs are increasingly using a wellness framework in their approaches to older adult health care, we will also describe how wellness can be used to introduce counseling within these settings.
Older Adult Wellness Counseling
To better conceptualize older adult wellness, it is helpful to summarize the eight dimensions of older adult wellness that have been described in our previous work (Fullen, 2019). These dimensions include physical, relational, emotional, developmental, spiritual, cognitive, contextual, and vocational domains. These dimensions are briefly defined in Table 1, with a corresponding assessment question included for reference.
Table 1
Eight Dimensions of Wellness in Older Adulthood
| Wellness Dimension |
Brief Definition (derived from Fullen, 2019) |
Sample Assessment Question |
| Physical |
Taking care of one’s body, as well as attending to needs associated with disability, chronic illness, or pain |
In what ways do you continue to care for your body? |
| Relational |
Maintaining meaningful relationships with friends, family, and others in your community |
Do you feel supported by those around you, and how do you support others? |
| Emotional |
Maintaining hope and resilience in spite of challenges one faces |
Are you content, and do you think you will be in the future? |
| Developmental |
The need to develop healthy, realistic attitudes about growing older |
What does growing older mean to you? |
| Spiritual |
Exploring your meaning and purpose |
Where do you find meaning in your daily life? |
| Cognitive |
Fostering control, self-efficacy, and commitment to brain health and lifelong learning |
How do you exercise your brain? |
| Contextual |
Inhabiting a community where you belong and thrive |
Do you feel secure and supported where you live? |
| Vocational |
Pursuing your life’s calling, regardless of whether the calling is associated with paid work |
What is your calling? |
Wellness Counseling
Multidimensional wellness is based on the assumption that older adults have holistic needs that may reflect intersections between physical, emotional, social, or spiritual domains (Fullen, 2019). Wellness counseling occurs when counselors incorporate multidimensional assessment and treatment planning, a focus on client strengths, and a paradigm shift from addressing illness to promoting growth and self-discovery (Fullen, 2016). Frameworks for wellness counseling across client ages have been described (Ohrt et al., 2019), and specific modifications for using wellness counseling with older adults exist (Fullen, 2019). Wellness counseling has been identified as a strategy to counteract ageism (Fullen, 2019), particularly because of the medicalization of aging and the shift away from illness and client deficits that is emphasized within the wellness paradigm. Because older adult wellness is multidimensional, counselors using a wellness framework may identify several wellness dimensions that correspond with particular presenting problems. Therefore, the practice of wellness counseling begins with a multidimensional assessment of a client’s wellness, followed by a review of the client’s strengths, and ongoing discussion about how to apply these strengths to meet specific, multidimensional wellness goals and challenges that older adult clients may bring to counseling. Consistent with its focus on holism, counselors using a wellness counseling approach emphasize how client strengths can be leveraged to address areas of vulnerability (Fullen, 2016). Areas of strength may be targeted for additional growth, whereas areas of present vulnerability may be highlighted for intervention. As interventions are applied, ongoing assessment of wellness dimensions occurs to advance the pursuit of holistic wellness.
Wellness Challenges Facing Older Adults in OALCs
Older adults residing in OALCs face many of the same challenges as their peers living outside of these settings. Living in a residential setting can provide older adults with security and comfort, enabling them to age in place. Many OALCs offer a range of care options, including independent living, assisted living, skilled nursing, long-term care, and memory care (Shippee, 2012). Although these communities are designed to promote aging well in multiple dimensions (e.g., physical wellness, social wellness, intellectual wellness; Johnson, 2025), some residents will experience wellness challenges that necessitate counseling intervention (Fullen, 2016). Counselors working in these settings need to be prepared to meet residents’ counseling needs and to be aware of the unique challenges that older adults living in OALCs routinely face. When considering how to apply a wellness framework to counseling older adults in OALCs, counselors can respond by engaging clients in dialogue about how common challenges impact their wellness, identifying clients’ wellness strengths, and developing strategies to leverage strengths to address specific challenges.
Grief and Loss
Grief and loss issues are common among older adults. In addition to grief associated with the loss of family members and friends, there are other substantial losses that older adults face, including the loss of independence, home, health and mobility, vision and hearing, career and purpose, finances, preferred living arrangements, and cognitive abilities (Gitterman & Knight, 2019). Sometimes the decision to move into an OALC is made after losing a spouse, which could include a long-term grieving process (Sopcheck, 2020). In some cases, people decide to move into OALCs shortly after retirement, anticipating a comfortable life with fewer responsibilities, appealing amenities, and the comfort provided by being surrounded by others in their same age cohort (Brecht et al., 2009). Considerations of both contextual and developmental wellness can be valuable when responding to grief and loss. For example, asking an OALC client to define what it would look like to feel secure and supported (i.e., contextual wellness) during a period of bereavement may promote their sense of belonging within the OALC, which could contribute to the belief that the next phase of life is still worthwhile (i.e., developmental wellness). Moreover, helping clients identify wellness strengths during a period of grief and loss can be beneficial. For example, an OALC client may experience encouragement at the thought that a deceased loved one would be proud of them for meeting new friends in their OALC community, which reflects a form of relational wellness.
For those moving into these communities shortly after retiring, the loss of career and vocation may result in tremendous challenges (LaBauve & Robinson, 2011). This life stage transition can result in feelings associated with a lack of purpose and belonging, and the loss of a social network that may have been in place for many years (Myers & Degges-White, 2007). Another challenging adjustment for older adults occurs when they are no longer able to drive. This decision is often prompted by other family members who encourage them to stop driving, making many older adults feel as if they have lost a key element of their independence (Bell & Menec, 2015). Supporting clients in reappraising their vocational wellness, which may involve broaching how they continue to pursue a sense of meaning and purpose in their lives, can be beneficial.
Adjustment
In contrast, other older adults are forced to move into these settings because of failing health, mobility issues, or cognitive decline (Krout et al., 2002). Adjustment issues related to failing health can be difficult for older adults, and many live with chronic pain, limited mobility, and full reliance on others for care. Older adults who relocate to an OALC may have left behind a home of many years, familiar surroundings and routines, as well as friends and neighbors. Many older adults are surprised by the intense feelings that arise shortly after moving into a facility (Ayalon & Green, 2012), including an extended period of grief. For older adults who have lived most of their lives in single family dwellings, sharing common areas such as dining halls and activity spaces may be difficult (Chaudhury et al., 2013). These adjustments are particularly pronounced for older adults who transition to higher levels of care in OALCs. Nighttime sleep disturbances are common and may result in a variety of physical and mental health issues (Martin & Ancoli-Israel, 2008). For individuals facing physical health challenges, the dimension of physical wellness may be most relevant. Specifically, encouraging clients to consider ways in which they continue to care for their bodies, despite bodily changes they may be experiencing, can shift the emphasis from a focus on client deficits to one of resilience and strength.
Moving into an OALC is a significant life adjustment that can lead to emotional distress. In the early stages of adjustment, residents may find it difficult to refer to their OALC as their home; instead, they may hold on to emotional connections to their prior residence. They may feel ambivalent and uncertain as they struggle to place themselves within the existing categories of residents, which may reflect the disenfranchisement of their grief and grieving process (Ayalon & Green, 2012). For some, this may be the first time they have been in a setting where most people around them use assistive devices such as canes, walkers, and wheelchairs (Ayalon, 2015). Mental health concerns may rise to a level of depression and/or anxiety. Depression may result from various factors, including the adjustment to living in an OALC, profound grief and loss, failing health, and lack of purpose and belonging (Ayalon & Green, 2012). Anxiety can also be a concern for adults in these settings as they face their mortality, financial worries, fear of decline and death, and loss of independence, which would require them to rely on others for care (Creighton et al., 2016). Understanding the impact of these adjustments on emotional wellness may be an important first step in these cases.
Relationships
One of the most challenging life transitions older adults face is the shift in family dynamics that occurs when children begin to take care of their parents (Branson et al., 2019). As older adults move into advanced levels of care in OALCs, their adult children may experience guilt for having placed their parents in a “home.” This guilt may lead to overinvolvement and overprotection by their children, which can be a source of frustration for the older adults (Davis et al., 2019). For spouses moving into OALCs together, the strain of living in a smaller environment may create tension (Ayalon & Greed, 2016). Oftentimes, one spouse may be the primary caregiver for the other, which can also create relational challenges (Polenick & DePasquale, 2019). Approaching these cases from a relational wellness perspective allows both the counselor and the client to assess changes in their relationship and how clients continue to receive and provide emotional support. The therapeutic relationship can also function as a source of relational wellness, which may provide clients with the foundation they need to pursue other relationships with OALC community members, friends outside the OALC, or family members.
Alzheimer’s Disease and Other Related Dementias
As the size and proportion of the U.S. population aged 65 and older continue to increase, the number of Americans with Alzheimer’s and other related dementias will continue to rise. There are currently an estimated 7.4 million Americans living with Alzheimer’s dementia (Alzheimer’s Association, 2026). Those in the earlier stages of the disease are often undiagnosed and still capable of living independently (Savva & Arthur, 2015). Older adults residing in OALCs during this phase of the disease may withdraw from social activities because of feelings of inadequacy associated with their cognitive impairment (Nelis et al., 2011). Others may not recognize the changes they are experiencing, which can lead to confusion, frustration, and embarrassment in social situations (Robinson et al., 2012). Maximizing the length of independence for those with early-stage dementia is critical because it is likely their last phase of life for living independently. Quality of life is likely to be significantly reduced as the disease progresses. Counselors can play a vital role for these individuals by maximizing the length of time they can live independently. Although counseling can be instrumental for people in all stages of dementia, OALC residents with early-stage dementia may find counseling services particularly beneficial.
Given the complexity of Alzheimer’s Disease and other related dementias, a multifaceted approach to older adult wellness could be useful (Fullen, 2019). By using the eight dimensions of wellness, a counselor may find specific strengths or shortcomings in areas such as relational wellness, cognitive wellness, emotional wellness, or contextual wellness. Clients who are caregivers may have needs in the same dimensions, as well as in areas such as vocational wellness, developmental wellness, and spiritual wellness. Identifying wellness dimensions in which clients and caregivers maintain strengths may be a helpful strategy in maintaining quality of life and bolstering a sense of resolve during what can be an overwhelming and discouraging experience.
Substance Misuse
As the Boomer generation (i.e., adults born between 1946 and 1964) continues to enter older adulthood, a growing number of older adults are at risk for alcohol and substance abuse (Barry & Blow, 2016). Misuse of alcohol and prescription drugs among older adults is currently higher than in previous generations, partially attributed to the 25% of older adults who are prescribed potentially addictive psychoactive medications, which are the most prevalent medications prescribed to this age group (Ogbonna & Lembke, 2019). Older adults residing in OALCs typically have convenient and frequent access to alcohol at planned social gatherings. Researchers assert that alcohol may be used as a coping mechanism for those living in these settings (Sacco et al., 2015). There may be less concern about limiting social drinking, as driving is less common. However, there are numerous negative consequences for older adults, including increased fall risks and harmful drug interactions (Barry & Blow, 2016). Many older adults are unaware of substance abuse ramifications, particularly related to the physiological changes related to aging that make them more vulnerable to these adverse effects (Williams et al., 2005).
Counselors can play a supportive role for these older adults through both psychoeducation and professional treatment. Problematic substance use has a multifaceted connection to wellness, requiring counselors to consider an array of relevant wellness dimensions, such as physical wellness, emotional wellness, and relational wellness. Once one or more areas of wellness are identified for greater emphasis during treatment, it is also important to discuss which areas of wellness continue to be sources of strength. For example, an OALC resident whose alcohol use has negatively impacted their relationships may describe how taking care of their body through walking or lifting weights (physical wellness) continues to provide a healthy sense of control and self-efficacy (cognitive wellness).
Ageism
Counseling professionals in OALCs should be knowledgeable about experiences associated with aging, including societal stigma against older adults. Ageism, or prejudice, stereotyping, and discrimination against older adults based on age (Butler, 1969), negatively influences older adults’ mental health (Gendron et al., 2016). Like other forms of prejudice, ageism is systemic (Fullen, 2018).
For example, stereotypes about older adults permeate American culture and can lead to poor mental health outcomes for older adults (Fullen, 2018). Systemic ageism is reinforced by individual, interpersonal expressions of ageism, which older adults may experience from medical professionals, family members, and even OALC staff.
Furthermore, older adults may assimilate negative stereotypes about aging and late life into their self-concept, leading to internalized ageism, through which they may believe negative stereotypes about themselves or discriminate against other older adults (Gendron et al., 2016). Counselors working in these settings should be aware of the impact that ageism can have on older adults and remain vigilant in identifying ways in which ageism is organizationally embedded in OALCs. Attitudes toward aging contribute to a person’s developmental wellness, which can be more broadly assessed through therapeutic dialogue (Fullen, 2019). When clients describe internalized aging attitudes, it is important to identify the origin of these messages. Gently challenging these ageist assumptions can enhance the therapeutic relationship (relational wellness) and result in a greater sense of resilience (emotional wellness) and self-efficacy (cognitive wellness).
Culturally Responsive Care With Older Adults in OALCs
In addition to being prepared to work with a wide variety of clinical concerns using a wellness framework, counselors working in OALCs should be prepared to work with clients from many different backgrounds with diverse lived experiences. It is important to ask clients how their sociocultural experiences, as well as gender, socioeconomic status, and religious affiliations, influence how they define the eight dimensions of wellness for themselves. Counselors can best meet their clients’ needs when they understand clients contextually, considering the unique experiences that have informed clients’ lives based on their sociocultural identities (Ratts et al., 2016). Although all clients have specific cultural considerations counselors should attend to, counselors who desire to work in OALCs must be aware of specific issues in later life and how sociocultural factors can influence development across the lifespan (Fullen, 2020b).
Use an Intersectional Lens
Counselors who practice in OALCs will undoubtedly work with clients who have been impacted by ageism. However, many clients will hold additional marginalized identities that influence their experiences of aging and ageism. The intersection of age with other marginalized identities significantly alters the experiences of aging for older adults (Wang et al., 2025). Crenshaw (1989) introduced the construct of intersectionality to explain how occupying two or more marginalized positionalities creates a gestalt experience of discrimination. Intersectionality is a framework that enables people to understand how interlocking systems of oppression can exacerbate one another, creating a unique experience for individuals who hold multiple minoritized identities (Crenshaw, 1989). In essence, understanding clients in OALCs through an intersectional lens is crucial for developing a nuanced understanding of their experiences and clinical concerns. Therefore, in addition to the necessity of understanding systemic ageism (Fullen, 2018), counselors who provide services in the context of OALCs should be aware of the unique intersections other sociocultural factors can have with age in such settings.
Social determinants of health, such as race/ethnicity, gender/gender identity, sexual orientation, and socioeconomic status, influence clients’ mental health across the lifespan, with some effects emerging in later life (Allen et al., 2014). Additionally, there is evidence that inequity across the lifespan leads to poorer mental health outcomes in older adulthood for marginalized groups, such as racial/ethnic minority older adults (Ferraro et al., 2017); lesbian, gay, bisexual, and transgender (LGBTQ+) older adults (Fredriksen-Goldsen et al., 2017); and older adults with disabilities (Kattari et al., 2017). These findings suggest that the older adults who are most likely to need counseling are also more likely to have experienced unique intersectional challenges. Therefore, understanding clients’ contexts and backgrounds, selecting appropriate interventions and assessments that account for clients’ unique cultural considerations, and providing opportunities for clients to process experiences of discrimination and stigma are all critical components of culturally competent care for all clients.
Broach Culture
Counselors should endeavor to learn about their clients’ cultures, broach cultural differences, select culturally appropriate interventions and assessments, and engage in advocacy within OALCs to ensure equitable access to resources and programming (Day-Vines et al., 2007; Ratts et al., 2016). To understand the salience of client identities and how these identities have influenced the client’s life, it is crucial to directly discuss both the client’s culture and the cultural differences between the counselor and the client early in the counseling process (Day-Vines et al., 2007). Broaching the client’s culture provides them with the opportunity to share their most salient identities, how those identities have shaped their lives, and how those identities influence their experience in their OALC. This strategy also provides an opportunity for the counselor to demonstrate cultural humility and indicate that they will not perpetuate the same harm that clients may experience from staff or other residents in the community.
Similarly, counselors must commit to learning about their clients’ cultures, including the influence of age and generational cohort (Ratts et al., 2016). For example, counselors who work in OALCs should familiarize themselves with adult development and aging rather than educating themselves on the basics related to that process. By developing a knowledge base around the aging process, counselors create space for their clients to share their unique experiences of aging. In order to conceptualize their clients through an intersectional framework, counselors should also research how aging is perceived in the various cultures their clients belong to (Ratts et al., 2016). This approach may require the counselor to develop self-awareness concerning implicit biases they may possess regarding their clients’ cultural identities to ensure that they do not contribute to their clients’ experience of marginalization. Particularly salient is ageism, which counselors may invoke in counseling if they do not develop awareness around their biases related to the aging process (Fullen, 2018). In learning about their clients’ cultures, counselors have the opportunity to select interventions and assessments that are culturally appropriate based on age and other sociocultural factors that impact the client.
Address Systemic Barriers
Finally, inequitable access to resources impacts older adults who reside in OALCs. Counselors should advocate within their workplace to address systemic barriers to access within the community (Ratts et al., 2016), help specific clients access necessary resources (Ratts et al., 2016), and develop programming that meets the unique needs of residents who are disproportionately impacted. Ultimately, counselors must attend to their clients’ holistic cultural experiences and maintain an awareness of the risks posed to older adults by a lifetime of marginalization. An essential consideration for culturally responsive work with older adults is selecting appropriate theory and empirically sound interventions.
Case Study
Michelle, a licensed counselor, begins a new staff position at a local continuing care retirement community, where she will provide talk therapy services to residents. This is the retirement community’s first counselor, and Michelle understands that this may be some of the residents’ first experience with a mental health professional. To broach the topic of mental health at a services fair hosted by the community, Michelle creates a booth and designs a flyer outlining the eight dimensions of wellness and describing how they relate to older adult mental health. Residents stop by Michelle’s booth at the services fair, and she uses the tool as a conversation starter about mental health and also a preview of what working with her in individual therapy sessions may entail.
One community resident, Roy, tells Michelle that he is struck by her description of vocational wellness, particularly the question, “What is your calling?” Roy admits that he has only thought about “vocation” in terms of his career, from which he retired over a decade ago. He tells Michelle that he has been struggling with the concepts of purpose and meaning since moving to the community, and Michelle invites Roy to schedule an individual session with her to discuss these ideas in depth.
During their intake session, Michelle reminds Roy of the eight dimensions of wellness and asks him to point out any dimensions that are going particularly well in his life. She also broaches culture with Roy and invites him to share how aging is viewed among people who share his cultural background. Roy remarks that he had previously seen aging as “only going downhill” and admits that he has not thought about his wellness so much as his illness. Michelle uses this as an opportunity to take a strengths-based approach with Roy, explaining that enhancing certain aspects of wellness can help offset any inevitable or sudden deterioration in other aspects of wellness. Hearing this, Roy describes his robust social life in the retirement community—a sign of high relational wellness—and how his relationships increased his well-being, in spite of a worsening eye condition that has left him unable to see far distances (an example of decreasing physical wellness). Michelle notes how Roy’s increased relational wellness may be positively offsetting his declining physical wellness; she uses this as an example of the importance of a holistic approach to wellness in Roy’s life. Michelle and Roy decide to include vocational, physical, and relational wellness in Roy’s treatment plan. Together, they decide on three counseling treatment goals: 1) Determine what gives Roy meaning and purpose, and identify concrete actions to incorporate meaning and purpose into each day (vocational wellness); 2) Care for his eyesight as best he can while also maintaining a healthy diet and routine exercise in consultation with his primary care provider (physical wellness); and 3) Invest in existing and new friendships within his OALC with a goal of thriving in the area of relational wellness.
After the initial session, Michelle reflects on her session with Roy. She is pleased that the eight dimensions of wellness provide her with a helpful, strengths-based lens through which to view aging and older adulthood. She reflects that previously in her career, she overly focused on older adults’ physical wellness, often medicalizing the aging process and “othering” aging bodies. By exposing herself to a holistic approach to older adult mental health, Michelle challenges her own ageist beliefs and behaviors and notes that wellness can exist at any age.
Challenges Facing Counselors Working in OALCs
Despite the numerous benefits of integrating wellness-based counseling services within OALCs (Fullen, 2020b), there are several challenges to consider. Historically, OALCs have been slower to integrate mental health services compared to medical services. Payment barriers for counseling have historically interfered with creating opportunities to work within this context. Finally, there are barriers associated with how counselor education programs prepare students, which have limited the growth of counseling within OALCs. The following section will describe each of these barriers.
Mental Health Services Integration Challenges
Although older adults’ mental health needs are well documented (Moye et al., 2019), the number of OALCs that employ or contract with a mental health professional is unclear. In a large survey of counseling professionals, only 1.6% described 65 years of age and older as a primary area of clinical emphasis (Fullen, Lawson, & Sharma, 2020). Additionally, in a study of psychologists, scholars found that only 1.2% described geropsychology as a specialty area (Moye et al., 2019). Moye and colleagues found that psychologists who specialize in working with older adults were more likely to work in independent practice, including over half of private practice practitioners. However, it is not clear how often their services were integrated into OALCs.
The presence of counseling services within long-term care settings is slightly more apparent. A survey of Florida nursing homes indicated that approximately 50% had a psychiatrist and a psychologist present at their site on a weekly basis. However, 90% of these providers were independent practitioners who were not formally affiliated with the long-term care facility (Molinari et al., 2009). Meanwhile, wellness programming, which aims to address the holistic needs of OALC members, is increasingly being implemented within OALCs, particularly in communities that provide ongoing care to older adults as their needs evolve. Those wellness initiatives are often focused on enhancing physical and social wellness (Edelman et al., 2010), frequently excluding other dimensions, including psychological or emotional well-being (Fullen, Wiley, et al., 2020).
Counselors who aim to work within OALCs should consider that some residents prioritize finding resources available on the community’s campus over seeking counseling services outside the community (Plys & Kluge, 2016). This suggests that until counseling services are offered in the OALC setting’s immediate vicinity, residents may continue to experience a barrier to access. Therefore, efforts are needed to integrate counseling services into the range of other on-site services offered directly to OALC residents (Fullen, Wiley, et al., 2020). Two other barriers are payment challenges and a dearth of training opportunities for working with older adults in counselor preparation programs.
Counselor Education, Training, and Supervision Challenges
Developing counselor training opportunities to provide services for older adults, including those who reside in OALCs, is an additional barrier that must be addressed. Historically, the counseling profession has not adequately prioritized the counseling needs of older adults. For example, the 2016 Standards of the Council for the Accreditation of Counseling and Related Educational Programs (CACREP) failed to include any reference to terms like old, older, older adults, or ageism, and only one reference each to the words age and aging (CACREP, 2015; Fullen, 2018). A content analysis of 26 years of research in the counseling profession indicated that only 1.6% of all publications focused on issues associated with aging (Fullen et al., 2019). However, following revisions to the Medicare mental health law, there have been recent indications that efforts to equip counseling students and counseling professionals to work with older adults are underway. The 2024 CACREP Standards include subtle improvements, such as including age and generational status in glossary definitions of diversity, cultural identity, and marginalized populations (CACREP, 2023). This reflects the viewpoint that older adults should not be overlooked in discussions of how social and cultural identities impact the needs of clients. There is evidence that exposure to working with older adults and greater self-efficacy around this work are associated with increased interest in working with older adults (Schmidt et al., 2024; Wagner et al., 2019). Likewise, Moye et al. (2019) found that psychologists expressed a strong interest in further gerontology education on depression, dementia, anxiety, bereavement, caregiver stress, and adjustment to medical illness or disability. These findings suggest that there is recognition of the need for greater emphasis on aging-related topics during training programs and beyond.
To address this shortage of training opportunities, developing partnerships between university-based mental health training programs and local OALCs is essential (Silva-Smith et al., 2011). Fortunately, OALCs near universities are common and university-based OALCs are popular among older adults (Gresham, 2024). Expanding counseling services in OALCs by embedding a mental health trainee represents an innovative approach to service delivery that is mutually advantageous for students, training programs, community residents, and the OALC (Fullen, Wiley, et al., 2020). Anecdotally, we have curated a counselor training program within a local OALC. Recognizing the need for emotional well-being supports, the counselor training program at Fullen’s university (Virginia Tech) partnered with a local OALC in 2018 to launch an innovative program in which graduate students in counseling provide pro bono counseling services to older adults. Individual, couples, and group counseling services are provided to residents in independent living, assisted living, skilled nursing, and long-term care, resulting in a diverse array of opportunities to address unmet mental health needs and promote emotional well-being.
This partnership alleviates cost barriers by enlisting graduate students who are completing their clinical internships. Accessibility concerns are mitigated by integrating the counseling services directly on the OALC campus. By making counseling available and visible within the community, stigma about working with older adult clients appears to be shrinking. Students are exposed to older adults’ mental health needs within their counselor training program using a strengths-based wellness model. This approach introduces students to the effectiveness of counseling services for older people while addressing myths about aging. Counseling services are advertised at the site’s health and wellness fair, at meet and greets, and in the OALC newsletter. Referrals from site staff or other residents are customary. Overall, the services have been well-received by residents of the community. The OALC, counselor training program, and counseling interns all report a high degree of program satisfaction.
Future Research
There is considerable opportunity for future research to illuminate the impact of wellness counseling within OALCs. For example, outcome research on the use of a multidimensional wellness framework within OALCs, such as the eight-dimensional model previously described, is needed to demonstrate the utility and effectiveness of this approach to counseling. Similarly, research demonstrating whether certain wellness dimensions are prioritized more or less by OALC clients would be useful. If more counselor training programs are developed within OALCs, future research on the supervision of counselor trainees using wellness counseling within OALCs would be beneficial.
In addition to a focus on wellness counseling outcomes, more research on multicultural competence when working with OALC clients is necessary. For example, research is needed to improve the practice of broaching in the areas of age and ability, given the fact that most counselors and counselor trainees will hold chronological ages, and in some cases ability levels, that differ from their OALC clients. Studies are needed to better understand how counselors proactively engage their older adult clients in dialogue around age identity, age differences, ageism and ableism, and the potential for misunderstanding within the therapeutic relationship based on these differences.
Conclusion
In conclusion, OALCs are an emergent setting for the delivery of wellness counseling services. The interest in wellness among industry leaders, combined with a growing awareness of the mental health needs of older adults, suggests that OALCs have a great deal of potential for counselors. By incorporating multidimensional wellness approaches that are responsive to the unique needs of older adults, counselors have an opportunity to expand their footprint and promote mental health and well-being across the lifespan.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Matthew C. Fullen, PhD, LPCC (OH), is an associate professor at Virginia Tech. Jonathan D. Wiley, PhD, LPC (VA), is an assistant professor at Tennessee Tech. Paul M. Delaughter, PhD, LPC (VA), is an assistant professor at Appalachian State University. Connie C. Tomlin, MA, LPC (TN), is the owner of Tomlin Counseling & Consulting. Jordan B. Westcott, PhD, NCC, is an assistant professor at the University of Tennessee-Knoxville. Nick Gowen, LPC (CO), is a counselor at Verve Therapy. Correspondence may be addressed to Matthew C. Fullen, Virginia Tech, School of Education, 1750 Kraft Drive, Blacksburg, VA 24061, mfullen@vt.edu.
Apr 1, 2026 | Volume 16 - Issue 1
Emily Goodman-Scott, Rawn Boulden, Aaron Albright, Jenna Alvarez, Betsy M. Perez
The counseling profession is rooted in prevention, wellness, mental health, and a critical social justice approach to serving historically marginalized communities, including people with disabilities. The overarching construct of disability comprises subtypes, such as neurodivergence. Given the prevalence of neurodivergent individuals worldwide (approximately 15%–20%), the counseling profession must be prepared to support this community. At the same time, there is a dearth of peer-reviewed literature on neurodiversity specifically for the counseling profession. In this article, we address a timely topic in the profession. We discuss utilizing a critical counseling lens and centering marginalized identities, such as people with disabilities; prominent disability models, including the neurodiversity paradigm; and suggestions to infuse neurodiversity throughout the counseling profession.
Keywords: neurodiversity paradigm, disabilities, counseling, neurodivergence, disability models
According to the American Counseling Association (ACA), “counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan et al., 2014, p. 92). These ACA priorities are echoed in seminal counseling texts. The Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) outline the counseling profession as grounded in a culturally affirming, contextual approach to address systemic oppression and intersectionality. The ACA Advocacy Competencies also center context and identities as critical in advocating for systemic change (Toporek & Daniels, 2018). Thus, the counseling profession promotes a strengths-based approach to prevention and mental health, centering equity, social justice, and the use of a critical lens, particularly for those with marginalized intersectional identities (Hays & Singh, 2023; Proctor & Rivera, 2022).
People with disabilities (PWDs) are a historically marginalized identity or culture that includes neurodivergent individuals (Deroche & Mautz, 2024; Long et al., 2024; Roberson et al., 2021). Because of the prevalence of neurodivergence worldwide (15%–20%; Doyle, 2020), allied professions have started incorporating the neurodiversity paradigm into their scholarship, including psychology (Pellicano & den Houting, 2022), occupational therapy (Chen & Patten, 2021; Rajotte et al., 2025), and speech-language pathology (DeThorne & Searsmith, 2021). However, the neurodiversity movement is largely absent from the peer-reviewed counseling literature (Long et al., 2025). In this article, we fill a gap in the literature, noting: (a) a critical counseling lens and the importance of centering marginalized identities, such as PWDs; (b) prominent disability models, including the neurodiversity paradigm; and (c) suggestions to infuse neurodiversity throughout the counseling profession.
Critical Theories
Overall, critical theories are an overarching paradigm centering the importance of recognizing and changing systemic oppression, advocating for historically marginalized identities, and emphasizing the impact of intersectionality (Hays & Singh, 2023; Proctor & Rivera, 2022). First, critical theorists view the world through the socially constructed dimensions of power, privilege, and marginalization, which suggests that power structures in society were historically developed and are presently maintained to provide power and privilege to some and oppress and marginalize others. These power structures will continue unless identified (i.e., increase critical consciousness) and actively changed (i.e., interrogate and dismantle oppressive systems and move toward more equity and justice). For instance, according to critical theories such as feminism and critical race theory (CRT), dominant established power structures, such as patriarchy and colonialism, should be challenged. Overall, critical theorists prioritize historically marginalized voices and strive to ensure that knowledge is rooted in these communities rather than imposed by dominant outsiders (Hays & Singh, 2023; Proctor & Rivera, 2022).
Next, intersectionality is also central to critical theories (Hays & Singh, 2023; Proctor & Rivera, 2022). Introduced by Kimberlé Crenshaw (1989), intersectionality is a framework that examines how overlapping social identities, such as race, gender, class, and disability, interact to create unique experiences of oppression, privilege, and power. Crenshaw introduced the term to address the ways in which Black women, for example, were often excluded from both feminist and anti-racist discourses, revealing how single-axis analyses failed to capture their experiences. Intersectionality does not simply add identities together. Rather, it highlights how these identities interlock within systems of power and shapes how individuals navigate the world. Therefore, intersectionality accentuates how social activism dismantles systems of oppression and injustice.
Critical Theories and Counseling
Drawing from critical theories, the counseling profession works to expose and uproot oppressive systems that reinforce privilege for some identities while suppressing others (Hays & Singh, 2023; Proctor & Rivera, 2022). Ratts et al. (2016) developed the seminal MSJCC, which underscores the need for counselors to engage in intersectional and social justice practices, as well as acknowledges the impact of marginalized and privileged identities within the counselor–client relationship. Similarly, ACA (2025) has reinforced the crucial need for counselors to support marginalized populations because of the prevalence of systemic injustices.
As such, several scholars have discussed the importance of CRT and anti-racism within counseling. Holcomb-McCoy (2022) called for the counseling profession to utilize an anti-racist lens to interrogate and change inequitable systems that disproportionately harm those with marginalized racial/ethnic identities. Similarly, Mayes and Byrd (2022) proposed a framework for anti-racist school counseling emphasizing critical consciousness, evidence-based practices, and strategies to interrupt harmful school policies. Haskins and Singh (2015) recommended pedagogical strategies for incorporating CRT into counseling programs to promote counselor trainees’ racial awareness.
In a similar vein, scholars like Sharma and Hipolito-Delgado (2021) and Locke (2021) reflected on the role of feminist and Latino CRT, respectively, in fostering critical consciousness and anti-racism in counselor training, particularly for students from marginalized groups. LaMantia et al. (2015) also applied feminist pedagogy to counselor education, promoting student ally behaviors. Further, Shavers and Moore (2019) incorporated Black Feminist Thought to explore the experiences of Black female doctoral students at predominantly White institutions.
Finally, several scholars have utilized a critical lens when discussing LGBTQ+ communities. Moe et al. (2020) brought post-colonial theory to the fore in their exploration of working with LGBTQI+ youth internationally by advocating for culturally aware counseling practices that address Eurocentric biases. Also, Moe et al. (2017) applied queer theory to support queer and genderqueer clients through emphasizing the importance of acknowledging intersectional identities and the unique needs of queer people of color. Similarly, Smith (2013) applied critical theory to LGBTQ+ youth in schools and addressed the capability of the American School Counselor Association’s National Model (2025) to reinforce or dismantle heteronormativity practices. Overall, counseling scholars have applied a critical lens (e.g., CRT, anti-racism, feminism, queer theory) to serve several historically marginalized identities. However, a focus on PWDs and critical disability theory (CDT) is absent from this body of critical counseling scholarship.
Disabilities
Those who identify as PWDs are part of one of the largest historically marginalized groups in the United States, with a population of over 70 million (Centers for Disease Control and Prevention [CDC], 2024). Though the construct of disability can be understood in a variety of ways, we utilize the definition from the U.S. Census Bureau (n.d.): “Disability is a complex process between an individual’s physical, emotional, and mental health, and the environment in which they live, work, and play. . . . individuals may experience disability if they have difficulty with certain daily tasks due to a physical, mental, or emotional condition” (p. 1).
In Multicultural and Social Justice Counseling (2024), authors Deroche and Mautz organized disabilities into three primary categories: (a) physical disabilities, such as paralysis, chronic illness, or blindness; (b) cognitive or neurodivergent disabilities, such as learning, developmental, or intellectual disabilities, including autism spectrum disorder or dyslexia; and (c) psychiatric disabilities, including mental health disorders such as anxiety, depression, and substance use, among others. Further, these authors also relayed that disability is an overarching term to represent diverse, varied, intersecting identities and experiences that are shaped by factors such as disability onset, symptom progression and impact, degree of visibility, and disability models.
Disability Models Historically
The construct of disabilities must be understood within its historical context. U.S. society has utilized several models of disability that have evolved over time (Brown, 2015; Deroche & Mautz, 2024; Olkin, 2002). The moral model is one of the oldest and is closely tied to religion; this perspective holds that disabilities are inherently negative and result from one’s lack of faith or as punishment for immoral behaviors (Deroche & Mautz, 2024; Olkin, 2002). The moral model is seen as problematic because it views disabilities adversely and places responsibility on the PWD for their condition, fostering stigma and shame rather than understanding or support.
More recently, disabilities have been conceptualized by two opposing perspectives: the medical model and the social model. Per the medical model, conditions or disorders are classified by the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2022), and pathologized as impairments or deficits that deviate from a set standard and need to be treated (Brown, 2015; Chen & Patten, 2021; Long et al., 2024; Olkin, 2002). Thus, the medical model recommends that PWDs receive intervention and accommodations to help them operate more closely to a culturally constructed standard of typical. The medical model is currently the most widely utilized disability model, including in the counseling profession. However, this model is critiqued as being deficit-focused and needing greater consideration for both culture and context (Chen & Patten, 2021; Deroche & Mautz, 2024; Olkin, 2002). Further, privileging and encouraging assimilation to a socially constructed norm has been related to adverse mental health for PWDs, such as anxiety and depression from masking or hiding aspects of oneself from others (DeThorne & Searsmith, 2021).
Countering the medical model, the social model considers disability as a social construct, which places the onus on the environment and larger culture, with the aim of removing socially created barriers hindering PWDs from fully accessing societal institutions and spaces (Chen & Patten, 2021; Long et al., 2024; Olkin, 2002). In other words, according to the social model, PWDs are impacted not by their specific disability, but because of how society has structured the world to be unaligned with the unique needs and experiences of PWDs. Scholars have also suggested that the social model is too concrete (Meekosha & Shuttleworth, 2009) and that disabilities must be considered comprehensively, beyond environmental and cultural factors (Dwyer, 2022).
Contemporary Disability Paradigms
Overall, disability models have been shaped by societal beliefs and historical events, evolving with time, as described by Brown (2015) and Deroche and Mautz (2024). Beginning in the mid-1900s, the larger civil rights movement opened doors for federal protections around disabilities and was crucial in securing legal protections and advancing social inclusion for PWDs. Specifically, the disability rights movement initially addressed workplace discrimination, striving for equitable access to employment and work accommodations; this has since progressed to include advocating for more disability inclusive education, health care, and intersectional identities. Hence, the confluence of these factors—evolving disability models, increased civil rights, activism, and centering diversity—have led to the emergence of the present-day neurodiversity paradigm, a contemporary model of disability rooted in critical theories, such as CDT (Brown, 2015; Deroche & Mautz, 2024).
Critical Disability Theory
Expanding upon the social model, CDT explores the broader systems and structures that influence disability (Botha & Gillespie-Lynch, 2022; Hays & Singh, 2023). In alignment with the overarching lens of critical theories, CDT is a framework that challenges previous models of disability to instead espouse the complex experience of PWDs, centering the voices of this marginalized identity or cultural group (Gillies, 2014; Meekosha & Shuttleworth, 2009). Gaining momentum in the 2000s, CDT explores how society constructs, defines, and responds to disabled bodies and minds within the context of systemic power, privilege, and marginalization (Meekosha & Shuttleworth, 2009). Rather than defining disability as abnormal or a medical condition requiring treatment, CDT challenges these prevailing views. Mainly, scholars who subscribe to this paradigm recognize disability as a natural aspect of society, with the need to transform public policies and perceptions, as well as redistribute power, control, and autonomy (Deroche & Mautz, 2024; Long et al., 2024). As such, supporters of CDT advocate to ensure that PWDs can fully participate in all aspects of society such as employment and social and educational dimensions, as well as having equitable access to rights, opportunities, and resources. Thus, the CDT paradigm, grounded in social justice, activism, and the disability rights movement, calls for viewing disability as a unique culture, a dimension of diversity, and through the lens of historically marginalized, intersectional identities or cultures.
The Neurodiversity Movement
While CDT is a critical theory applied toward disabilities, it has also been a driving force in the neurodiversity movement (Roberson et al., 2021). Chapman and Botha (2023) stated:
The neurodiversity movement is a social justice and civil rights movement led by and for people with neurocognitive, developmental, and psychological disabilities. Neurodiversity theory proposes that divergence from expected functioning (such as autism, attention-deficit/hyperactivity disorder [ADHD], developmental coordination disorder, or dyslexia) are natural variations of human minds, and those who diverge from the norm (neurominorities) are equally deserving of dignity, respect, and accommodation. . . . with the acknowledgement of neurocognitive diversity as natural, valuable, and in need of support. (p. 310)
While neurodivergence is considered to be a type of cognitive disability (e.g., autism, ADHD, dyslexia) impacting approximately nearly one in five individuals worldwide (Doyle, 2020), the neurodiversity paradigm is a larger movement rooted in social justice and civil rights, countering earlier deficit-based disability models, such as the medical model (Deroche & Mautz, 2024; Long et al., 2024; Sonuga-Barke & Thapar, 2021). As a result, neurodiversity is seen as a movement or paradigm influenced by CDT, in addition to being a type of disability.
The neurodiversity movement began in the 1990s with sociologist Judy Singer drawing on Crenshaw’s lens of intersectionality (Botha & Gillespie-Lynch, 2022; Chapman, 2021). Though originally conceptualized for autism, this paradigm has since expanded (Chapman, 2021; Dwyer, 2022). Rather than perpetuating a continuum of typical and atypical neurological functioning, the neurodiversity paradigm reinforces normal diversity in human neurology instead of pathologizing neurological variations (Chapman, 2021; Chen & Patten, 2021; Olkin, 2002).
Because it is aligned with critical theories such as CDT (Hays & Singh, 2023; Roberson et al., 2021), neurological diversity should be viewed through the lens of culture (Long et al., 2025), as well as through societal and historical systems of power and oppression. Thus, like other historically marginalized groups (e.g., cultural, ethnic, and sexual minorities; Chapman & Botha, 2023), proponents of the neurodiversity movement describe unique aspects of a shared culture, pride, and identity (Brown, 2015). One such example is identifying as neurominorities (Chapman & Botha, 2023).
For instance, Roberson and colleagues (2021) posited that, historically, neurodivergent individuals have been viewed through an ableist lens that judged them based on their ability to conform to neurotypical standards. A CDT approach denounces this deficit-based historical framing and instead highlights the positive cognitive traits and leadership of neurodivergent individuals. Rather than emphasizing the obstacles they face in meeting conventional norms, CDT and the neurodiversity paradigm redefine neurodivergence as a valuable and distinctive strength and skill set that can be used for enhancement (Roberson et al., 2021).
Furthermore, scholars have examined the confluence of neurodiversity and intersectionality (e.g., Mallipeddi & VanDaalen, 2022). Botha and Gillespie-Lynch (2022) made the case for including the neurodiversity paradigm within the intersectionality conversation, specifically focusing on autistic individuals. Namely, they highlighted the systemic barriers and inequities disproportionately impacting the Autistic community. This includes restricted access to gender-affirming care for autistic transgender people, which can correspond to increased odds of mental health challenges such as depression and suicidality (Tordoff et al., 2022). Furthermore, these risk factors may be compounded when additional identities are incorporated, such as when persons of color are also economically disadvantaged individuals (Botha & Gillespie-Lynch, 2022). Thus, taking an intersectional lens to the neurodiversity paradigm is not only aligned with CDT, but also exemplifies a more nuanced understanding of how multiple layers of identity or culture (e.g., race, gender, socioeconomic status) interact with neurodivergence in order to address the compounded barriers and inequities faced by marginalized groups. As such, intersectionality has been interwoven into CDT to highlight the layered identities and aspects of power, privilege, and oppression within the neurodiversity movement (Botha & Gillespie-Lynch, 2022).
Counseling, Disabilities, and the Neurodiversity Movement
Despite the prevalence of those with disabilities (CDC, 2024), PWDs are often not seen as an underrepresented group or a culture, leading to misconceptions and often a lack of resources and support (Brown, 2015; Olkin, 2002; Pierce, 2024). Within the counseling profession, Degeneffe and colleagues (2021) studied how disability is addressed in ACA’s flagship journal, the Journal of Counseling & Development (JCD). Their results mirrored previous research, noting “limited scope of disability content in JCD . . . [and that] disability is largely neglected in JCD and other counseling-related journals” (Degeneffe et al., 2021, p. 118).
While counseling scholars have focused on critical theories, the literature on CDT is sparse. Öksüz and Brubaker (2020) discussed the historical lens of counseling PWDs and advocated for CDT to shape counseling training. Aligned with CDT, Pierce (2024) outlined the richness of disability culture, recommending that the counseling profession incorporate greater disability justice.
To our knowledge, there has been one peer-reviewed, U.S.-based journal article discussing the neurodiversity paradigm within the counseling profession. Long and colleagues (2025) conducted a qualitative content analysis, examining 21 peer-reviewed counseling journals published between 2013 and 2022. They searched for what they defined as neurodiversity constructs, or content they conceptualized as relating to neurodiversity. Examples of the most frequent terms, or neurodiversity constructs, that they found include autism, ADHD, and twice exceptional, with the most common word/phrase being neurotypical. Thus, while scholars found counseling scholarship demonstrating neurodiversity constructs, these phrases did not include the actual word or a derivative of neurodiversity. Rather, Long et al. (2025) found content more generally related to the construct. These findings underscore the lack of neurodiversity content within counseling. Though the counseling profession centers critical theories with an emerging focus on CDT, the neurodiversity paradigm is absent from the peer-reviewed counseling literature.
Despite the limited counseling scholarship on the neurodiversity paradigm, a different trend exists within allied professions, and scholars have recommended that clinicians utilize the neurodiversity approach in their work (Chapman & Botha, 2023; Sonuga-Barke & Thapar, 2021). Furthermore, the neurodiversity paradigm is being covered in psychology (Pellicano & den Houting, 2022), occupational therapy (Chen & Patten, 2021; Rajotte et al., 2025), and speech-language pathology (DeThorne & Searsmith, 2021). In terms of therapeutic clinicians across disciplines, Sonuga-Barke and Thapar (2021) described the importance of clinicians moving beyond the deficit-based medical model to instead center the perspectives of neurodivergent individuals. Similarly, Chapman and Botha (2023) stated that the need exists for clinical therapeutic approaches to include practical strategies for supporting neurodiversity, including multidisciplinary work across disciplines.
Incorporating the Neurodiversity Movement Into Counseling: A Call to Action
As Long and colleagues (2025) relayed, “counselors across practice settings encounter neurodivergent clients and are responsible for understanding neurodivergence and its impact on client well-being . . . [and] the social, political, and cultural considerations” (p. 57). As approximately 15–20% of the population is neurodivergent (Doyle, 2020), it is likely that counselors will work with this population. As such, counselors must be informed of the neurodiversity paradigm and how to utilize neuro-affirming practices across counseling specialties and the profession as a whole. Next, we provide a call to action, recommending steps for infusing the neurodiversity paradigm throughout the profession: awareness and introspection; guiding documents; professional organizations; research; clinical practice; and pre-service preparation, supervision, and training. It is important to note that these suggestions are preliminary recommendations acting as a springboard for a litany of additional efforts. More depth and focus are warranted across each of the following topics.
Awareness and Introspection
Neuro-affirming counseling begins by looking at the foundational values guiding our profession. In alignment with critical theories (Hays & Singh, 2023; Proctor & Rivera, 2022), the MSJCC (Ratts et al., 2016), and the ACA Advocacy Competencies (Toporek & Daniels, 2018), we must interrogate and dismantle how the counseling profession and greater society privileges certain abilities and neurological existences while oppressing and marginalizing others. This requires both a paradigm shift and heightened critical consciousness as counselors, as a profession, and for the systems we work within (e.g., schools, agencies, private practices, counselor education programs). The following sample questions guide this introspection: How can the counseling profession challenge the historically deficit-laden conceptualization of disabilities that requires assimilating to a socially constructed norm of typicality? How can counselors advocate for systemic changes that increase access and opportunities for all, rather than placing the onus of change primarily on individuals? How can the profession celebrate and affirm the benefits of diverse ability levels and neurological functioning? How are we incorporating intersectionality within neuro-affirming counseling? How are we ensuring that neurodivergent individuals are leading and integral in the application of the neurodiversity movement within the counseling profession? How can we learn from and collaborate with allied professions engaged in neuro-affirming practices?
Guiding Documents
The counseling profession would benefit from integrating the neurodiversity movement into its core frameworks. For example, though ACA Code of Ethics (2014) standards C.5., E.8., and H.5.d. explicitly reference disability, they make no direct mention of neurodiversity. Furthermore, H.5.d. is the only standard that addresses accessibility, and it is within the context of website creation. While this inclusion is valuable, there remains an opportunity to expand considerations of accessibility, flexibility, and inclusivity to better support neurodivergent clients within the counseling relationship.
Next, the MSJCC (Ratts et al., 2016) provides a conceptual framework that highlights ways in which counselors can incorporate advocacy within their work with a range of individuals who experience marginalization. Mainly, competency area III.1. indicates that competent counselors “are aware of how client and counselor worldviews, assumptions, attitudes, values, beliefs, biases, social identities, social group statuses, and experiences with power, privilege, and oppression influence the counseling relationship” (Ratts et al., 2016, p. 9). Overall, the MSJCC is a broad framework designed for application to counselors and clients who identify with a range of identities and cultures, within the context of the many systems that impact them individually and in their interactions with one another. However, as there is no research specifically exploring disability or neurodiversity through the lens of the MSJCC framework, we recommend that disability and neurodiversity should be discussed and investigated as cultural variables.
Like the MSJCC, the ACA’s Advocacy Competencies (Toporek & Daniels, 2018) outline guidelines for advocacy work. These competencies could be expanded to include neurodiversity and disability by addressing ability status as a key contextual factor. Historically, disability and neurodiversity have been omitted from diversity and social justice conversations, often being overlooked as cultural variables. To affect social change, explicit inclusion of these groups or factors is necessary.
Professional Organizations
ACA is the flagship counseling organization, comprised of subgroups, such as divisions representing specialty areas (e.g., substance abuse, veterans, multicultural counseling, child and adolescent counseling). The American Rehabilitation Counseling Association (ARCA) is often viewed as the primary organization relevant to disability within the counseling profession. According to the organization’s website, ARCA is an association of professionals, educators, and students in rehabilitation counseling who are committed to enhancing the well-being of individuals with disabilities. Its goal is to support the growth of PWDs throughout their lives and to advance the quality of the rehabilitation counseling profession (Dunlap, 2024). While the mission is impactful, both the mission and messaging from the organization as a whole often frame disability in terms of rehabilitation or correction. This perspective is discordant with the strengths-based perspective of neurodiversity, affirming the benefits of diverse abilities. Next, we acknowledge ARCA’s commitment to inclusivity and advocacy, which aligns with key principles of the neurodiversity paradigm. However, instead of viewing it as a supplementary task driven by legal requirements, ARCA could benefit from recognizing neurodiversity as an essential aspect of diversity that enriches both the counseling profession and society at large.
Next, the Association for Multicultural Counseling and Development (AMCD; 2025) is the primary organization for multicultural counseling representation within ACA. Notably, the group includes a variety of subgroups (e.g., Native American, Multiracial-Multiethnic, Latinx, International, Asian American-Pacific Islander, African American, Women’s Concerns). Proponents of the disability rights movement, and the neurodiversity movement in particular, consider disabilities and neurodiversity to be both a unique culture with elements of shared identity and a population that represents an element of diversity and multiculturalism (Brown, 2015; Chapman & Botha, 2023). Hence, the AMCD’s mission of connecting, advocating for, and empowering people across multicultural identities makes it ideal for incorporating a neurodiversity or disability subgroup. This is especially fitting as both CDT and the neurodiversity paradigm emphasize intersectionality, wholeness, and cross-movement solidarity as essential to the advocacy and liberation of people with multiple marginalized identities.
Finally, the Association for Counselor Education and Supervision (ACES; 2021) has several interest networks, including Disability Justice and Accessibility in Counseling. This group seems most aligned with the neurodiversity movement because it prioritizes disability justice, intersectionality, and anti-oppression, and addresses neurodiversity. However, as ACES serves counselor education and supervision, additional counseling organizations can share this focus.
Research
Future research in counseling must intentionally center neurodivergent individuals and their lived experiences with attention to affirming and identity-conscious practices. This research should focus not only on clients, but also on neurodivergent counselors, supervisors, leaders, graduate students, and scholars. Scholars have increasingly called for more rigorous research within counseling and related clinical professions (Botha & Gillespie-Lynch, 2022; Dwyer, 2022; Long et al., 2025), yet the counseling profession continues to lag in fully integrating neuro-affirming approaches. A promising starting point is the development of a conceptual theoretical framework for neuro-affirming counseling, which can be tailored to specific counseling specialty areas. Grounded theory, rooted in the voices and narratives of neurodivergent individuals, may serve as a powerful methodology to generate such a framework. Follow-up studies could include Delphi panels with expert practitioners and neurodivergent partners; concept mapping to refine theoretical constructs; and the development and validation of instruments to assess counselor competence and client outcomes. In addition, researchers should explore the lived experiences of neurodivergent individuals across various counseling settings to better understand barriers to care, perceptions of counselor responsiveness, and markers of affirming practice.
Participatory action research and other inclusive methods should be prioritized to ensure that research is not only about neurodivergent communities but is created with them. Lastly, as the MSJCC offers a meaningful lens through which to examine how counselors engage with clients who identify as neurodivergent and/or PWDs, researchers could explore how the MSJCC framework supports (or falls short in) guiding counselors’ development of awareness, knowledge, and skills in working with this population. These research directions offer rich, essential opportunities to bridge gaps in the literature and advance counseling equity.
Clinical Practice
In alignment with the ACA Code of Ethics (2014), which emphasizes honoring diversity and embracing a multicultural approach, practicing counselors must recognize neurodiversity as a vital aspect of human diversity. As Long et al. (2025) noted, this has historically been overlooked in multicultural counseling, despite the growing advocacy of the neurodiversity movement. Clinicians are called to adopt a neuro-affirming framework that acknowledges and respects neurological differences as natural human variations rather than deficits. This approach aligns with ethical principles of dignity, potential, and uniqueness, and encourages counselors to critically examine their own biases, clinical language, and treatment paradigms. Counselors should broach the topic of neurodivergence with clients when appropriate; tailor treatment planning to reflect clients’ sensory, communication, and identity needs; and shift from symptom-reduction models to those centered in self-advocacy, autonomy, and strengths.
Meaningful application of a neuro-affirming approach requires attention to all stages of the clinical process, from treatment to diagnosis, as well as to the cultural identities and needs of each counselor and client both independently and within the counseling relationship. Counselors should assess how the physical space, documentation practices, and session structures either promote or inhibit accessibility and inclusion. For example, using flexible communication methods or creating low sensory environments may significantly improve comfort and therapeutic rapport. These shifts are especially important given that many counselors practice in systems governed by the medical model (e.g., DSM-driven environments), which can conflict with neuro-affirming values. Clinicians must grapple with this tension, asking: Can we hold space for both DSM-informed practice and neuro-affirming care? Though diagnoses may be necessary for access to care, counselors have an ethical responsibility to advocate for affirming practices, consult with allied professionals, and frame client experiences in ways that empower rather than pathologize. Ultimately, neuro-affirming counseling must be rooted in intersectionality, accessibility, and cultural humility, core values of an inclusive, socially just counseling practice.
Pre-Service Preparation, Supervision, and Training
Counselor preparation plays a critical role in shaping how future professionals engage with neurodivergent individuals. However, current training models often fall short in addressing this population through an affirming, socially just lens. Although the Council for the Accreditation of Counseling and Related Educational Programs (CACREP; 2023) sets the standards for counselor education, its integration of disability, and more specifically, neurodiversity, remains limited and inconsistent. For example, though Standard 3.A.4. encourages the removal of systemic, institutional, architectural, and attitudinal barriers that hinder equity and access, it does not explicitly frame neurodiversity as an element of human diversity. Additionally, Section 3.B., which focuses on social and cultural identities and experiences, omits reference to neurodivergence, disability culture, and ability status as meaningful sociocultural identities. This exclusion reinforces a medicalized view of disability and misses the opportunity to promote a strengths-based, identity-affirming framework that aligns with the neurodiversity paradigm.
To address these gaps, counselor education programs should intentionally integrate disability and neurodiversity content across the curriculum. Courses such as human development, multicultural counseling, ethics, and diagnosis can provide students with information about the neurodiversity movement and CDT, as well as suggest counseling strategies that are strengths-based, utilize a critical systemic lens, and acknowledge disabilities as unique cultural identities. Supervision and training for practicing counselors should do the same by utilizing a neuro-affirming approach and encouraging critical reflection on ableism, diagnostic language, and counselor attitudes toward disability. Moreover, the MSJCC can serve as a guiding framework for both counselor education and clinical supervision to teach awareness, knowledge, skills, and advocacy specific to neurodivergent clients and normalize the perspectives of neurodivergent counseling professionals. Infusing disability culture and neurodiversity into preparation, supervision, and training not only equips pre-service and practicing counselors with the tools to work competently and compassionately but also creates space for neurodivergent individuals within the profession to thrive as students, educators, supervisors, clinicians, and leaders.
Conclusion
According to Kaplan and colleagues (2014), counseling organizations and leaders have come together to clarify a shared professional identity: to strengthen the profession and ensure high-quality practices toward those we serve. The counseling profession has a history of evolving, changing, and improving, incorporating knowledge and new trends as they develop. The neurodiversity paradigm has been increasingly discussed across society, such as in allied professions like psychology (Pellicano & den Houting, 2022). The counseling profession must also evolve to stay relevant. This includes expanding the profession to integrate the neurodiversity paradigm and neuro-affirming practices. Utilizing and embracing neurodiversity in counseling strengthens the profession by better equipping scholars, practitioners, leaders, supervisors, and professional organizations. Incorporating a neuro-affirming lens also contributes to a societal shift of increasing awareness, reducing stigma, and advocating for systemic change, particularly for identities who have been historically marginalized. These are fundamental goals at the root of both the neurodiversity movement and the counseling profession.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Aug 26, 2025 | Volume 15 - Issue 3
Andie Chilson, Melissa Mecadon-Mann, Rebecca Gwira, Loidaly G. Rosario-Singer
This scoping review examines 12 years of research on body image ideals and eating disorder (ED) pathology in Black American women. The authors synthesized the aims, methods, and results of 10 studies to outline the specific body image ideals within this population and the relationships between these ideals and ED risk. The findings from this review provide important insights to inform counseling and integrated care approaches for working with Black American women struggling with body image and disordered eating. This study highlights the existing evidence on body image and EDs in this understudied population and points to critical directions for future investigation.
Keywords: body image ideals, eating disorders, Black American, women, counseling
Body image as it relates to disordered eating has been a widely researched topic within the medical and psychology fields (Blostein et al., 2017; Brandsma et al., 2019; Jung & Forbes, 2012; Malachowski & Myers, 2013; Mölbert et al., 2018; Reslan & Saules, 2013). Researchers have explored racial and cultural differences in disordered eating pathology and identified specific body image ideals among racial and ethnic communities (Aldalur & Schooler, 2019; Capodilupo & Kim, 2014; Goel et al., 2021). Disordered eating research has primarily focused on Western European, White body image ideals. Therefore, a scoping review was warranted to achieve a comprehensive view of this underexamined topic. According to Arksey and O’Malley (2005), there are four commonly cited reasons to warrant a scoping review: to examine the extent and nature of existing research on a topic; to discern whether a full systematic review is necessary; to summarize and disseminate key findings; and to identify gaps in the existing literature. We have observed a dearth of research on the intersection of body image ideals and eating disorders (EDs) in Black American women and, therefore, endeavored to summarize and disseminate key findings and identify gaps in the existing literature.
Research is limited on the most effective modalities to treat disordered eating in minoritized populations. Cognitive behavioral and dialectical behavioral therapy are among the most popular counseling treatments for disordered eating in clients who are striving for a thin body ideal (Federici et al., 2012; Fursland et al., 2012). However, the body image ideals for Black and African American women differ from their White, Asian, Latine, and Native American peers (Smith et al., 2020; Talleyrand, 2012). Therefore, counseling modalities centered around the thin ideal are not the best fit for Black and African American clients who present with EDs. For example, Labarta and Bendit (2024) suggested a relational–cultural approach to ED treatment that provides space for the decolonization of traditional treatment models. As such, this scoping review was driven by the following research question: What are the most common body image ideals (as they relate to body weight/shape) for Black women living in the United States and how does this impact their risk for/presentation of disordered eating?
Body Image Ideals in Black Women Living in the United States
Studies have shown that Black women may feel less pressure to be thin than their White peers (Awad et al., 2020). Historically, the Black community has seen larger bodies as resilient, healthy, and a symbol of wealth. Awad et al. (2015) identified a thick/toned/curvy body shape as optimal for Black women. Some Black women exercise not to lose weight but to achieve a large backside and a small waist. However, when in a majority White community, the pressure to conform to the thin ideal is still present (Awad et al., 2015). In these instances, diet (or not eating at all) and exercise are emphasized.
The ideal body shape for Black American women also includes acceptance of a larger body size, or what some call the curvy ideal (Boutté et al., 2022; Cotter et al., 2015; Gitau et al., 2014; Hunter et al., 2017; Parker et al., 2022; Scott, 2019). The curvy ideal, sometimes described as a Coke-bottle figure (Hunter et al., 2017), consists of a large bust, a small waist, and a large backside. It has been stated that because Black women have wider acceptance of a larger body size or the curvy ideal, they experience body dissatisfaction less than their White peers (Boutté et al., 2022). It is important to note that the curvy ideal is not necessarily more attainable or healthy than the thin ideal (Scott, 2019). The curvy ideal is also related to body dissatisfaction and can be associated with body monitoring or body checking (Shafran et al., 2003). Body checking, or continual monitoring of weight, waist size, and body measurements, can be a risk factor for developing bulimia nervosa (BN) and anorexia nervosa (AN; Shafran et al., 2003).
Eating Disorder Prevalence and Risk/Protective Factors in Black American Women
The scope of the existing research on ED pathology in Black and African American individuals is extremely limited. The most recent comprehensive study examining the prevalence of EDs in Black Americans was conducted in 2007. The study found that binge eating disorder (BED) was the most common ED among Black adults, comprising 2.24% of participants, and AN was the least common, with 0.17% of adults meeting diagnostic criteria (Taylor et al., 2007). Although this study is extremely useful in providing a point of reference for the prevalence of eating pathology in Black Americans, updated research on the topic is needed.
According to Cotter et al. (2015) and Hunter et al. (2017), Black women have similar rates of disordered eating to their White peers. Many Black women feel an expectation to be thin and/or fit into a specific body ideal; however, there is a lack of research specific to Black women and ED pathology. Additionally, the research that does exist is highly focused on body mass index (BMI) and obesity rates, which have been proven to be poor indices of physical health (Rasmussen, 2019) and fail to address the underlying cause(s) and risk factors of disordered eating in Black communities (Hunter et al., 2017). Black women are often categorized as overweight and/or diagnosed as obese while EDs are likely undiagnosed or underdiagnosed in this demographic (Boutté et al., 2022).
Racial identity development can act as a protective factor against disordered eating (Capodilupo & Kim, 2014; Rakhkovskaya & Warren, 2014). Capodilupo and Kim (2014) found that identification with the majority culture leads to higher levels of disordered eating, while Black women who identify with Black culture have lower levels of body dissatisfaction. As one works through racial identity development, they tend to identify more with cultural norms and push away from the body ideals of White culture and influence. The Black community emphasizes beauty ideals beyond size and shape (attitude, self-confidence, hair; Rakhokovskaya & Warren, 2014). Therefore, rejecting White beauty ideals through racial identity development may protect some women from disordered eating behaviors.
Present Investigation
This scoping review was inspired by a review published by Harris (2015), which explored three different strata of research on EDs in Black American women from 1980–2015. The first stratum of research discusses the clinical implications of the exclusion of Black women from ED research in the 1980s. Harris demonstrated that as ED presentations in Black women became increasingly recognized, the rate of treatment for Black women with EDs similarly increased. However, ED research and treatment at this time still largely centered around economically advantaged White women and the Eurocentric beauty ideals with which they aligned (Harris, 2015).
The second stratum of research highlighted by Harris (2015) emphasizes an expanded definition of body image to include affective, psychological, and behavioral facets, thus creating a more nuanced and inclusive dialogue around the implications of body image concerns for Black women. This expanded definition of body image also opened up the conversation for cultural variables related to body image that could be precursors to EDs in Black women (Harris, 2015).
The third and final stratum of research examined by Harris (2015) saw an increase of within-group studies of Black American women compared to the between-group studies with White and Black women that dominated ED literature up to that point. This stratum of research also identified strong ethnic identity as a protective factor against EDs in Black women, and low ethnic identity as a risk factor for BED and BN symptomatology (Harris, 2015). In the conclusion of the paper, Harris called for further investigation into risk factors associated with eating pathology in Black American women.
The goal of the present investigation, therefore, is to bridge the gap between the findings of the Harris (2015) study and the existing body of research. We endeavored to accomplish this in three ways: first, identify the most common body image ideals for Black women living in the United States; second, identify what relationship (if any) exists between body image and disordered eating in Black women living in the United States; and third, identify implications for counselors based on the research findings of the first two objectives. The language “Black” and “African American” was utilized to capture as many ethnic identities as possible, including those that did not originate in the United States. When articles specified ethnic identities in their demographics, we indicated as such.
Methods
Author Positionality
There were four authors for the present investigation. It is critical to acknowledge that the first and second authors, Andie Chilson and Melissa Mecadon-Mann, are White women who have learned, only as outsiders, about the intersecting experiences of body image challenges and eating disorders in Black American women. Chilson has benefited both directly and indirectly from systemic racism, particularly as it pertains to adherence to Eurocentric beauty ideals and the inherent protection provided in identity. She has extensive experience working with eating disorders and body image challenges in women from diverse racial backgrounds. The second author, Mecadon-Mann, identifies as a cisgender White American woman in a large body. She has experience working with adolescents and emerging adults with diverse ethnic backgrounds and varied body image ideals and disordered eating behaviors. The third author, Rebecca Gwira, identifies as a first-generation, cisgender, Black woman in a mid-sized to large body. She also has experience working clinically with diverse eating disorder patients across demographic characteristics and levels of care. Her research centers marginalized voices, specifically Black women’s eating and body image concerns and intersectional stress. The fourth author, Loidaly G. Rosario-Singer, identifies as a cisgender Puerto Rican woman; she has benefited from some aspects of Eurocentric body ideals because she has had a small to mid-sized body the majority of her life. She has experience working with multilingual children and families with a focus on health equity and reproductive justice.
Methodology
The following research questions guided this scoping review:
RQ1: What specific body ideals are most commonly endorsed by Black American women, and how do these ideals differ from or align with the thin ideal traditionally emphasized in ED research?
RQ2: What (if any) relationship does the existing literature identify between culturally specific body image ideals and the manifestation of different types of disordered eating behaviors in Black American women?
RQ3: Identify implications for counselors based on the research findings of the first two objectives.
Our systematic search was conducted based on the guidelines put forth by the PRISMA extension for scoping reviews (PRISMA-ScR), a 22-item checklist aimed at helping readers develop a better understanding of the terminology and key concepts reported in scoping reviews (Tricco et al., 2018). The checklist was created by a panel of 24 expert members and two research leads and was informed by the published guidelines of the EQUATOR (Enhancing the QUAlity and Transparency Of Health Research) Network (Tricco et al., 2018). A five-step scoping review process was undertaken, including 1) identifying the research question and objectives; 2) defining the scope of the review; 3) selecting the records; 4) charting the data; and 5) summarizing the results. Inclusion and exclusion criteria were identified a priori and documented in a protocol.
Eligibility Criteria
The eligibility criteria for inclusion were based on population (P)—Black American women; exposure (E)—body image ideals; and outcome (O)—disordered eating. To attempt to capture all relevant literature published after or around the time of Harris (2015), articles published in English between 2013 and 2025 were eligible for inclusion in this review. Sources examining a pediatric population (under 18 years) or research conducted outside of the United States were excluded from the review.
Information Sources
Inclusion and exclusion criteria were established a priori with the assistance of a public health librarian at Western Carolina University. These criteria were used to develop a standard checklist for study eligibility for screening titles/abstracts and subsequently full-text sources. All stages of the screening process were conducted using Covidence, an online software tool used to organize records in the systematic or scoping review process and to blind the results between the researchers. Study selection was conducted independently by Chilson and Mecadon-Mann based on the preestablished checklist. All decisions were automatically recorded via Covidence. Conflicts between the authors were resolved through discussion. Records were identified through searching the following electronic databases: Academic Search Premier, Biological & Agricultural Index Plus (H.W. Wilson), Business Source Premier, Child Development & Adolescent Studies, CINAHL Plus with Full Text, Communication & Mass Media Complete, eBook Collection (EBSCOhost), Education Source, ERIC, Gender Studies Database, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE Complete, Mental Measurements Yearbook with Tests in Print, Military & Government Collection, Philosopher’s Index, APA PsycArticles, APA PsycInfo, APA PsycTests, SocINDEX with Full Text, SPORTDiscus with Full Text, and Ebony Magazine Archive.
Search
To achieve an extensive review on the topic, literature from the past 12 years was included in the search. Because of limitations with access to sources outside of Western Carolina University, reference mining was not conducted as part of the present study. The search strategy was created by a public health librarian at Western Carolina University in collaboration with Chilson. The search strategy was checked for comprehensiveness and errors against the PRESS Peer Review of Electronic Search Strategies Guidelines. The specific search terms utilized were as follows: (Black OR Blacks OR African American*) AND (female* OR woman* OR women* OR lady OR ladies* OR gyn* OR girl*) AND (“eating disorder*” OR “disordered eating” OR anore* OR “binge eating” OR bulimi* OR purging OR purgeing OR “restrictive eating” OR orthore* OR overeat* OR pica) AND (body OR personal) AND (image OR perception OR satisfaction OR dissatisfaction OR psychosocial OR societ*).
Data Charting Process
A data extraction template in Covidence was used to record key characteristics and relevant information from eligible records, including study design, research purpose, study participants, and research findings/results. Chilson and Mecadon-Mann independently charted the data, discussed the results, and regularly updated the data extraction form in Covidence.
Data Items
Chilson and Mecadon-Mann abstracted data on article characteristics (i.e., country of origin, publication date, language), sample characteristics (i.e., race, gender, and age), and constructs/outcomes examined (i.e., body image ideals and EDs). Gwira subsequently vetted all the extracted articles based on the same criteria.
Critical Appraisal of Individual Sources of Evidence
An in-depth examination of the unique body image ideals held by Black women and their influence on the risk for EDs is lacking in the current literature. Therefore, we endeavored to explore the link between specific body image ideals of Black women and their correlation with EDs. We also aimed to identify the most common body image ideals for Black women living in the United States as an independent construct. Individual articles were screened for eligibility using the systematic review management tool, Covidence. Chilson and Mecadon-Mann independently screened the articles against inclusion/exclusion criteria, which were established a priori. We then screened articles at the abstract level for general relevance and subsequently conducted full-text screenings. Articles included in the full-text screening were assessed to determine if sources examined Black American women, specifically; examined body image ideals, specifically, or body image ideals as an independent variable and ED as a dependent variable; and examined an adult sample (18 years or older) from the United States. After reviewing at the full-text level to determine that Black American women, specifically, were examined, Chilson and Mecadon-Mann looked for language such as Black American, African American, Caribbean American, and Haitian American to encompass the full spectrum of Black American women. Also at the full-text level, we screened for clearly identified body image ideals, which required reference to a preferred size/shape of a specific body part (e.g., Coke-bottle waist; Hunter et al., 2017) or preferred shape of the body, generally (e.g., curvy ideal; Scott, 2019). If the intersection of an ED was present, Chilson and Mecadon-Mann screened for either general reference to ED (e.g., “ED pathology”; Siegfried, 2021) or specific reference to an ED diagnosis (e.g., anorexia and bulimia; Hunter et al., 2017). Gwira screened each source separately against the established inclusion/exclusion criteria and charted assessments in an Excel spreadsheet. Gwira and Rosario-Singer reviewed the manuscript for accuracy and offered feedback for Chilson and Mecadon-Mann’s consideration.
Synthesis of Results
The synthesis included quantitative analyses (e.g., means, standard deviation) to summarize the characteristics of included records, body image ideals in Black women, and any ED intersection noted. The results are presented in both a table and a descriptive format that aligns with the review’s objectives of identifying the most common body image ideals for Black women living in the United States and identifying the relationship between body image and disordered eating in Black women living in the United States.
Results
The record identification process is outlined in Figure 1. A total of 501 records were identified through the initial search process. After removing all duplicates (n = 301), the authors were left with 200 records for screening. Next, 107 records were excluded based on criteria such as examination of a pediatric population (under age 18), women outside of the United States, and a lack of focus on Black women. There were 93 records then screened for eligibility, 83 of which were excluded because of patient population, type of publication, and lack of access. This process resulted in 10 records selected for inclusion.
Figure 1
PRISMA Flow Diagram for Scoping Reviews
Note. Adapted from Page et al., 2021.
Characteristics of the Sources of Evidence
Included records examined Black women living in the United States. One study (Bruns & Carter, 2015) also examined White women, and another study (Siegfried, 2021) examined Hispanic/Latina/x women in addition to Black women. Participant ages ranged from 18–73 years and there was no discernible trend in the age selection of the included records. Only one study specifically examined a sample of women 25 years and older (Talleyrand et al., 2016). The majority of records included the age range with mean/standard deviation, except two papers, which only reported the age range and not the mean/standard deviation (Bruns & Carter, 2015; Siegfried, 2021).
Included study designs were qualitative research (n = 4), randomized controlled trial (n = 2), cross-sectional (n = 2), mixed methods (n = 1), and exploratory factor analysis (n = 1). The 10 included records presented data from sample sizes ranging from 11 to 232. Two studies (Awad et al., 2015; Hollier, 2019) were conducted with women enrolled in universities across the United States. One study (Talleyrand et al., 2016) was conducted in the greater Washington metropolitan area. The other seven studies did not specify where they were conducted within the United States.
Four studies utilized focus group questions aimed at identifying common themes pertaining to beauty ideals specific to Black women. Two studies used the Eating Disorders Inventory – 3 (Garner, 2004) to determine specific body image ideals and assess for the presence of ED pathology. Two studies employed the Eating Attitudes Test – 26 (Garner et al., 1982) to measure disordered eating behaviors. Other instruments utilized in the included studies were the Contour Drawing Rating Scale (n = 2; M. A. Thompson & Gray, 1995), The Skin Color Satisfaction Scale (n = 1; Falconer & Neville, 2000), The Reese Figure Rating Scale (n = 2; Patt et al., 2002), the Rosenberg Self-Esteem Scale (n = 2; Rosenberg, 1965), Family Experiences Related to Food Questionnaire (n = 1; Kluck, 2008), Family Food Experiences-Black Questionnaire (n = 1; Hunter et al., 2017), Body Image Disturbance Questionnaire (n = 1; Cash et al., 2004), Visual Analog Scale- Body Satisfaction (n = 1; Heinberg & Thompson, 1995), The Curvy Ideal Silhouette Scale (n = 1; Scott, 2019), Curvy Ideal Questionnaire (n = 1; Scott, 2019), The Sociocultural Attitudes Towards Appearance Questionnaire—3rd Edition (n = 1; J. K. Thompson et al., 2004), The Sociocultural Attitudes Towards Appearance Questionnaire—4th Edition (n = 1; Schaefer et al., 2015), Objectified Body Consciousness Scale (n = 1; McKinley & Hyde, 1996), Body Shape Questionnaire (n = 2; Cooper et al., 1987), Eating Disorder Examination-Questionnaire (n = 1; Fairburn, 2008), and Gormally Binge Eating Scale (n = 1; Gormally et al., 1982).
Table 1
Results of Individual Sources of Evidence
| Author(s), Publication Date |
Aim of Study |
Study Participants |
Study Design |
Body Image Ideals |
Eating Disorder Intersection |
| Awad et al., 2015 |
Examine the issues that arise pertaining to AA women’s conception of beauty and body image, identify body image themes, and identify the sources of the body image messages received and internalized. |
Female AA students enrolled in a large Southwestern university in the United States between the ages of 19–25 |
Qualitative research |
Thick/toned/curvy as optimal
(n = 33) |
Yes |
| Bruns & Carter, 2015 |
Examine how model ethnicity and body shape impact body dissatisfaction. |
Women self-identifying as African American or Caucasian between the ages of 18–45 |
Randomized controlled trial |
Thin ideal and plus-sized ideal |
No |
Capodilupo
& Kim, 2014 |
Explore how race and gender interact and inform body image ideals. |
Women between the ages of 21–35; identified as African American (n = 10), Black American (n = 4), Caribbean American (n = 4), and Haitian American (n = 2); six women did not specify their ethnicity |
Qualitative research |
Large breasts, shapely hips, and full backside |
No |
| Hollier, 2019 |
Examine body dissatisfaction and self-esteem factors that contribute to BEDs among Black female students. |
Black college women currently enrolled in a private or public university in the United States between the ages of 18–54. All participants self-identified as “Black,” but 3.2% of the participants identified as “other” and “multi-racial” under this umbrella |
Cross-
sectional |
Thighs, breasts, waist/hip ratio |
Yes |
| Hunter et al., 2017 |
Explore family food experiences (FFEs) of AA women and develop a measure of FFEs related to disordered eating. |
Studies 1 & 3: AA women from two National Pan-Hellenic Council sororities at a Southeastern university; Study 4: AA women from across the United States younger than 25 |
Mixed methods |
“Boobs and booties” (Study 1) and “Coke-bottle figure” (Study 3) |
Yes |
| Author(s), Publication Date |
Aim of Study |
Study Participants |
Study Design |
Body Image Ideals |
Eating Disorder Intersection |
| Javier, 2017 |
Increase understanding of body image and eating behaviors in AA and Asian American women. |
Study 1: AA women between the ages of 18–30 who reported body image problems |
Qualitative research |
Curvy and thin ideals |
Yes |
| Scott, 2019 |
Examine the effect of exposing Black women to rap lyrics that promote the curvy ideal on their level of body image dissatisfaction. |
Black women between the ages of 18–34 who had access to audio output (e.g., headphones, speaker); all participants identified as AA, 2.1% also identified as American Indian/Alaska Native, and 4.2% also identified as White |
Randomized controlled trial |
Curvy ideal |
No |
| Siegfried, 2021 |
Increase understanding of the ways cultural values and pressure impact the development of EDs in Black and Latinx women in the United States. |
Black, Hispanic/Latina/x, and Afro-Latina/x women between the ages of 18–25 living in the United States; 125 participants (49.2%) identified as Black, 107 (42.1%) identified as Hispanic or Latina/x, and 22 women (8.7%) identified as Afro-Latina/x |
Cross-sectional |
Thin ideal |
Yes |
| Talleyrand et al., 2016 |
Explore the phenomena that impact body image ideals, eating behaviors, and appearance in AA women over the age of 25 who report body/weight concerns. |
AA/Black women in the greater Washington metropolitan area; seven women identified as African American, two identified as Black, and two identified as African American/Black. |
Qualitative research |
Thin, sculpted “ripped” arms, and “sistah girl” hips |
No |
| Wilfred & Lundgren, 2021 |
Assessing the psychometric properties and validity of a body image assessment
for Black women. |
Women between the ages of 18–73 who identified as African American (73.4%), African (8.5%), Afro-Latina (3.5%), Caribbean (1.5%), Caribbean American (1.5%), other Black descent (3.0%), and multiple racial identities (8.5%) |
Exploratory factor analysis |
“Slim-thick,” thin, and muscular |
Yes |
Main Study Outcomes
The most salient findings of the current study were twofold: first, the identification of specific body ideals held by Black women living in the United States; and second, the identification of a relationship between specific body image ideals and the presence of ED behaviors in Black women living in the United States. The first predominant body image ideal identified was a thick/slim-thick/curvy ideal. The majority of the included records indicated a striving for the curvy ideal (i.e., large breasts, shapely hips, and large backside) as opposed to the more commonly cited thin ideal. Four studies identified specific body parts that were highlighted as part of the curvy ideal. For example, Hunter et al. (2017) discussed “boobs and booties” (p. 29) as two specific body parts on which Black women focused their attention when striving for the curvy ideal.
Although the curvy ideal was the predominant body shape ideal that was identified in the included records, the influence of the thin ideal was also present. Five studies highlighted the influence of the thin ideal on their sample populations, either on its own or in conjunction with the curvy ideal (e.g., Bruns & Carter, 2015). The final body image ideal noted in the included records was the muscular/toned ideal. Both Talleyrand et al. (2016) and Wilfred and Lundgren (2021) identified being visibly fit, toned, or muscular as desirable qualities for Black women. Talleyrand et al. described the desirability of Michelle Obama’s “ripped” arms, stating that she was the ideal combination of curvy and healthy. Wilfred and Lundgren identified a similar muscular internalization, specifically regarding having a toned abdomen as a desirable physical trait for Black women.
The second major finding was that the majority of included records reported a relationship between specific body image ideals and the presence of an ED. More specifically, six out of the 10 included records noted this positive relationship (see Table 1 for specific studies). Hunter et al. (2017) identified an increased risk for AN and BN among Black women in a sorority who idealized being curvy, but only in certain places. Additionally, Awad et al. (2015) described the relationship between experiencing discrimination and the presence of disordered eating behaviors. Both Awad et al. and Javier (2017) found that a disconnect between one’s cultural heritage and the ideals of the White dominant group often led to disordered eating behaviors. If one perceives that they are divergent from the ideals of the dominant group (i.e., the thin ideal), they are likely to engage in potentially harmful disordered eating patterns. Finally, Wilfred and Lundgren (2021) found that the experience of a double consciousness (i.e., the pressure to adhere to two separate cultural ideals) increased ED pathology, specifically BED, among Black women.
Several of the included articles correlated variation in skin tone with positive/negative body image and ED pathology. Wilfred and Lundgren (2021) and Hollier (2019) noted that pressure to meet White body image ideals, including a fair complexion, increase the risk for ED behaviors, BED in particular. Similarly, Awad et al. (2015) determined that women who experienced discrimination stress, dissonance between the dominant culture and their culture of origin, or identification as a devalued group by the majority culture were at an increased risk for ED pathology. Awad et al. (2015) used the example of having a darker complexion to illustrate this, noting that if a woman was darker complected than her peers, and felt devalued because of it, she was more likely to engage in ED behaviors. Capodilupo and Kim (2014) discussed the influence of skin tone in a similar manner, asserting that women who are lighter complected are more likely to be desired by Black men and are more frequently and positively portrayed in the media, decreasing their risk for poor body image and ED behaviors.
The authors also examined moderating factors such as level of education, profession, and socioeconomic status, and found that only one study (Siegfried, 2021) examined the relationship between education and body image/ED pathology and determined that there was no substantial correlation with any of the measures. However, significantly, Siegfried (2021) determined that higher income was highly correlated with lower levels of acculturative stress as well as lower levels of internalization of the thin ideal but noted that there was no predictive factor between income and ED pathology.
Discussion
This scoping review centered around four objectives: first, to identify the most common body image ideals for Black women living in the United States; second, to identify what relationship (if any) exists between body image and disordered eating in Black women living in the United States; third, to bridge the gap between the findings of the Harris (2015) study and the current body of research; and fourth, to identify implications for counselors based on the research findings.
Common Body Image Ideals
Although some Black women in the United States are driven by the thin ideal, many describe a thick, toned, or curvy body shape as ideal. Most of the examined studies identified the thin ideal in combination with the curvy ideal as most desirable among the examined population. For example, Wilfred and Lundgren (2021) identified a “slim-thick” figure, high muscularity, and thinness as the predominant body ideals for Black women. Only one study, Siegfried (2021), identified thinness alone as the predominant body ideal. It is notable, however, that 50% of the included records highlighted thinness as a prominent body ideal for Black women. Although it has previously been assumed (Bruch, 1966) that Black women did not value thinness, the present findings indicate that this is not the case. Although Black women overwhelmingly value thinness in conjunction with the curvy ideal, thinness alone is still emphasized as a desirable quality.
Black American Body Image and Disordered Eating
Black women have lower rates of body dissatisfaction than their White peers but comparable rates of disordered eating. However, Black women have also been associated with disordered eating behaviors that center around culturally specific ideals or factors. For example, Siegfried (2021) described the positive relationship between acculturative stress and the internalization of the thin ideal, which then positively predicts an increased risk for ED pathology. Siegfried further identified a relationship between the internalization of the thin ideal and the development of BN, specifically.
One of the overarching messages regarding the relationship between specific body image ideals and disordered eating in Black American women was that being discrepant from one’s identified cultural ideals was a significant risk factor for disordered eating behaviors (Awad et al., 2015; Hollier, 2019; and Javier, 2017). For example, if an individual strongly identifies with a culture that emphasizes the curvy ideal and they naturally have a curvy figure, they are less likely to engage in disordered eating behaviors to alter their body shape. If an individual with the same curvy figure has a low degree of cultural identity, or identifies more strongly with another culture that emphasizes the thin ideal, they would be at increased risk to engage in disordered eating behaviors. Additionally, women who feel pressured to conform to the body ideals of two cultures are at an increased risk for eating pathology. This experience is referred to as double consciousness (Du Bois, 1903), which in this context means being made to feel like one needs to adhere to the beauty ideals of both mainstream (White European) culture and Black culture.
Gaps in Existing Literature
Although the included records identified general body image ideals that are emphasized by Black American women, there was a dearth in the existing literature surrounding specific ED diagnoses that are linked with certain body image ideals. In the present investigation, only three of the included records identified a specific diagnosis that is linked with certain body image ideals in Black American women. Therefore, future research is warranted surrounding specific ED diagnoses and the associated prevalence rates in this demographic. We also identified that many Black women perceive beauty through a wider lens than simply body shape/size, including elements such as skin tone, hair (length, style, neatness), self-esteem, and attitude. Further investigation into these ideals will deepen the conceptualization of beauty and attractiveness ideals in Black women living in the United States today. Finally, the authors also identified a gap in recent literature examining moderating factors such as level of education and profession that may serve as risk/protective factors for ED behaviors. Further investigation into these factors is warranted to broaden the conceptualization of ED presentations in Black women.
Additionally, there is a gap in the current research surrounding disordered eating and body image ideals in Black LGBTQ+ women, specifically. The studies included in the present investigation either excluded discussion of sexuality entirely or conceptualized it in relation to the male gaze. Therefore, further research into the relationship between sexuality and body image ideals/disordered eating in Black American women is warranted. Another identified gap in the existing literature centers around the influence of the Black/White male gaze on Black women’s self-identified body ideals. More specifically, research is warranted surrounding whether there are different body image ideals for Black women who identify more closely with the body shape/size preferences of Black men compared to White men, and any eating pathology associated with these ideals.
Implications for Counseling and Integrated Care
Traditionally, there has been a limited focus on Black women and ED behaviors outside of the thin ideal. Counselors and care providers must be aware of the culturally embedded protective factors (e.g., racial identity development) that can support healthy eating patterns as well as potential risk factors. It is common for Black women to have higher body weight and BMI, but this does not mean they are immune from disordered eating. It is important to explore how stress and trauma may affect restriction and eating patterns (Small & Fuller, 2021). Boutté et al. (2022) suggested that care providers utilize strengths-based interventions that are holistic rather than interventions focused solely on diet and exercise. It is important, also, to assess for disordered eating before making recommendations to lose weight or form a weight loss plan. Counselors and other helping professionals should consider the implications of skin tone when supporting Black women. As previously noted, darker complected women who exist in a dominant White culture may be at a higher risk for poor body image and ED behaviors (Awad et al., 2015; Capodilupo and Kim, 2014; and Wilfred and Lundgren, 2021). The influence of White, Eurocentric beauty standards on Black women of varying skin tones should be accounted for when conceptualizing treatment plans.
Labarta and Bendit (2024) suggested the use of an integrated relational–cultural approach to ED treatment. Relational–cultural theory (RCT) is rooted in feminist and multicultural theory with a central goal of connection, mutuality, and relationship (Jordan, 2017). RCT approaches to ED treatment allow the care provider and client to work in mutuality, break down power differentials, and repair relationships with food and the body. This framework provides space for discussion and healing focused on racial and social marginalization and how it affects body dissatisfaction, thus building self-image and resilience and empowering clients to live authentically. Further, Labarta and Bendit suggested a self-compassion approach to help clients build knowledge and skills about self-compassion, common humanity, and mindfulness. These factors are helpful in building resilience and can serve as protective factors for people from marginalized communities.
Lastly, care practitioners should be trained in holistic approaches and cultural humility (Matthews et al., 2021). One way practitioners can do this is through expanding care services into the communities where marginalized people live and work. For example, community outreach partnerships can be made with organizations that promote Black female health and wellness. Additionally, practitioners should read literature and attend professional development presented by Black women. One suggested book is Treating Black Women with Eating Disorders (Small & Fuller, 2021).
Strengths and Limitations
This review outlines research spanning a 12-year timeframe, providing a bridge to the anchor article written by Harris (2015). Because of reasons outside of our control, there were a handful of articles that were inaccessible. Furthermore, because of these constraints, we did not conduct reference mining as part of the search strategy. These articles may have added to the findings of the present study. We utilized Covidence software to review articles and lessen the chance of reviewer bias. After consensus was reached between Chilson and Mecadon-Mann, Gwira and Rosario-Singer provided insight into the articles and cultural implications of the research. However, bias is still a possibility in identifying terms and phrases that allude to body image satisfaction or dissatisfaction. An additional limitation is that this review only examined cisgender women. Research examining body image ideals and eating disorder prevalence in individuals outside of the gender binary is needed. The most substantial limitation is the dearth of research specifically focused on body image and EDs in Black women. Therefore, the authors identified a need for ED research and practice publications specifically focused on treating Black women in the United States.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Andie Chilson, MS, LGPC, is a psychotherapist at Greenhouse Psychotherapy. Melissa Mecadon-Mann, PhD, NCC, LPC, LSC, is an assistant professor at Western Carolina University. Rebecca Gwira, PhD, is a clinical postdoctoral fellow at the University of North Carolina at Chapel Hill School of Medicine. Loidaly G. Rosario-Singer, PhD, NCC, LCMHC-A, is Founder and Mental Health Consultant of De Colores Family Wellness. Correspondence may be addressed to Andie Chilson, 1519 Connecticut Ave NW, Washington, DC 20036, andie@greenhousepsych.com.
Jul 25, 2025 | Volume 15 - Issue 2
Michael T. Kalkbrenner, Shannon Esparza
Physicians in the United States are a client population facing increased risks for mental distress coupled with a reticence to seek professional counseling. Screening tools with valid scores have utility for helping counselors understand why prospective client populations who might benefit from counseling avoid seeking services. The Revised Fit, Stigma, and Value (RFSV) Scale is a screener for measuring barriers to counseling. The primary aims of the present study were to validate RFSV scores with physicians in the United States and to investigate demographic differences in physicians’ RFSV scores. Results revealed that the RFSV Scale and its dimensionality were estimated sufficiently with a national sample of physicians (N = 437). Physicians’ RFSV scores were a significant predictor (p = .002, Nagelkerke R2 = .05) of peer-to-peer referrals to counseling. We also found that male physicians and physicians with help-seeking histories were more sensitive to barriers to counseling than female physicians and physicians without help-seeking histories, respectively. Recommendations for how counselors can use the RFSV Scale when working with physician clients are provided.
Keywords: Revised Fit, Stigma, and Value Scale; counseling; barriers to counseling; help-seeking; physicians
Because of the particularly stressful nature of their work, coupled with the pressure in medical culture to not display psychological vulnerability (Linzer et al., 2016), physicians in the United States must be vigilant about their self-care. Physicians are responsible for treating over 300 million patients in the United States, which can lead to elevated psychological distress that may undermine the quality of patient services and physicians’ personal well-being (Walker & Pine, 2018). Attending personal counseling is associated with a number of personal and professional benefits for physicians (Melnyk et al., 2020). However, a stigma toward seeking counseling and other mental health support services exists in the U.S. medical culture (Dyrbye et al., 2015). Lobelo and de Quevedo (2016) found that physicians are attending counseling at lower rates since 2000, with approximately 40%–70% attending counseling before the year 2000 and only 12%–40% after 2000. One of the next steps in this line of research is gaining a better understanding of barriers to counseling, including reasons why physicians are reluctant to attend.
Screening tools with valid scores are one way to understand why individuals are reticent to attend counseling (Goldman et al., 2018). For example, the Revised Fit, Stigma, and Value (RFSV) Scale is a screening tool with rigorously validated scores for measuring barriers to counseling (Kalkbrenner et al., 2019). Scores on the RFSV Scale have been validated with seven different normative samples since 2018, including adults in the United States (Kalkbrenner & Neukrug, 2018), mental health counselors (Kalkbrenner et al. 2019), counselors-in-training (Kalkbrenner & Neukrug, 2019), college students attending a Hispanic Serving Institution (HSI; Kalkbrenner et al., 2022), and STEM students (Kalkbrenner & Miceli 2022).
At the time of this writing, RFSV scores have not been validated with a normative sample of physicians. Validity evidence of test scores can fluctuate between normative samples (American Educational Research Association [AERA] et al., 2014; Lenz et al., 2022). Accordingly, counseling practitioners, researchers, and students have a responsibility to validate scores with untested populations before using the test in clinical practice or research (Lenz et al., 2022). Validating RFSV scores with a national sample of U.S. physicians may provide professional counselors with a clinically appropriate screening tool for ascertaining what barriers contribute to physicians’ reluctance to attend counseling services. Identifying barriers to counseling within this population may also promote efforts to increase physicians’ support-seeking behaviors (Mortali & Moutier, 2018).
Barriers to Counseling
Counseling interventions provide physicians with protective factors such as promoting overall health and wellness (Major et al., 2021) and decreasing emotional exhaustion associated with burnout (Wiederhold et al., 2018). Despite these correlations, Kase et al. (2020) found that although 43% of a sample of U.S. pediatric physicians had access to professional counseling and support groups, only 17% utilized these services. Participants cited barriers to attending counseling, including inconvenience, time constraints, preference for handling mental health issues on their own, and perceiving mental health services as unhelpful.
A significant barrier contributing to U.S. physicians’ reticence to attend counseling is the influence of medical culture which reinforces physician self-neglect and pressure to maintain an image of invincibility (Shanafelt et al., 2019). This pressure can begin as early as medical school and may lead to a decreased likelihood of seeking counseling, as medical students who endorsed higher perceptions of public stigma within their workplace culture perceived counseling as less efficacious and considered depression a personal weakness (Wimsatt et al., 2015). An association of frailty with mental health diagnoses and treatment may be driven by incongruences in medical culture between espoused values and actual behaviors, such as teaching that self-care is important, yet practicing excessive hours, delaying in seeking preventive health care, and tolerating expectations of perfectionism (Shanafelt et al., 2019). Such hidden curricula may perpetuate the stigma of seeking mental health treatment, which is considered a primary driver of suicide in the health care workforce (American Hospital Association [AHA], 2022).
In addition to the barrier presented by medical culture, the stigmatization and negative impact on licensure of receiving a diagnosis also discourages physicians from seeking care (Mehta & Edwards, 2018). Almost 50% of a sample of female U.S. physicians believed that they met the criteria for a mental health diagnosis but had not sought treatment, citing reasons such as a belief that a diagnosis is embarrassing or shameful and fear of being reported to a medical licensing board (Gold et al., 2016). It is recommended best practice for state medical licensing boards to phrase initial and renewal licensure questions to only inquire about current mental health conditions, to ask only if the physician is impaired by these conditions, to allow for safe havens, and to use supportive language; yet in a review of all 50 states, the District of Columbia, and four U.S. territories, only three states’ or territories’ applications met all four conditions (Douglas et al., 2023). Thus, it is unsurprising that out of a sample of 5,829 U.S. physicians, nearly 40% indicated reluctance to seek formal care for a mental health condition because of licensure concerns (Dyrbye et al., 2017). The barriers of medical culture and its expectations, stigma, and diagnosis are consequential; further research is needed given the pressure physicians may experience to remain silent on these issues (Mehta & Edwards, 2018).
Demographic Differences
A number of demographic variables are related to differences in physicians’ mental health and their attitudes about seeking counseling (Creager et al., 2019; Duarte et al., 2020). For example, demographic differences such as gender and ethnoracial identity can add complexity to physicians’ risk of negative mental health outcomes (Duarte et al., 2020). Sudol et al. (2021) found that female physicians were at higher risk of depersonalization and emotional exhaustion than male physicians, while physicians from racial/ethnic minority backgrounds were more likely to report burnout than White physicians. Gender identity can also affect help-seeking behavior, as female physicians are more likely than male physicians to utilize social and emotional supports and less likely to prefer handling mental health symptoms alone (Kase et al., 2020). Work setting is another demographic variable that is associated with physicians’ mental health wellness, as Creager et al. (2019) identified lower burnout and stress rates among physicians working in private practice than those working in non–private practice settings.
Help-seeking history has become a more frequently examined variable in counseling research, often categorized into two groups: (a) individuals who have attended at least one session of personal counseling or (b) those who have never sought counseling (Cheng et al., 2018). This demographic variable is especially important when evaluating the psychometric properties of screening tools for physicians, who encounter numerous obstacles to accessing counseling services. Help-seeking history is related to more positive attitudes about seeking counseling, as Kevern et al. (2023) found that 80% of a sample of U.S. resident physicians who attended mental health counseling reported their sessions increased their willingness to attend counseling. These collective findings suggest demographic variables such as gender, ethnoracial identity, work setting, and help-seeking history may impact physicians’ mental health and their sensitivity to barriers to attending counseling and thus warrant further investigation.
The Revised Fit, Stigma, and Value Scale
Neukrug et al. (2017) developed and validated scores on the original 32-item Fit, Stigma, and Value (FSV) Scale with a sample of human service professionals in order to appraise barriers to attending personal counseling. The FSV subscales assess sensitivity to three potential barriers to counseling attendance, including fit, the extent to which a respondent trusts the counseling process; stigma, the feelings of shame or embarrassment associated with attending counseling; and value, the perceived benefit of being in counseling. Kalkbrenner et al. (2019) also developed and validated scores on a briefer 14-item version of the FSV Scale (the RFSV Scale), that contains the original three subscales. Additionally, Kalkbrenner and Neukrug (2019) identified a higher-order factor, the Global Barriers to Counseling Scale, which is the composite score of the RFSV’s Fit, Stigma, and Value single-order subscales.
Integrative Behavioral Health Care
Mental health challenges and attitudes toward seeking support are shaped by both individual (microsystemic) and broader societal (macrosystemic) factors, making it impossible for a single discipline to address these issues (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023). As a result, the counseling profession is increasingly adopting interdisciplinary collaboration models, in which mental health professionals work together to deliver holistic care to clients or patients. Emerging research highlights interventions aimed at reducing barriers to accessing counseling services (e.g., Lannin et al., 2019). However, the complex interplay of ecological factors influencing mental health distress and service utilization makes evaluating these interventions challenging. Accordingly, counselors and other members of interdisciplinary teams need screening tools with valid scores to help determine the effectiveness of such interventions.
The primary aims of the present study were to validate RFSV scores with a national sample of physicians in the United States and to investigate demographic differences in physicians’ RFSV scores. The validity and meaning of latent traits (i.e., RFSV scores) can differ between different normative samples (AERA, 2014; Lenz et al., 2022). RFSV scores have not been normed with physicians. Accordingly, testing for factorial invariance of RFSV scores is a pivotal next step in this line of research. In other words, the internal structure validity of RFSV scores must be confirmed with physicians before the scale can be used to measure the intended construct. Although a number of different forms of validity evidence of scores exists, internal structure validity is a crucial consideration when testing the psychometric properties of an inventory with a new normative sample (AERA, 2014; Lenz et al., 2022). If RFSV scores are validated with a national sample of U.S. physicians, counselors can use the scale to better understand why physicians, as a population, are reticent to seek counseling.
Pending at least acceptable validity evidence, we sought to investigate the capacity of physicians’ RFSV scores for predicting referrals to counseling and to examine demographic differences in RFSV scores. Results have the potential to offer professional counselors a screening tool for understanding why physicians might be reticent to seek counseling. Findings also have the potential to reveal subgroups of physicians who might be especially unlikely to access counseling services. To these ends, the following research questions (RQs) were posed:
RQ1. What is the factorial invariance of scores on the RFSV Scale among a national sample of U.S. physicians?
RQ2. Are U.S. physicians’ RFSV scores statistically significant predictors of making at least one referral to counseling?
RQ3. Are there demographic differences to the RFSV barriers among U.S. physicians’ RFSV scores?
Method
Participants and Procedures
A quantitative cross-sectional psychometric research design was utilized to answer the research questions. The current study is part of a larger grant-funded project with an aim to promote health-based screening efforts and wellness among physicians. The aim of the previous study (Kalkbrenner et al., 2025) was to test the psychometric properties of three wellness-based screening tools with physicians. In the present study, we further analyzed the data in Kalkbrenner et al. (2025) to answer different research questions about a different scale (the RFSV Scale) on barriers to counseling. This data set was collected following approval from our IRB. Crowdsourcing is an increasingly common data collection strategy in counseling research with utility for accessing prospective participants on national and global levels (Mullen et al., 2021). Qualtrics Sample Services is a crowdsource solutions service with access to over 90 million prospective participants who voluntarily participate in survey research for monetary compensation. Grant funding was utilized to engage the services of a data collection agency to enlist a nationwide cohort of U.S. physicians. Qualtrics Sample Services was selected because they were the only crowdsource service we came across that could provide a sample of more than 400 licensed U.S. physicians. A sample greater than 400 was necessary for answering the first research question because 200 participants per group is the lower end of acceptable for multiple-group confirmatory factor analysis (MG-CFA; Meade & Kroustalis, 2006). Qualtrics Sample Services provided us with a program manager and a team of analysts who undertook a meticulous quality assessment of the data. This quality assessment involved filtering out respondents exhibiting excessive speed in responding, random response patterns, failed attention checks, and instances of implausible responses (e.g., individuals claiming to be 18 years old with an MD).
A total of N = 437 valid responses that met quality standards were obtained. An analysis of missing values indicated an absence of missing data. Examination of standardized z-scores and Mahalanobis (D) distances identified no univariate outliers (z > ± 3.29) and no multivariate outliers, respectively. Skewness and kurtosis values for physicians’ scores on the RFSV Scale were within the range indicative of a normal distribution of test scores (skewness < ± 2 and kurtosis < ± 7). Participants in the sample (N = 437) ranged in age from 25 to 85 (M = 47.80, SD = 11.74); see Table 1 for the demographic profile of the sample.
Table 1
Demographic Profile of the Sample (N = 437)
| Sample Characteristics |
n |
% |
| Gender |
|
|
| Male |
217 |
49.7 |
| Female |
215 |
49.2 |
| Transgender |
1 |
0.2 |
| Nonbinary |
1 |
0.2 |
| Preferred not to answer |
3 |
0.7 |
| Ethnoracial Identity |
|
|
| American Indian or Alaska Native |
1 |
0.2 |
| Asian or Asian American |
28 |
6.4 |
| Black or African American |
76 |
17.4 |
| Hispanic, Latinx, or Spanish origin |
97 |
22.2 |
| Middle Eastern or North African |
6 |
1.4 |
| Multiethnic |
6 |
1.4 |
| White or European American |
216 |
49.4 |
| Identified as another race, ethnicity, or origin |
1 |
0.2 |
| Preferred not to answer |
4 |
0.9 |
| Help-Seeking History |
|
|
| No help-seeking history |
228 |
52.2 |
| Help-seeking history |
208 |
47.6 |
| Work Setting |
|
|
| Private practice |
202 |
46.2 |
| Non–private practice |
233 |
53.3 |
| Did not report work setting |
2 |
0.5 |
Measures
Prospective participants voluntarily indicated their informed consent and confirmed that they met the eligibility criteria for participation, including being a physician licensed as an MD, treating patients in the United States, and being over 18 years old at the time of data collection. Participants then responded to a demographic questionnaire and completed the RFSV Scale.
The RFSV Scale
The RFSV Scale is a screening tool designed to measure respondents’ sensitivity to barriers to attending counseling (Kalkbrenner et al., 2019) and is comprised of three subscales. Participants respond to a stem (“I am less likely to attend counseling because . . . ”) on the following Likert scale: 1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree nor Disagree, 4 = Agree, or 5 = Strongly Agree. Higher scores indicate greater reluctance to seek counseling. The Fit subscale measures the degree to which a respondent believes that the counseling process is congruent with their personality, values, or beliefs (e.g. “I couldn’t find a counselor who would understand me”). The Stigma subscale measures one’s reluctance to attend counseling because of shame or embarrassment (e.g. “It would damage my reputation”). The Value subscale appraises the degree to which a respondent perceives the effort required to attend counseling as beneficial (e.g. “It is not an effective use of my time”).
Kalkbrenner et al. (2019) found moderate to strong reliability evidence of scores on the RFSV subscales (Fit α = .82, Stigma α = .91, Value α = .78) and support for the internal structure validity of the RFSV through factor analysis. Additionally, Kalkbrenner and Neukrug (2018) demonstrated evidence of internal structure validity of RFSV scores through confirmatory factor analysis (CFA). Moreover, Kalkbrenner et al. (2022) found internal structure validity and criterion validity evidence of RFSV scores. More specifically, Kalkbrenner et al. (2022) found internal structure validity evidence of RFSV scores via CFA with a normative sample of STEM students. In addition, Kalkbrenner et al. (2022) found that STEM students’ scores on the Value barrier were a statistically significant predictor of a non-test criterion (referrals to the counseling center), which supported criterion validity of RFSV scores.
Cronbach’s alpha (α) and McDonald’s omega (ω) were calculated to estimate the reliability of physicians’ scores on the RFSV Scale. Consistent with the Responsibilities of Users of Standardized Tests (RUST-4E) standards, we computed confidence intervals (CIs) for each point reliability estimate (Lenz et al., 2022). All CIs were estimated at the 95% level. The following interpretive guidelines for internal consistency reliability evidence of test scores were used: α > .70 (Tavakol & Dennick, 2011) and ω > .65 (Nájera Catalán, 2019). Among the sample of physicians in the present study, scores on the Fit subscale showed acceptable internal consistency reliability of scores (α = .819, 95% CI [.789, .846]; ω = .827, 95% CI [.799, .851]). Scores on the Stigma subscale displayed acceptable-to-strong internal consistency reliability evidence of scores (α = .896, 95% CI [.877, .912]; ω =. 902, 95% CI [.885, .918]). Physicians’ scores on the Value subscale displayed acceptable internal consistency reliability of scores (α = .817, 95% CI [.781, .848]; ω =.820, 95% CI [.783, .850]). Finally, we found strong internal consistency reliability estimates of scores on the Global Barriers scale (α = .902, 95% CI [.885, .915]; ω = .897, 95% CI [.887, .911]).
Data Analytic Plan
MG-CFA is an advanced psychometric analysis for determining the extent to which the meaning of latent constructs remain stable across subgroups of a sample (Dimitrov, 2012). MG-CFA is particularly sensitive to sample size (Meade & Kroustalis, 2006). A number of guidelines for MG-CFA sample size exist; however, at least 200 participants per each level of every invariance variable tends to be the minimum. To ensure that the present sample included 200+ participants in each group (see Table 2), the gender identity and ethnoracial identity variables were coded as female or male and White or non-White, respectively, for sample size considerations. This method of dummy coding highlights a frequent sample size–based challenge encountered in survey research, particularly in the context of assessing gender or ethnoracial identity (Ross et al., 2020). However, this coding method can be appropriate for survey research provided that the authors openly acknowledge the limitations inherent in such procedures, and that there is at least some degree of consistency between the dummy-coded groups and both the existing literature and the research questions (Ross et al., 2020). The coded groups are consistent with the literature and RQs, as findings in the extant literature (e.g., Duarte et al., 2022) demonstrated mental health care disparities between White and non-White and between male and female physicians. There are macro- and microlevel inequalities in the U.S. health care system between White and non-White populations (Matthew, 2015). Using the comparative method between participants with White and non-White ethnoracial identifies can have utility for highlighting the discrepancies in the U.S. health care system (Matthew, 2015; Ross et al., 2020). The limitations of this statistical aggregation procedure in terms of external validity will be articulated in the Discussion section.
Table 2
Multiple-Group Confirmatory Factor Analysis: RFSV Scale With U.S. Physicians
| Invariance Forms |
CFI |
∆CFI |
RMSEA |
∆RMSEA |
RMSEA CIs |
SRMR |
∆SRMR |
Model Comparison |
| Ethnoracial Identity: White (n = 216) vs. Non-White (n = 215) |
| Configural |
.934 |
|
.057 |
|
.049; .064 |
.070 |
|
|
| Metric |
.933 |
.001 |
.055 |
.002 |
.048; .063 |
.070 |
< .001 |
Configural |
| Scalar |
.928 |
.005 |
.055 |
< .001 |
.048; .062 |
.071 |
.001 |
Metric |
| Gender Identity: Female (n = 215) vs. Male (n = 217) |
|
| Configural |
.936 |
|
.056 |
|
.048; .063 |
.060 |
|
|
| Metric |
.935 |
.001 |
.055 |
.001 |
.047; .062 |
.066 |
.006 |
Configural |
| Scalar |
.921 |
.014 |
.057 |
.002 |
.051; .064 |
.067 |
.001 |
Metric |
| Help-Seeking History: Yes (n = 208) vs. No (n = 228) |
|
| Configural |
.921 |
|
.062 |
|
.055; .070 |
.080 |
|
|
| Metric |
.921 |
< .001 |
.061 |
.001 |
.053; .068 |
.080 |
< .001 |
Configural |
| Scalar |
.906 |
.015 |
.063 |
.001 |
.057; .070 |
.079 |
.001 |
Metric |
| Work Setting: Private Practice (n = 202) vs. Non-Private Practice (n = 233) |
|
| Configural |
.942 |
|
.053 |
|
.045; .061 |
.062 |
|
|
| Metric |
.937 |
.005 |
.054 |
.001 |
.046; .061 |
.075 |
.013 |
Configural |
| Scalar |
.936 |
.001 |
.052 |
.002 |
.044; .059 |
.075 |
< .001 |
Metric |
|
|
|
|
|
|
|
|
|
|
We computed an MG-CFA to test the factorial invariance of U.S. physicians’ RFSV scores (RQ1). All statistical analyses were computed in IBM SPSS AMOS version 29 with a maximum likelihood estimation method. The fit of the baseline configural models was compared to the following cutoff scores: root mean square error of approximation (RMSEA < .08 = acceptable fit and < .06 = strong fit), standardized root mean square residual (SRMR < .08 = acceptable fit and < .06 = strong fit), and the comparative fit index (CFI, .90 to .95 = acceptable fit and > .95 = strong fit (Dimitrov, 2012; Schreiber et al., 2006). Pending at least acceptable fit of the baseline models, we used the following guidelines for factorial invariance testing: < ∆ 0.010 in the CFI, < ∆ 0.015 in the RMSEA, and < ∆ 0.030 in the SRMR for metric invariance or < ∆ 0.015 in SRMR for scalar invariance (Chen, 2007; Cheung & Rensvold, 2002).
A binary logistic regression analysis was computed to investigate the predictive capacity of physicians’ RFSV scores (RQ2). The predictor variables included physicians’ interval level scores on the RFSV Scale. The criterion variable was whether or not physicians have made at least one referral to counseling (0 = no or 1 = yes). Interscale corrections between the RFSV scales ranged from r = .44 to r = .55, indicating that multicollinearity was not present in the data.
A 2 (gender) X 2 (ethnicity) X 2 (work setting) X 2 (help-seeking history) factorial multivariate analysis of variance (MANOVA) was computed to investigate differences in physicians’ RFSV scores (RQ3). The categorical level independent variables (IVs) included gender (female or male), ethnoracial identity (White or non-White), help-seeking history (yes or no), and work setting (private practice or non–private practice). The dependent variables (DVs) were physicians’ interval level scores on the RFSV Scale. Box’s M test demonstrated that the assumption of equity of covariance matrices was met, F = (90, 73455.60) = 86.28, p = .719.
Results
Factorial Invariance Testing
An MG-CFA was computed to answer the first research question regarding the factorial invariance of U.S. physicians’ scores on the RFSV Scale. First, the baseline configural models were investigated for fit. We then tested for invariance, as the baseline models showed acceptable fit based on the previously cited guidelines provided by Dimitrov (2012) and Schreiber et al. (2006), including gender identity (CFI = .936, RMSEA = .056, 90% CI [.048, .063], and SRMR = .060), ethnoracial identity (CFI = .934, RMSEA = .057, 90% CI [.049, .064], and SRMR = .070), help-seeking history (CFI = .921, RMSEA = .062, 90% CI [.055, .070], and SRMR = .080), and work setting (CFI = .942, RMSEA = .053, 90% CI [.045, .061], and SRMR = .062).
In terms of invariance, all of the fit indices (∆CFI, ∆RMSEA, and ∆SRMR) supported both metric and scalar invariance of scores for ethnoracial identity and work setting (see Table 2). For the gender identity and help-seeking history variables, the ∆RMSEA and ∆SRMR supported both metric and scalar invariance of scores. The ∆CFI supported metric but not scalar invariance of scores for the help-seeking history and gender identity variables. Demonstrating invariance can be deemed acceptable solely based on metric invariance (Dimitrov, 2010). This is particularly true when only a single fit index, such as the CFI, confirms metric invariance but not scalar invariance of scores.
Logistic Regression
A logistic regression analysis was computed to answer the second research question regarding the predictive capacity of physicians’ RFSV scores. The logistic regression model was statistically significant, X2 (3) = 15.36, p = .002, Nagelkerke R2 = .05. The odds ratios, Exp(B), demonstrated that an increase of one unit in physicians’ scores on the Stigma subscale (higher scores = higher barriers to counseling) was associated with a decrease in the odds of having made at least one referral to counseling by a factor of .711, Exp(B) 95% CI [.517, .947], p = .036. In addition, an increase of one unit in physicians’ scores on the Value subscale was associated with a decrease in the odds of having made at least one referral to counseling by a factor of .707, Exp(B) 95% CI [.508, .984], p = .040.
Factorial MANOVA
A 2 (gender) X 2 (ethnicity) X 2 (work setting) X 2 (help-seeking history) factorial MANOVA was computed to investigate differences in physicians’ RFSV scores (RQ3). A significant main effect emerged for gender on the combined DVs, F = (3, 409) = 6.50, p < .001, Λ = 0.95, n2p = .05. The statistically significant findings in the MANOVA were followed up with post-hoc discriminant analyses. The discriminant function significantly discriminated between groups, λ = 0.94, X2 = 25.07, df = 3, Canonical correlation = .29, p < .001. The correlations between the latent factors and discriminant functions showed that Fit (−1.17) loaded more strongly on the function than Stigma (0.68) and Value (0.62), suggesting that Fit contributed the most to group separation in gender identity. The mean discriminant score on the function for male physicians was 0.24 and the mean score for female physicians was −0.25 (higher scores = greater barriers to counseling).
A significant main effect emerged for help-seeking history on the combined DVs, F = (3, 409) = 4.57, p = .004, Λ = 0.95, n2p = .03. The post-hoc discriminant function significantly discriminated between groups, Wilks λ = 0.96, X2 = 19.61, df = 3, Canonical correlation = .21, p < .001. The correlations between the latent factors and discriminant functions showed that Value (1.03) loaded more strongly on the function than Stigma (0.28) and Fit (0.26), suggesting Value contributed the most to group separation in help-seeking history. The mean discriminant score on the function for physicians with a help-seeking history was −0.23 and the mean score was 0.21 for physicians without a help-seeking history.
Discussion
The aims of the present study were to: validate RFSV scores with a national sample of physicians in the United States, investigate the capacity of RFSV scores for predicting physician referrals to counseling, and investigate demographic differences in physicians’ RFSV scores. The findings will be discussed in accordance with the RQs. The model fit estimates for each of the baseline configural models were all in the acceptable range based on the recommendations of Dimitrov (2012) and Schreiber et al. (2006; see Table 2). The acceptable fit of the configural models supported that the RFSV Scale and its dimensionality were estimated adequately with a normative sample of physicians. RFSV scores have been normed with seven different normative samples since 2018, including adults in the United States (Kalkbrenner & Neukrug, 2018), mental health counselors (Kalkbrenner et al., 2019), counselors-in-training (Kalkbrenner & Neukrug, 2019), college students at an HSI (Kalkbrenner et al., 2022), and STEM students (Kalkbrenner & Miceli, 2022). The baseline CFA results in the present study extend the generalizability of RFSV scores to a normative sample of physicians in the United States. Because we found support for the baseline configural models, we proceeded to test for invariance of scores.
Invariance testing via MG-CFA takes internal structure validity testing to a higher level by revealing if the meaning of a latent trait stays consistent (i.e., invariant) between specific groups of a normative sample (Dimitrov, 2012). The results of factorial invariance testing were particularly strong and evidenced both metric and scalar invariance of RFSV scores for the ethnoracial identity and work setting variables. The ∆ in RMSEA and SRMR also supported both metric and scalar invariance for the help-seeking history and gender identity variables. The ∆ in CFI revealed metric, but not scalar invariance of scores for the help-seeking history and gender identity variables. Metric invariance alone can be sufficient for demonstrating invariance of scores across a latent trait (Dimitrov, 2010). This is particularly true when only a single fit index, such as the CFI, supports metric invariance but not scalar invariance of scores. In totality, the MG-CFA results supported invariance of physicians’ RFSV scores by ethnoracial identity, work setting, and, to a lesser but acceptable degree, help-seeking history and gender identity.
The MG-CFA results demonstrated that RFSV scores were valid among a national sample of U.S. physicians (RQ1). This finding adds rigor to the results of RQs 2 and 3 on predictive and demographic differences in physicians’ RFSV scores, as the scale was appropriately calibrated with a new normative sample. A test of the predictive capacity of RFSV scores revealed that physicians’ scores on the Stigma and Value subscales were statistically significant predictors of having made one or more referrals to counseling (RQ2). In other words, lower levels of stigma and higher attributions to the value of counseling were associated with higher odds of physicians making one or more referrals to counseling at a statistically significant level. This finding is consistent with Kalkbrenner and Miceli (2022), who found that scores on the Value subscale were predictors of referrals to counseling among STEM students. Similarly, Kalkbrenner et al. (2022) found that scores on the Value subscale predicted supportive responses to encountering a peer in mental distress among college students attending an HSI. Collectively, the findings of the present study are consistent with past investigators (e.g., Kalkbrenner et al., 2022) who found that more positive attitudes about counseling tend to predict increases in the odds of having made one or more peer referrals to counseling.
The final aim of the present study was to test for demographic differences in physicians’ sensitivity to the RFSV barriers (RQ3). We found statistically significant main effects for the gender identity and help-seeking history variables. Results revealed that male physicians were more sensitive to the Fit barrier than female physicians. This finding suggests that physicians who identify as male might be more skeptical about the counseling process in general and may doubt their chances of finding a counselor they feel comfortable with. This finding adds to the extant literature on physicians’ mental health and attitudes about seeking counseling. Past investigators (e.g., Sudol et al., 2021) documented female physicians’ increased risk for mental health stress when compared to male physicians. The findings of the present study showed that male physicians were more sensitive to the Fit barrier than female physicians. Accordingly, it is possible that female physicians are more likely to report symptoms of and seek support services for mental health issues than male physicians. This might be due, in part, to differences between male and female physicians’ beliefs about the fit of counseling. Future research is needed to test this possible explanation for this finding.
We found that physicians with a help-seeking history (i.e., attended one or more counseling sessions in the past) were less sensitive to the Value barrier when compared to physicians without a help-seeking history. Similarly, past investigators found associations between help-seeking history and more positive attitudes about the value and benefits of seeking counseling, including among STEM students (Kalkbrenner & Miceli 2022), college students at an HSI (Kalkbrenner et al., 2022), and adults living in the United States (Kalkbrenner & Neukrug, 2018). Collectively, the results of the present study are consistent with these existing findings, which suggest that physicians and members of other populations with help-seeking histories tend to attribute more value toward the anticipated benefits of counseling.
Limitations and Future Research
We recommend that readers consider the limitations of the present study before the implications for practice. Causal attributions cannot be drawn from a cross-sectional survey research design. Future researchers can build upon this line of research by testing the RFSV barriers using an experimental approach. Such research could involve administering the scale to physician clients before and after their counseling sessions. Such an approach might yield evidence on how counseling reduces sensitivity to certain barriers. However, it is important to note that pretest/posttest approaches can come with a number of limitations, including attrition, regression to the mean, history, and maturation.
Dummy coding the sociodemographic variables into broader categories to ensure adequate sample sizes for MG-CFA was a particularly challenging decision, especially for the ethnoracial identity variable. Although this statistical aggregation procedure can be useful for making broad and tentative generalizations about ethnicity and other variables (Ross et al., 2020), it limited our ability to explore potential differences in the meaning of the RFSV barriers among physicians with identities beyond White or non-White, and male or female. Future research with a more diverse sample by gender and ethnoracial identity is recommended.
Implications for Practice
The findings from this study provide robust psychometric evidence that supports the dimensionality of U.S. physicians’ scores on the RFSV Scale and carries important implications for counseling professionals. The National Board for Certified Counselors (NBCC; 2023) emphasizes the use of screening tools with valid scores as a means of improving clinical practice. Additionally, ethical guidelines for counselors stress the importance of ensuring that the screening tools that they utilize offer valid and reliable scores, derived from representative client samples, to uphold their effectiveness and proper application (AERA, 2014; Lenz et al., 2022; NBCC, 2023). Mental health issues and attitudes about utilizing mental health support services are influenced by microsystemic and macrosystemic factors (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023). To this end, implications for practice will be discussed on both microsystemic and macrosystemic levels.
The practicality of the RFSV Scale adds to its utility, as it is free to use, simple to score, and typically takes between 5 and 8 minutes to complete. Identifying barriers or doubts that physician clients have about counseling during the intake process might help increase physician client retention. To these ends, counselors can include the RFSV Scale with intake paperwork for physician clients. Counselors can use the results as one way to gather information about doubts that their physician clients might have about attending counseling. Suppose, for example, that a physician client scores higher on the Fit subscale (higher scores = higher barriers to counseling) than the Stigma or Value subscales. It might be helpful for the counselor and client to discuss how they can make the counseling process a good fit (i.e., how and in what ways the counseling process can be congruent with their personality, values, or beliefs). Increasing physician clients’ buy-in regarding the counseling process may increase retention.
Counselors could also administer the RFSV Scale at the beginning, middle, and end of the counseling process when working with clients who are physicians or medical students. Results might reveal the utility of counseling for reducing barriers to counseling among clients who are physicians or medical students. Our results revealed that physicians with help-seeking histories perceived greater value about the benefits of counseling than physicians without help-seeking histories. Mental health support services provided by counselor education students can be a helpful resource for medical students and residents (Gerwe et al., 2017). Accordingly, there may be utility in counselor education programs collaborating with medical colleges and schools to address stigma around seeking counseling that can exist in the medical field. This broader perspective is consistent with the ecological systems direction that the counseling profession spearheaded (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023) and could help address stigma toward seeking counseling before medical students become physicians. More specifically, directors and clinical coordinators of counseling programs can reach out to directors of medical schools to establish collaborative relationships in which counseling interns provide supervised counseling services to medical students and residents. This might have dual benefits because medical schools would be able to offer their students free mental health support services and counseling programs would provide additional internship sites for their students. Early intervention before students become physicians could reduce stigma toward counseling throughout their careers.
Time constraints can be a barrier to counseling among physicians, residents, and medical students (Gerwe et al., 2017; Kase et al., 2020). Accordingly, it could be beneficial for counseling students who are interested in working with medical students or residents to complete their internship placements in the same settings where medical students and residents work. In all likelihood, providing supervised group and individual counseling for medical students at their work sites would increase the accessibility of counseling.
The counseling profession is moving toward interdisciplinary collaboration models that involve teams of mental health professionals working together to provide comprehensive client/patient care (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023). Interventions designed to reduce barriers to counseling are only beginning to appear in the extant literature (e.g., Lannin et al., 2019). The ecological systemic nature of mental health distress and influences on attitudes about accessing mental health support services makes evaluating the utility of reducing barriers to counseling interventions complex. To address this, counselors and interdisciplinary teams need screening tools with reliable and valid scores in order to effectively assess the impact of these interventions.
The results of CFA and MG-CFA in the present study confirmed that the RFSV Scale measured the intended construct of measurement with a national sample of U.S. physicians (RQ1). Thus, the RFSV Scale may have utility as a pretest/posttest for measuring the effectiveness of interventions geared toward reducing barriers to counseling. The extant literature on interventions for reducing barriers to counseling is in its infancy. Lannin et al. (2019) started to fill this gap in the knowledge base by conducting an intervention study with random assignment. Lannin et al. (2019) tested the extent to which contemplation about seeking counseling and self-affirmation were related to seeking mental health screening and general information about mental health support services. Results revealed that participants who used both self-affirming personal values and contemplation were significantly more likely to seek mental health screening and general information about mental health than participants in the contemplation-only group. In addition, participants in the contemplation about seeking counseling group only reported higher self-stigma. Findings indicated that interventions including both contemplation and self-affirmation of participants’ personal values were more likely to increase receptivity to outreach efforts.
Lannin et al. (2019) sampled undergraduate students attending a historically Black college/university. Lannin et al.’s (2019) intervention might have utility with physicians. However, to the best of our knowledge, the screening tools used by Lannin et al. have not been validated with U.S. physicians. Accordingly, professional counselors can use the RFSV Scale as one way to measure potential reductions in barriers to seeking counseling before and after participating in interventions geared toward promoting help-seeking among physicians. Fully developing an intervention that reduces barriers to counseling is beyond the scope of this study. Although future research is needed in this area, the results of this study confirmed that the RFSV Scale measured the intended construct of measurement with a national sample of U.S. physicians. Accordingly, professional counselors can use the RFSV Scale to better understand why prospective or current physician clients are reluctant to seek counseling. For example, professional counselors can work with medical supervisors and the directors of physician residency programs to administer the RFSV Scale at orientations for new physician employees and medical residents. The results could reveal specific barriers that are particularly salient in a given medical setting. Professional counselors can use the results to structure psychoeducation sessions about the utility of counseling for physicians. Suppose, for example, that physicians in a particular setting score higher on the Stigma subscale. A counselor can structure the content of the psychoeducation session on reducing stigma toward counseling. Specifically, the session could involve reframing seeking counseling in the context of the courage it takes for one to reach out to a counselor and the benefits associated with participating in counseling. These sessions may also help strengthen interpersonal bonds among physicians and begin to normalize mental health support within the medical community.
Consistent with the findings of Kalkbrenner and Miceli (2022), we found that lower scores on the Value subscale (lower scores = greater perceived benefits of counseling) was a statistically significant predictor of higher odds of participants having made one or more peer referrals to counseling. This finding, combined with the extant literature on physicians’ vulnerability to mental health distress and reticence to seek counseling (Lobelo & de Quevedo, 2016; Walker & Pine, 2018), suggested that peer-to-peer support may be a valuable resource for counselors who work in medical settings. In other words, we found that greater perceived value of the benefits of counseling was a statistically significant predictor of an increase in the odds of physicians recommending counseling to another physician. Accordingly, professional counselors who work in medical settings are encouraged to organize peer-to-peer support networks among physicians within their work setting. For example, professional counselors can work to promote physicians’ awareness of the value of attending professional counseling, particularly for reducing burnout, grieving the loss of a patient, coping with the demanding work life of physicians, and increasing general health (Major et al., 2021; Trivate et al., 2019; Wiederhold et al., 2018). Our results revealed that when compared to female physicians, male physicians scored higher on the Fit subscale (higher RFSV scores = poorer attitudes about counseling) and physicians with a help-seeking history scored higher on the Value subscale than those without help-seeking histories. To this end, there may be utility in focusing outreach sessions about the benefits of counseling to male physicians. For example, professional counselors could produce short videos, flyers, or other types of media on the benefits that attending counseling can have for physicians. These media sources can be shared with physicians. Such awareness advocacy about the benefits of counseling may result in an increase of peer-to-peer referrals to counseling among physicians.
Summary and Conclusion
Physicians in the United States face increased risks for mental distress and often hesitate to seek professional counseling (Lobelo & de Quevedo, 2016; Walker & Pine, 2018). Screening tools with validated scores are essential resources for helping professional counselors to understand why potential clients avoid seeking counseling services. The RFSV Scale measures barriers to counseling. This study aimed to validate RFSV scores among U.S. physicians and investigated demographic differences in their scores. Results indicated that the RFSV Scale and its dimensions were adequately estimated with a national sample of physicians in the United States. Physicians’ RFSV scores significantly predicted peer-to-peer counseling referrals. We identified demographic differences in sensitivity to barriers to counseling based on gender identity and help-seeking history. Physicians who self-identified as male and those without help-seeking histories were more sensitive to barriers to counseling than female physicians or physicians with help-seeking histories, respectively. At this phase of development, professional counselors can use the RFSV Scale as a tool for understanding barriers to seeking counseling among physicians.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Michael T. Kalkbrenner, PhD, NCC, is a full professor at New Mexico State University. Shannon Esparza, BA, is a graduate student at New Mexico State University. Correspondence may be addressed to Michael T. Kalkbrenner, Department of Counseling and Educational Psychology, New Mexico State University, Las Cruces, NM 88003, mkalk001@nmsu.edu.
