Oct 15, 2014 | Article, Volume 3 - Issue 3
Melanie H. Iarussi, Jessica M. Tyler, Sarah Littlebear, Michelle S. Hinkle
Motivational interviewing (MI), a humanistic counseling style used to help activate clients’ motivation to change, was integrated into a basic counseling skills course. Nineteen graduate-level counseling students completed the Counselor Estimate of Self-Efficacy at the start and conclusion of the course. Significant differences were found between students’ pre/post measures of self-efficacy (t(18) = –7.055, p = .0005). Qualitative data collected concerning students’ experiences learning counseling skills in the context of MI are described by four main themes: (a) valuable and relevant learning experience, (b) more self-assuredness in working with challenging clients, (c) uncertainty in applying technique, and (d) feelings of restriction with MI application. Implications for integrating MI in skills courses and future directions in research are discussed.
Keywords: counseling skills, counseling students, motivational interviewing, self-efficacy, student experiences
Self-efficacy is an important mediator of performance and involves the degree to which people are capable, diligent and committed in their work (Chen, Casper, & Cortina, 2001). Specific to counselor education, there is a supported relationship between counseling self-efficacy and counselor training (Larson et al., 1992; Nilsson & Duan, 2007). Counseling self-efficacy has been shown to play a fundamental role in counselor development and training (Barnes, 2004; Lent et al., 2006), and higher counseling self-efficacy can be related to greater performance due to motivation factors (Bandura, 1986; Greason & Cashwell, 2009). In this study, the authors explored counselor trainees’ counseling self-efficacy before and after the completion of a counseling skills course that integrated MI. This technique was incorporated into the course to increase students’ humanistic people-responsiveness skills and to expose students to a defined evidence-based practice to help increase their counseling self-efficacy. Students’ experiences in this course were also a focus in the current study.
Counseling Self-Efficacy
Counseling self-efficacy can be defined as a counselor’s belief about his or her ability to effectively counsel a client in the near future (Larson, 1998; Larson & Daniels, 1998; Lent et al., 2006). Based on Bandura’s (1997) theory, this confidence is an important factor in the likelihood of counselor trainees applying specific counseling skills. Counseling skills can be defined as the ability of a counselor to demonstrate attending behavior that displays empathy, support, and a unified effort with the client toward a common goal of resolution and movement forward (Ivey, Packard, & Ivey, 2006; Schaefle et al., 2005; Schaefle, Smaby, Packman, & Maddux, 2007). More specifically, counseling attending behavior can be demonstrated through clarifications, encouragement, paraphrasing, reflecting and summarizing of client statements (Easton et al., 2008; Ivey et al., 2006). Self-efficacy theory states that the ability to thrive in the workplace entails not only content knowledge and appropriate application of required skills, but also the worker’s belief that he or she will use the skills successfully (Barnes, 2004; Melchert, Hays, Wiljanen, & Kolocek, 1996; Tang et al., 2004). Counseling self-efficacy theory holds the assumption that self-efficacy is the instrument through which effective practice occurs and perseverance is strengthened for navigating challenging professional scenarios. The theory also contends that self-efficacy enables an environment where counselor trainees are better able to value feedback in their learning processes (Barnes, 2004; Larson, 1998).
Providing opportunities for students to practice, learn and master counseling skills is a powerful way to develop self-efficacy (Greason & Cashwell, 2009). Within pedagogy literature, researchers suggest that counselor competency can be best developed through critical thinking activities such as role-play, modeling, and receiving practice feedback. Such activities build students’ self-efficacy to help them cope with real-work challenges (Daniels & Larson, 2001; Larson et al., 1992; Duys & Hedstrom, 2000; Tang et al., 2004). These purposeful and challenging interventions, which are important for developing counseling self-efficacy, have also been found to be most effective early in skill training (Barnes, 2004; Larson, 1998; Larson et al., 1999). Although new counselors may not feel confident or be fully prepared in their skills, research has found that experience in the field will likely compensate for any earlier deficiencies (Lent et al., 2006; Tang et al., 2004). As such, self-efficacy has been found to be higher among counselors with more education in counseling, more years of experience practicing counseling, and more hours of supervision (Larson et al., 1992).
When pertaining to counselor training, higher self-efficacy has been associated with greater execution of microskills among counselors-in-training who conducted mock sessions (Larson et al., 1992). Counseling self-efficacy includes having confidence in problem-solving and decision-making skills when working with clients (Easton, Martin, & Wilson, 2008). Self-efficacy is positively related to self-esteem, self-perceived planning effectiveness, and outcome expectations (Easton, Martin, & Wilson, 2008; Larson et al., 1992; Schaefle, Smaby, Maddux, & Cates, 2005; Tang et al., 2004), and negatively related to anxiety (Barnes, 2004; Daniels & Larson, 2001; Larson et al., 1992; Lent et al., 2006; Schaefle et al., 2005). Greason and Cashwell (2009) stated that although self-efficacy and competence are not interchangeable, counselors with strong self-efficacy report less anxiety and interpret their professional concerns as “challenging rather than overwhelming or hindering” (p. 3).
The current study assessed students’ counseling self-efficacy before and after completing a basic counseling skills course that integrated MI. Bandura (1984) described self-efficacy as a “generative capability in which multiple subskills must be flexibly orchestrated in dealing with continuously changing realities, often containing ambiguous, unpredictable, and stressful elements” (p. 233). We assert that integrating MI into a basic counseling skills course can provide counselor trainees with this capability as MI is a structured, evidence-based counseling style that requires the practitioner to approach clients in a humanistic people-responsive manner.
Motivational Interviewing
MI is a collaborative, person-centered counseling style intended to elicit and explore clients’ personal motivations to change in an accepting and compassionate environment (Miller & Rollnick, 2013). MI practice includes an indispensable humanistic “spirit” that contains four components: partnership, acceptance, compassion and evocation (Miller & Rollnick, 2013). Within the client-counselor partnership, or collaboration, the counselor is not doing anything “to” the client, but rather is working “with” or “for” the client, and the client is considered the “expert” on his or her own life. Acceptance is an extension of Rogers’s (1957) concept of unconditional positive regard. Expressions of acceptance in MI include supporting client autonomy, expressing accurate empathy, and reflecting client strengths and attributes through genuine affirmations. Compassion emphasizes the primary focus on the client’s welfare. In regard to evocation, the counselor elicits information about the problem from the client’s perspective, as well as information about the client’s goals, values and struggles. Further, the counselor explores the client’s ambivalence about change and evokes the client’s personal motivations to change. By teaching MI in basic skills courses, graduate counseling students learn to base their practice on these humanistic principles, emphasizing the establishment of a working therapeutic relationship based on empathic acceptance.
In addition to a foundational humanistic spirit, the essential skills of MI derive from person-centered counseling. Open questions, reflective statements, summarizations, and statements of affirmation are heavily utilized and emphasized throughout the four phases of MI: engaging, focusing, evoking and planning (Miller & Rollnick, 2013). Phase one—engaging—requires the establishment of a therapeutic relationship, which may include diminishing any relationship discord (formerly known as “resistance”) that is initially present. In phase two, the counselor guides the focus of the interaction to whatever change the client may be considering. In phase three, the MI counselor focuses on evocation by eliciting the client’s arguments in favor of change and helping guide the client to further develop these ideas based on the client’s personal beliefs, values and goals. Counselor behaviors such as confrontation, persuasion and coercion are the antithesis to evocation and are not utilized in MI practice. Providing unsolicited advice and attempting to impose change are seen as counterproductive as these behaviors tend to result in discord in the therapeutic relationship and inhibit client change (Madson, Loignon, & Lane, 2009).
Instead, MI focuses on strategic use of evocation and reflective listening to help guide clients to consider change as they come to recognize and resolve inconsistencies between their values or goals and current behaviors (i.e., developing discrepancies; Miller & Rollnick, 2013). In this way, MI is goal-directed as the counselor intentionally moves with the client to explore and resolve client ambivalence that is interfering with change, and ultimately assist the client to enhance his or her personal motivations to implement and sustain positive behavior change. Finally, once a sufficient level of motivation is present, the counselor and client collaboratively develop a plan for change (phase four). Throughout the four phases of MI, counselors retain the humanistic spirit, meet clients where they are in their unique process of change, and respond to the individualized needs and circumstances of the client.
Basis for Integrating Motivational Interviewing into a Skills Course
The usefulness of MI and the diversity of its application informed the decision to incorporate MI into a basic counseling skills course. Adhering to the four phases of MI provides a clear blueprint for counselor trainees to engage clients in the counseling process, establish a working therapeutic relationship, focus on specific client goals, and develop a plan for change. Further, learning MI includes learning basic counseling skills such as open-ended questions, summarizations, reflections, and highlighting client strengths (i.e., affirmations); therefore, integration of MI might help strengthen these basic skills (Young & Hagedorn, 2012). In addition to these essential skills, learning MI also provides students with the opportunity to learn how to manage discord in the counseling relationship and help resolve client ambivalence about change—both common clinical challenges, especially for beginning counselors. We anticipated that these factors would lead to enhanced self-efficacy among counselor trainees.
In addition to providing a clear framework for counselor trainees to follow to begin the counseling process and a defined method that requires the practice of a humanistic spirit and skills, MI is considered an evidence-based practice (EBP) in the treatment of substance use disorders, the area in which it originated. In addition to substance-abuse treatment, MI has demonstrated efficacy across diverse populations, symptoms and behaviors (Hettema, Steele, & Miller, 2005; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). From hundreds of research studies and several meta-analyses, MI has been found to be efficacious in the areas of chronic mental disorders management, treatment adherence, problem gambling, smoking cessation, generalized anxiety disorder, and co-occurring mental health and substance use disorders, as well as various health issues (Barrowclough et al., 2010; Burke, Arkowitz, & Menchola, 2003; Cleary, Hunt, Matheson, & Walter, 2009; Hettema et al., 2005; Lundahl et al., 2010; Westra, Arkowitz, & Dozois, 2009). MI also has been applied to adolescent counseling (e.g., Knight et al., 2005; Peterson, Baer, Wells, Ginzler, & Garrett, 2006), group therapy (e.g., Walters, Ogle, & Martin, 2002), and couples therapy (e.g., Burke, Vassilev, Kantchelov, & Zweben, 2002). By training counseling students to use an approach that has demonstrated effectiveness with a broad range of clients and issues, it seems likely that students’ self-efficacy with regard to clients would increase. In addition, counselor training programs are encouraged to expose students to EBPs (e.g., Council for Accredited Counseling and Related Educational Programs [CACREP], 2009).
Increasing Counselor Trainee Self-Efficacy Through MI Training
Learning to effectively implement MI is a complex task that requires specific training. Extensive training that includes practice feedback or coaching has been found to be helpful in establishing and maintaining proficient MI practice (Abramowitz, Flattery, Franses, & Berry, 2010; Doran, Hohman, & Koutsenok, 2011; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). To our knowledge, in the only study that has explored MI training with counselor trainees, researchers implemented a 4-hour MI training with graduate counseling students who were in practicum, which resulted in enhanced MI skills compared to a control group who did not receive the 4-hour MI training (Young & Hagedorn, 2012). In the current study, first-year counseling graduate students were exposed to MI starting in the fourth week of a 15-week semester course on basic counseling skills.
This study responded to two research questions. The first question asked, “Does an introductory counseling skills course that incorporated MI significantly increase counseling students’ self-efficacy?” Further, it was expected that an increase in self-efficacy would occur at rates comparable to or exceeding other skill training methods (e.g., skilled counselor training model; Urbani et al., 2002). Second, the authors sought to gain an understanding about the students’ experiences of learning counseling skills within the context of MI.
Description of the Course
Course Materials and Assignments
Two textbooks were used in the described course: the first was a general interview and counseling skills text (Ivey, Ivey, & Zalaquett, 2010), which was used exclusively for the first three classes and then intermittently throughout the semester. The second textbook was specific to building MI skills (Rosengren, 2009) and introduced in the fourth class meeting and also incorporated throughout the remainder of the semester. The third edition of the Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013) text was scheduled to be released shortly after the end of the course. Therefore, students learned the MI concepts as they were presented in the second edition of the text (Miller & Rollnick, 2002) which was a recommended, not required, text for the course. Additional resources were incorporated into the course throughout the semester including supplemental readings related to MI (e.g., Lundahl et al., 2010; Miller & Rollnick, 2004; Miller & Rose, 2009) and video demonstrations of specific MI skills (Miller, Rollnick & Moyers, 1998). The summary of course content provided in Table 1 shows how MI was integrated into the course week-by-week.
Table 1
Integration of MI in Counseling Course
Students were required to complete four video-recorded demonstrations (one 15-minute session, three 45- to 50-minute sessions) of the counseling skills learned in class—with increasing complexity—using role-play with a classmate. Grading rubrics, which were developed by senior faculty and used in this course in previous years and therefore not MI-specific, were used to grade the skill demonstrations. In addition to recorded demonstrations, various written assignments were required throughout the semester, such as reflection papers, a self-evaluation, a completed intake form, a transcribed segment of a recorded mock session, and progress notes.
Course Process
In regard to the process of the course, skill development and practice were emphasized. For each skill presented, a video or interactive demonstration was shown, after which students practiced the skills in dyads or small groups using role-plays. Feedback was provided to the “counselor” from classmates and the instructor and/or a teaching assistant (TA). Three doctoral-level TAs (only one of whom had formal MI training) circulated with the primary instructor (first author) while the students practiced skills in small groups. In the third class meeting, students learned how to give appropriate, constructive feedback to their peers prior to engaging in the first role-play (Ivey, Ivey & Zalaquett, 2010).
Method
A pretest-posttest single group design was employed to investigate the differences in students’ self-efficacy between the start and end of the course, as measured by a self-administered counselor self-efficacy questionnaire. A qualitative case study approach was used to investigate students’ experiences in the course. Qualitative data was collected via an open-ended questionnaire distributed at the final class meeting. All data was collected anonymously and study participation was voluntary.
Participants
This study took place with 19 participants who were graduate students in the counseling programs offered at a large public university in the southern United States. Participants were enrolled in the required Introduction to Counseling Practice course during their second semester of study in their respective counseling programs. Forty-two percent (n = 8) of participants were enrolled in the CACREP-accredited school counseling program, 37% (n = 7) were in the CACREP-accredited clinical mental health counseling program, and 21% (n = 4) were in the APA-accredited counseling psychology program. Twenty-one percent (n = 4) of participants were Black/African American and 79% (n = 15) were White/Caucasian. Sixteen percent (n = 3) of the participants were men and 84% (n = 16) were women. Ages ranged from 22–29 with a mode of 22. All but one of these 19 participants passed this course.
Instruments
The Counselor Estimate of Self-Efficacy (COSE) is a 37-item measure of self-efficacy on a 6-point Likert scale. Sample items include, “When using responses like reflection of feeling, active listening, clarification, probing, I am confident I will be concise and to the point” and “I feel that I have enough fundamental knowledge to do effective counseling.” The COSE has demonstrated reliability and validity as Larson et al., (1992) reported the internal consistency of the COSE was .93 and the test-retest reliability over three weeks was .87. The range for total scores on the COSE is 37–222, with higher scores indicating greater self-efficacy.
The feedback questionnaire distributed at the end of the course consisted of five questions: (a) How would you describe your overall experience of learning counseling skills in the context of MI?; (b) What, if any, were the benefits of learning counseling skills in the context of MI?; (c) What, if any, were the challenges of learning counseling skills in the context of MI?; (d) Would you recommend that this course follow a similar format (integrating MI into the course) for subsequent cohorts? Why or why not?; and (e) Please provide any other comments/suggestions you may have.
Procedure
This counseling course was a required course that met weekly for 2 hours and 50 minutes over the course of a 15-week semester in the Spring of 2012. The course instructor (first author) was an assistant professor and a member of the Motivational Interviewing Network of Trainers (MINT), meaning she had completed a 3-day training to train others in MI. Three doctoral students assisted with the instruction of the course (one of whom is the third author). These TAs taught segments of the course that were not specific to MI, observed and provided students with feedback during class practice sessions, and provided written feedback on students’ recorded skill demonstrations using a grading rubric that was focused on general counseling skill demonstrations (i.e., not specific to MI).
The second author, who was not part of the course instruction, conducted the informed consent and data collection following protocol approval from the Institutional Review Board. Participants completed a demographic form and a pretest COSE on the first day of class. During the final class meeting (week 14), students completed the posttest COSE and the feedback questionnaire. To reduce coercion and protect participant confidentiality, each participant was issued a code that only he or she knew to match his or her pretest and posttest; students completed the qualitative questionnaire anonymously. The course instructor (first author) was not present during the consenting procedures or data collection, and participants were directed not to provide any identifying information on data collection materials. Finally, participants were informed that their decision to participate in the study, not to participate in the study, or to stop participating would not affect their grade in the course, their relationship with the instructor/researchers, or their future relations with the department or university. No incentives were provided for study participation. Nineteen of the 20 students enrolled in the course completed the study in full. One student was absent during the final class meeting, and therefore did not complete the posttest or the qualitative questionnaire. The pretest from this student was destroyed and not used in data analysis.
Case Study Analysis
A case study design was chosen for qualitative portion of this study in order to explore students’ experiences within a bounded system: the counseling skills course that integrated MI (Creswell, Hanson, Plano, & Morales, 2007). The second and third authors completed the qualitative analysis and aimed to arrive at a description of this specific case using case-based themes (Creswell et al., 2007). To do so, the textual data collected via the feedback questionnaire was typed verbatim by the second author. Then, the second and third authors read over participant responses several times to become familiar with the data. Throughout data analysis, these authors engaged in reflexivity and memo writing with the purpose of reflecting on their personal perspectives and experiences in an effort to see the data as it was and to avoid undue influence from their own histories (Morrow, 2005; Patton, 2002), as well as to record and facilitate analytical thinking (Maxwell, 2005).
Consistent with case study research, the second and third authors independently used categorical aggregation to identify patterns and emergent themes from the data (Creswell, 2007). These authors then came together to reach a consensus about the meaning of the data by discussing their independent categories, referring back to the data, and identifying and agreeing upon preliminary categories. The researchers identified major ideas within the data and identified substantiating evidence across participants’ accounts to support each key issue (Creswell, 2007). Through data analysis, the initial 12 categories (practical skills, beneficial experience, client autonomy, helpful experience, enjoyable experience, effective skills, client resistance, client motivation, adaptable skills, difficult clients, ambivalent clients, and client connection) were collapsed into four information-rich themes, one of which contained two subthemes (Creswell, 2007). The authors repeatedly reverted back to the data when considering the wording of the themes and subthemes to confirm that the titles were consistent with the contents.
A peer reviewer (Creswell et al., 2007; Lincoln & Guba, 1985), who is the fourth author and who was familiar with qualitative research, was employed on two occasions in which the themes and analysis process were examined and questioned in terms of rationale, clarity and holistic understanding of the raw data. After each peer review session, the second and third authors discussed the themes and subthemes and made changes to the organization of the themes and their titles. Final themes were agreed upon by the second and third authors as they reflected the overall meaning of the data. These themes served as naturalistic generalizations or descriptions from which others may learn about this case (Creswell, 2007).
Results
Counseling Students’ Self-Efficacy
Participants’ point increases on the COSE ranged from 0 to 74 with the mode being 19 and the mean 30 points. No student showed a decrease in self-efficacy and one student’s score did not change between the pretest and posttest. After determining the assumption of normality was met using normal Q-Q plots, a dependent t-test was used to determine if significant differences existed between the COSE pretest and posttest for these participants. Results showed that a significant improvement occurred at the .0005 level in which the pretest COSE scores had a mean of 144.79±19.6 and the posttest scores averaged at 174.42 ± 16.0, t(18) = –7.055, p = .0005.
Experiences Learning Counseling Skills Using Motivational Interviewing
The feedback questionnaire elicited participants’ perceived benefits and challenges of learning counseling skills in the context of MI. Overall, participants provided more rich descriptions of positive experiences and benefits rather than negative experiences or challenges. Additionally, each participant responded affirmatively to the fourth question, “Would you recommend that this course follow a similar format (integrating MI into the course) for subsequent cohorts?” In response to the second research question, four main themes were identified to capture participants’ experiences of learning counseling skills within the context of MI. Two subthemes also emerged within the first theme. These themes are presented along with corroborating excerpts from the data.
Learning experience valuable and relevant to skill development. According to a majority of participants in this study, learning counseling skills in the context of MI could translate to their future professional experiences and be relevant in working with clients. Two subthemes emerged from this theme: (a) class instruction was useful and valuable, and (b) students felt they had learned practical and effective skills.
Class instruction useful and valuable. Many students conveyed that class instruction was helpful and they expressed confidence in the expertise of their instructor. One student reflected on the overall experience of learning counseling skills in the context of MI and feeling better prepared following the course: “I see MI being very helpful in my profession and in the overall profession of counseling.” In response to the inquiry about challenges experienced, one student indicated that “the professors did a wonderful job breaking down the beginning and basic steps in order to build on them throughout the semester.”
Participant responses also suggested that students found practicing the skills during class time to be beneficial. One student reflected on the experience of practicing skills: “MI has a ton of great tool[s] that help you connect with your client as you work together to help them change. Practicing the skills in class helped me see how effective they can be in the real world.” When asked about the challenges encountered while learning skills in the context of MI, another student responded: “It is a lot of skills, but practicing them helped me remember and understand them.”
Practical and effective skills learned. Within this subtheme, almost all of the comments from participants suggest that the skills learned were versatile and effective. One student noted the versatile application of MI: “I think the skills can be applied to most any counseling session, regardless of the counselor’s theoretical perspective.” The students also appreciated the demonstrated efficacy of MI, perhaps enhancing their own counseling efficacy. For example, one student wrote, “I feel that learning the skills in the context of MI has enabled me to possess a wide variety of skills and interventions that will work effectively with the client while promoting client autonomy.”
Participants’ beliefs that they would be able to connect with clients also were viewed as a valuable and useful part of this experience. For example, one student reported that “the overall experience of learning MI has given me a new outlook and approach that I can use to connect with and help my clients.” Students also seemed to find the MI approach to be practical, as one student reflected: “All the information that goes with MI seems so practical and almost like common sense.” Another student responded, “I really appreciate the strengths-based approach and the empowerment-stance toward clients. I also like that the skills are specific enough to be practical and general enough to be applicable to a variety of clients.”
More self-assuredness about challenging clients. This theme captured participants’ experiences of an increased sense of self-assurance and comfort when working with clients who are not ready to change (e.g., ambivalent), or who might be considered “difficult” or “hesitant” clients. When describing the benefits of learning counseling skills in the context of MI, almost half the students commented on working with challenging clients with more self-assurance or comfort. For example, one student reflected: “MI allows you to understand that you cannot make someone change and this [rolling] with resistance really helps put the counseling skills to effective use.” Students also expressed they would feel more self-assured working with ambivalent clients in the future. One student noted that “MI has taught me how to work with ambivalence and gave me a whole new set of tools to help initiate change from within the client.” Finally, one student wrote, “I feel I am much more prepared with the skills that will help me when working with hesitant clients.”
Uncertainty in applying technique. Almost half of participants expressed a sense of uncertainty in applying techniques learned throughout the course. This uncertainty appeared to be associated with the technical application of the skills that were taught in conjunction with basic counseling skills. One student reflected on the challenges of learning counseling skills in the context of MI: “Sometimes it was hard to tell the difference between MI techniques and basic counseling techniques. There was a lot of overlap.” Another student responded, “I had trouble implementing the skills learned in class into the video tapes [assignments]. Some of the practice sessions were awkward.” Another student commented on the technicality of skill use: “For me, knowing exactly when to use the skills and how to use them so it’s a natural flow to things.”
Restrictions in applying Motivational Interviewing. Finally, a few students conveyed feelings that the application of MI techniques was somewhat rigid. This rigidity included difficulty in using the techniques in various situations and with a variety of clients as well as combining MI skills with other counseling skills. Although MI was introduced in the counseling skills course to provide a structured approach to practicing basic skills, beginning counseling students typically have had limited exposure to counseling approaches, which may be necessary for students to develop their own counseling style. As one student reflected, “I think it was difficult for me to focus the skills if MI is not being used with a client…kind of rigid in that aspect.” According to another student, “The only suggestion I would make is to incorporate other skills outside of MI.” Finally, one student noted a preference for the skills to be more specific to a school setting: “I would recommend maybe some of the taping sessions to be more school focused.”
Discussion
In the current study, significant differences were found between participants’ counseling self-efficacy pretests and posttests, suggesting that the counseling skills course that incorporated MI was effective in enhancing students’ beliefs that they can be successful counseling clients. The average point increase on the COSE was 30, which is comparable to the findings of Larson and colleagues (1992), who found that counselor trainees’ COSE scores increased approximately one standard deviation over the course of their clinical practicum experience and had an average point increase of 30.4. Similarly, the posttest scores of participants of the current study were comparable to those found by Urbani et al. (2002), who examined the self-efficacy of 53 students who learned counseling skills through the skilled counselor training model (SCTM; 176.46 compared to 174.42 in the current study). These comparable increases in student self-efficacy lend support to incorporating MI into counseling skill courses.
Although there is evidence that participants gained self-efficacy in counseling after learning MI skills in conjunction with basic counseling skills, the qualitative findings suggest that some students were uncertain how to directly apply the MI skills. This self-doubt was particularly expressed when students considered how they might incorporate the skills into sessions with “actual clients” and how to utilize the skills across various theoretical orientations. This concern might not be related to the specific integration of MI skills in a techniques course, but rather a reflection of where students are in their process of becoming a counselor and process of learning. Experiencing discomfort may be developmentally appropriate for beginning counselors and can facilitate growth and learning (Griffith & Frieden, 2000; Kember, 2001).
Rønnestad and Skovholt (2003) described Phase 2: The Beginning Student Phase (of their previously formulated eight stages of counselor development) as a time when students feel easily overwhelmed by new skills and information they are learning, and as a result lack confidence in their abilities. The researchers reported that during this stage, the introduction of basic helping skills that can be used with all clients is helpful in providing students with a sense of control and tranquility. Young and Hagedorn (2012) reported that students who had MI skills training had marked improvements in basic counseling microskills (e.g., empathy, open questions, support, evocation) and noted that this outcome might have been due to the overlap of basic counseling skills used in MI. As MI training reiterates the microskills that many counselor educators expect students to learn, its incorporation into a basic skills course might provide students with the practice and confidence needed to ease the anxiety students may experience in the beginning stages of counselor development.
Incorporating MI into a basic counseling skills course provides students with training in an EBP that possesses a humanistic foundation. Further, it may foster people-responsive counseling skills, such as how to respond to clients who are not ready to change (e.g., ambivalent or mandated clients); students might otherwise receive no or minimal exposure to such skills. Responses in the qualitative portion of this study indicated satisfaction and perhaps relief in learning specific skills that might be useful when working with challenging clients (e.g., reluctant, mandated, difficult). This is especially promising when considering that an obstacle for novice counselors is knowing how to respond to stress-invoking situations when clients show behaviors that seem confusing to counselors (e.g., lack of motivation; Skovholt & Rønnstad, 2003).
In their qualitative research on beginning psychotherapists in a counseling psychology doctoral program, Hill and colleagues (2007) identified that students shared similar frustration when working with clients who were reluctant to participate in the counseling process or who were not open to counselor help. Although other counseling methods might conceptualize and provide ways to work with resistant clients, MI offers a humanistic conceptualization and specific skills for counselors to meet and accept clients where they are in their process of change. Many of MI’s components are specific to working with clients who present in earlier stages of change (i.e., precomtemplation and contemplation), particularly those regarding relationship discord and ambivalence. MI also can be useful as clients prepare for change, take action, and work to maintain changes (DiClemente & Velasquez, 2002). As such, MI skills expand beyond a typical basic skill set and beginning counselors can benefit from having MI as part of their repertoire, especially to help them feel more confident when working with clients who are not ready for change.
Limitations
As with any research investigation, the current study has limitations for consideration. First, the primary instructor of the course also was the primary investigator for the study. This dual role may have influenced students’ responses. Second, this study lacked a control group, which would be necessary to determine between group differences. Third, this study was conducted at one university with a small sample size and is therefore limited in generalizability. Fourth and finally, although a case study design will typically incorporate multiple sources of data (Creswell, 2007), this study relied solely on the feedback questionnaire to gather qualitative data, thus limiting the richness of data collected.
Implications for Counselor Education
Results indicated that using MI skills in an introductory level skills course provided enhanced self-efficacy and positive experiences in learning basic counseling skills. These findings suggest that it might behoove counselor educators to utilize the MI spirit and skills as a way for students to gain a humanistic foundation, reiterate basic counseling skills, and prepare students to help clients who are not yet ready to change. However, it is important for counselor educators who choose to integrate MI into a skills course to be trained and competent in MI skills and application. Additionally, they should be prepared to demonstrate these skills to students.
Students reported higher confidence levels in their readiness to use specific counseling skills; however, they indicated uncertainty in how to integrate these skills with other skills they may have been learning specific to particular theoretical orientations. Since MI is a counseling style and not a theoretical approach, it can be used with other counseling approaches (e.g., cognitive behavior therapy) for a potential synergistic effect (Miller & Rose, 2009). In response to the need for a greater integrative understanding, counselor educators might consider providing additional opportunities for students to discuss and self-reflect on their use of MI skills with their preferred theories, and model ways to synthesize these skills cohesively across theories and various problems presented by clients. Such opportunities would likely occur in advanced coursework including practicum and internship when students are engaging with actual clients. In addition, it may be useful to have more experiential practice in integrating the skills rather than having the sole focus be on using a particular MI skill in isolation.
Overall, incorporating MI into an introductory skills course appeared to be helpful for students. The spirit of MI (Miller & Rollnick, 2013) is undeniably humanistic as it emphasizes self-directed growth and people responsiveness within the therapeutic relationship. Fitch, Canada, and Marshall (2001) reported that humanistic theories (person-centered, existential and Gestalt) are influential in practicum courses, perhaps due to their emphasis on relationship building. When considering MI’s humanistic tenets, it might be useful for counselor educators to consider the utility and worthiness of this approach among other influential and well-established humanistic theories in the field.
Future Directions in Research
Ongoing studies are investigating if these students demonstrated MI proficiency on their final recorded skill demonstration required for this course, and the degree to which students maintained use of MI after they learned and integrated cognitive behavior therapy into their practice. Research that includes a control group is needed in order to assess the effect of learning MI on counselor trainees’ self-efficacy and skill development. Future research also might investigate possible associations between student self-efficacy, satisfaction in a counseling skills course, and execution of skills within and beyond the counseling skills course. In addition, research is needed to inform optimal timing of this type of skill training, as students might be better equipped to incorporate such training later in the graduate programs (e.g., during practicum).
Conclusion
This study investigated students’ counseling self-efficacy before and after completing a counseling skills course that integrated MI. Results indicated that students’ self-efficacy increased at rates comparable to alternative counseling skill development models. Further, students reported positive overall experiences when learning MI skills, which were noted in qualitative themes highlighting their skill development and self-assuredness in working with challenging clients. Students also had some lingering questions about the implementation of MI; however, this might be expected given their early stages of counselor development. Given that student self-efficacy increased by the end of the course and students reported overall positive experiences, this study provides preliminary support of the integration of MI into a counseling skills course. Although further investigations are needed, it seems that the inclusion of MI in the course may be useful to reiterate humanistic counseling skills and prepare students to work with clients who are not yet ready to change and who might otherwise overwhelm a novice counselor.
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Melanie H. Iarussi is an Assistant Professor at Auburn University. Jessica M. Tyler, NCC, is Clinical Coordinator at East Alabama Mental Health and Adjunct Professor at Auburn University. Sarah Littlebear, NCC, is a doctoral candidate at Auburn University. Michelle S. Hinkle is an Assistant Professor at William Paterson University. Correspondence can be addressed to Melanie H. Iarussi, Auburn University, 2084 Haley Center, Auburn, AL 36830, miarussi@auburn.edu.
Oct 15, 2014 | Article, Volume 3 - Issue 3
Randall L. Astramovich, Wendy J. Hoskins, Antonio P. Gutierrez, Kerry A. Bartlett
Role ambiguity in professional school counseling is an ongoing concern despite recent advances with comprehensive school counseling models. The study outlined in this article examined role diffusion as a possible factor contributing to ongoing role ambiguity in school counseling. Participants included 109 graduate students enrolled in a CACREP-accredited counseling program at a large southwestern university. Findings suggest that providing direct counseling services is the most unique and least diffused role for today’s school counselors. The authors also review implications for professional school counselors and recommendations for future research.
Keywords: school counselors, role ambiguity, role diffusion, comprehensive school counseling, direct counseling services
School counselor roles and functions have been examined by scholars for many decades (Astramovich, Hoskins, & Coker, 2013; Burnham & Jackson, 2000; Gysbers 2004; Herr, 2003; Lieberman, 2004; Myrick, 1987). As professional school counseling evolved, standards of practice were developed as a means for solidifying professional identity and to help guide the specific duties expected of school counselors (Dahir, Burnham, & Stone, 2009; Dollarhide & Saginak, 2012). School counseling as a distinct profession has proliferated in the 21st century, yet inconsistencies in school counselor roles and functions have continued to challenge the field (Astramovich, Hoskins, & Bartlett, 2010; Culbreth, Scarborough, Banks-Johnson, & Solomon, 2005). This article defines and presents the results of a study of role diffusion among school counselors and calls for renewed emphasis on the professional counseling function of today’s school counselors.
Historically, several school counseling models have been discussed in the literature, each emphasizing various school counselor roles. Myrick (1987) and Gysbers and Henderson (2006) created developmental guidance models for school counseling that emphasized individual and small-group counseling services, guidance lessons, individual planning, and system support duties. Schmidt (2003) promoted an essential services model of school counseling that focused on the individual and group counseling, appraisal, coordination, and consultation roles of the counselor. Campbell and Dahir (1997) presented a set of national standards for school counseling programs that emphasized school counselor duties in the academic, career and personal-social domains. Based on the work of Campbell and Dahir (1997), the American School Counselor Association (ASCA, 2003) published its initial National Model for school counseling programs. Later, Brown and Trusty (2005) suggested a strategic comprehensive school counseling model that emphasized the developmental and preventive roles of the school counselor along with a focus on supporting student academic achievement. Most recently, ASCA (2012) published an updated edition of its National Model that emphasized the school counselor’s role in the implementation of a school counseling core curriculum, individual student planning, and responsive services, including individual, group, and crisis counseling. A common goal of these organizational frameworks for school counseling programs was to identify appropriate roles and duties for school counselors.
Models of school counseling were developed in part to strengthen and clarify the professional identity of school counselors, yet the specific roles of school counselors in educational systems have continued to be debated and refined (ASCA, 2012; Keys, Bemak, & Lockhart, 1998; Whiston, 2002, 2004). During the past decade, the Transforming School Counseling Initiative (TSCI; The Education Trust, 2009) and ASCA’s (2012) National Model have been discussed extensively in the school counseling literature. In contrast to earlier school counseling models, both the ASCA National Model and TSCI placed an increased emphasis on the academic support and advocacy roles of professional school counselors, while minimizing the role of providing direct counseling services to students (Astramovich et al., 2010; Grimmett & Paisley, 2008). For example, the ASCA (2012) National Model indicated that individual counseling in a therapeutic mode is not considered an appropriate duty for school counselors. Accordingly, it has been suggested that the roles and functions of school counselors promoted by these recent models have become less clearly focused on counseling, potentially leading to a weakened professional identity for school counselors (Bringman, Mueller, & Lee, 2010; Whiston, 2004). In addition, a broader philosophical difference—whether school counselors are considered to be educators or professional counselors or both—also has fueled the ongoing debate over school counselor roles (Paisley, Ziomek-Daigle, Getch, & Bailey, 2007).
With the myriad duties suggested by different school counseling models, role research in school counseling has often attempted to clarify what duties are expected of school counselors and how these should be prioritized. Some researchers have focused on views of educational administrators about the appropriate duties of school counselors. Amatea and Clark (2005) found that elementary, middle and high school principals preferred school counselors to focus on leadership, consulting, and providing individual and small-group counseling, as well as classroom guidance to students. Similarly, Zalaquett (2005) and Zalaquett and Chatters (2012) found that principals prefer counselors to focus on providing direct counseling services to students as well as crisis intervention, coordination and consultation. Other researchers have examined the views of practicing school counselors about their roles and duties. Nelson, Robles-Pina, and Nichter (2008) found that high school counselors reported spending much of their time in non-counseling duties such as class scheduling, thus having less than preferred time to provide counseling, consultation and coordination services to students. In another study, Walsh, Barrett, and DePaul (2007) found that elementary school counselors spent only about one-third of their time in responsive counseling services, with the remainder of their time spent in guidance, individual planning, and system support activities. From another perspective, Astramovich and Loe (2006) compared pre-service teachers’ views of the roles of school counselors and school psychologists and found that school counselors were considered more likely to help students with career development while school psychologists were viewed as more likely to help students with personal-social skills. Overall, findings from role research studies suggest that, despite advances in school counseling models, many school counselors continue to experience role ambiguity and role stress in their professional practice (Astramovich et al., 2010; Culbreth et al., 2005; Lieberman, 2004; Pyne, 2011).
Although role ambiguity has been identified as a significant concern of school counselors, the authors hypothesize that a preceding factor—termed as role diffusion—may be a major factor contributing to role ambiguity among professional school counselors. Role diffusion is defined by the authors as the process of assuming or being appointed to roles and duties that individuals from other fields or specialties are equally qualified to perform in the work environment. For example, role diffusion occurs when a school counselor is assigned by an administrator to be responsible for school-wide achievement testing—something that teachers, teacher specialists, or even school registrars may be equally competent to organize. Although a school counselor is certainly capable of coordinating achievement testing, such a duty does not draw upon the unique graduate-level training the professional school counselor has to offer, and thus the unique role of the school counselor is diffused, potentially leading to role ambiguity. The authors therefore believe that role ambiguity among school counselors may be a consequence of role diffusion. Furthermore, role diffusion may be unintentionally reinforced by school counseling models that do not emphasize the unique counseling roles of the school counselor in educational settings.
Research Questions
Considering the continued discourse over school counselor professional identity, role clarity and our hypothesis about how role ambiguity may be perpetuated, the researchers decided to explore for potential role diffusion among typically suggested school counseling duties. The following primary research questions were developed for this study:
1. Of the typical duties suggested for school counselors, which duties are the most unique to the role of the counselor (i.e., least role diffused)?
2. Of the typical duties suggested for school counselors, which duties are the least unique to the role of the counselor (i.e., most role diffused)?
3. What other school personnel are identified as equally qualified to perform various duties suggested for professional school counselors?
Method
Participants
A sample of 109 master’s-level graduate counseling students at a large southwestern university participated in the study. Students were enrolled in either the school counseling or clinical mental health counseling programs, both of which hold Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2009) accreditation. The sample was comprised of 97 (89%) females and 12 (11%) males with a mean age of 28.9 (SD = 6.9) years. Ethnicity of the participants included 81 (74%) Caucasian, 13 (12%) Latina/Latino, 4 (4%) Asian American, 3 (3%) African American, and 6 (5%) representing other or multiple ethnicities. Regarding area of specialization, 54 (49%) participants were school counseling majors and 55 (51%) were mental health counseling majors. In addition, the participants had completed a mean of 26.0 (SD = 17.4) graduate credit hours in counseling.
Instrument and Procedure
An instrument was developed by the researchers to explore the primary research questions, based partly on school counselor duties suggested in the ASCA (2012) National Model. The instrument identified potential school counselor duties grouped within five domains including Academic, Career, Personal-Social, Direct Counseling Services, and Support Functions. For each domain, five stem items were developed identifying specific duties commonly recommended of school counselors, resulting in a 25-item instrument with five domain scales.
For the Academic scale, the five stem items were drawn from the language in the ASCA (2012) National Model and included helping students to (1) identify attitudes and behaviors that lead to successful learning; (2) learn and apply critical thinking skills; (3) apply the study skills necessary for academic success; (4) become a self-directed and independent learner; and (5) apply knowledge of aptitudes and interests to goal setting.
For the Career scale, the five stem items were drawn from the language in the ASCA (2012) National Model and included helping students to (1) develop skills to locate, evaluate and interpret career information; (2) demonstrate knowledge about the changing workplace; (3) identify personal skills, interests, and abilities and relate them to career choices; (4) assess and modify educational plans to support career goals; and (5) describe the effect of work on lifestyle.
For the Personal-Social scale, the five stem items were drawn from the language in the ASCA (2012) National Model and included helping students to (1) identify and express feelings; (2) use effective communication skills; (3) learn how to make and keep friends; (4) learn how to cope with peer pressure; and (5) learn coping skills for managing life events.
The researchers developed five items for the Direct Counseling Services scale, including (1) providing individual counseling services; (2) providing small-group counseling services; (3) assessing student concerns for appropriate community referrals; (4) providing play therapy to elementary-aged children; and (5) providing activity-based counseling to older children and adolescents.
Finally, the researchers developed five items for the Support Functions scale, including (1) reviewing or changing students’ class schedule; (2) coordinating and administering achievement tests, (3) participating in lunch duty/hall duty/bus duty; (4) substitute teaching classes for absent teachers; and (5) helping administrators with principal’s office duties.
For each of the 25 items, participants were asked to indicate which of eight professionals typically working in school settings would be qualified to perform the specific duty. The eight professionals from which participants could select included school counselors, school psychologists, teachers, social workers, principals, paraprofessionals, registrars and administrative assistants. For each item, participants could select one or more of the eight professionals who would be qualified to perform the specific duty. The items were presented in a random order and not grouped by the five domains.
A Cronbach’s alpha coefficient was calculated for each of the five scales to evaluate the reliability of the instrument. Internal consistency reliability is an index of the consistency of participant responses on items purporting to measure the same construct. Greater consistency in responses signifies that there was less error in the measurement of the purported construct(s) of interest, which is desirable. High reliability also suggests that the scale is in fact measuring what it is intended to measure—that is, construct validity. Results indicated that the instrument had acceptable reliability on the Academic (α = .86), Career (α = .86), Personal-Social (α = .81), Direct Counseling Services (α = .77), and Support Functions (α = .80) scales.
For each item, a total item score was created by summing the number of school professionals identified as competent to perform the duty (range 0–8). Table 1 lists the means for each of the 25 items, sorted from most to least role-diffused. Next, overall domain scores were calculated by summing the mean item scores for the five items in the particular domain, resulting in a possible domain score ranging from 0–40. Table 2 lists the means for each of the five domains, sorted by most to least role-diffused. Finally, Table 3 lists the Pearson’s Product-Moment Correlation coefficients of the role diffusion ratings across the five domains. Prior to data analysis, the data were tested for requisite assumptions and screened for potential outliers. If not eliminated, outliers undermine the trustworthiness of the data because they unduly influence the group means and thus the normality of the data—that is, by affecting skewness and kurtosis. The data screening procedures yielded no outliers. Moreover, the data met all assumptions including normality (skewness and kurtosis values were within range), homogeneity of error variances and sphericity. Thus, data analysis proceeded without any adjustments.
Graduate counseling students enrolled in two sections of a course on Ethics and Legal Issues in Counseling and in two sections of a pre-practicum course at a large southwestern university were invited to participate in the study. After a review of informed consent, copies of the instrument were provided to participants and the researchers were available to answer questions as needed. A total of 120 students were eligible to participate, with a response rate of 109 (91%) completed instruments.
Results
Least and Most Role-Diffused School Counselor Duties
In order to address the first two research questions, a one-way analysis of variance (ANOVA) was conducted to test for differences between the levels of role diffusion among the five domains. Ratings of role diffusion differed significantly across the five domains (F (1, 107) = 7.81, p < .0005, η2 = .63) indicating a large strength of association between the variables under study. More specifically, the results suggest that the five domains account for approximately 63% of the variability in the ratings of role diffusion. Overall, results indicated that Direct Counseling was rated as significantly less role diffused (i.e., requiring more unique skills) than the other four domains (see Table 2 for means). Fisher’s Protected t-test analyses with the Bonferroni adjustment to obviate the family-wise Type I error rate inflation were requested to more adequately ascertain differences across the five domains with respect to role diffusion ratings. Results demonstrated that the ratings between Direct Counseling and the four other domains were statistically significantly different (all p-values < .05, effect size r ranging from –.42 to –.54, indicating moderate to large strengths of association between variables). No other comparison reached statistical significance (p < .05).
Other School Personnel Qualified to Perform Suggested School Counselor Duties
Addressing the third research question, a one-way ANOVA was conducted to test for differences between the eight school personnel and qualifications to perform duties in each of the five domains. There were statistically significant differences in the qualifications to perform duties in each of the five domains between the eight school personnel (F (4,28) = 13.50, p < .05, η2 = .12) indicating a moderate strength of association between the school personnel and qualifications. Thus, the eight school personnel roles account for 12% of the variability in qualifications to perform the duties of the five domains.
Results demonstrated that teachers, school psychologists, social workers and principals are equipped to perform school counselor duties within the Academic and Personal-Social domains, whereas administrative assistants, registrars and paraprofessionals are ill-equipped. Within the Career domain, teachers, school psychologists and social workers are equipped to fulfill school counselor duties and administrative assistants, registrars, paraprofessionals, principals and school psychologists were perceived as ill-equipped. All roles—that is, administrative assistants, school psychologists, paraprofessionals, principals, social workers, registrars and teachers—are equipped to perform school counselor duties in the Support domain. Finally, only school psychologists and social workers are rated as being equipped to perform school counselor duties in the Direct Counseling domain whereas all other roles are not.
Discussion
Findings from this study suggest that professional school counselors’ least diffused and thus most unique role in the school setting is in the provision of direct counseling services to students. These results coincide with research on principals’ views of the preferred roles for school counselors (e.g., Amatea & Clark, 2005; Zalaquett & Chatters, 2012) and the preferred roles of professional school counselors (e.g. Nelson, Robles-Pina, & Nichter, 2008). Interestingly, these results are in direct contrast to the ASCA (2012) National Model, which suggests that individual counseling with students in a “therapeutic mode” is an inappropriate function of professional school counselors. Of the eight school personnel roles examined in this study, only school psychologists and school social workers were rated as equally competent as school counselors to provide counseling services to students. However, because school psychologists and school social workers are each employed at less than a third of the rate of school counselors nationally (U.S. Department of Labor, 2012), school counselors remain the most likely professionals to provide direct counseling services to students in educational settings.
School counselor roles in the Personal-Social, Academic, Career, and Support domains were found to be significantly diffused among the other seven school personnel identified in this study. School psychologists and school social workers were rated equally capable as school counselors to perform duties in these four domains as well, suggesting that the roles of school counselors, school psychologists, and school social workers may have a significant degree of overlap and possible duplication. Another interesting finding was that teachers were rated as equally competent to perform duties suggested of school counselors in all domains except Direct Counseling. Because teachers are typically trained at the bachelor’s level, it may be inferred that work in the Personal-Social, Academic, and Career domains may not necessarily require graduate-level training. Thus, role diffusion may be perpetuated by school counselors who focus primarily on duties that do not draw on their more advanced skills.
Recommendations for Professional School Counselors and Counselor Educators
Given the persistence of role ambiguity and role stress among school counselors, addressing role diffusion at the individual school, district, state and national levels may significantly strengthen the professional identity of school counselors. Thus, school counselors must regularly and systematically advocate for their professional identity by proactively informing key constituents about the counseling services the school counselor provides to students.
Furthermore, state and national professional school counseling organizations must find ways to promote the unique counseling skill set of their members and must help elevate the work of professional school counselors by emphasizing their graduate-level counseling training, rather than developing models and standards that lead school counselors to focus on duties that other school personnel are qualified to perform. Kaplan and Gladding (2011) stressed the need for all counseling specialties to converge around a common counseling identity as a means for helping the public to understand the appropriate roles of professional counselors. In light of the results of this study, their call seems especially significant for school counselors who have struggled for decades to establish a consistent professional identity.
Counselor education programs may need to critically assess the utility of training future school counselors in models, including the ASCA (2012) National Model, which do not support school counselors providing direct counseling services and which may consequently foster role diffusion and role ambiguity. The development of Comprehensive School Based Counseling Centers as suggested by Astramovich et al. (2010) may provide an alternative approach to existing models and could help promote the unique counseling expertise of professional school counselors. Therefore, the graduate-level training of school counselors should emphasize the development of individual and group counseling skills to help prepare future counselors to work effectively with a wide range of student concerns. In addition, counselor education programs must help new school counselors develop skills to advocate for the provision of direct counseling services in schools. Finally, counselor education programs must help new school counselors to foster a strong counseling-focused professional identity that is distinguishable in practice from other personnel in educational settings.
Limitations and Future Research Recommendations
Limitations of this study should be noted. First of all, the sample comprised graduate counseling students at one university, and therefore, caution must be taken in generalizing the findings to other populations, including working school counselors. Unlike practicing school counselors, school and mental health graduate counseling students may have differing perspectives about the roles of school counselors. In addition, the study focused on duties as suggested by the ASCA (2012) National Model domains, which may not reflect the actual day-to-day practice of professional school counselors at various school settings nationally.
Future role diffusion research could be strengthened by sampling currently practicing school counselors as well as school administrators who oversee and evaluate school counselor performance. In addition, examining role diffusion at the elementary, middle and high school levels may help identify unique challenges faced by school counselors in each school setting. Lastly, role studies that help clarify and distinguish the role of the school counselor from the roles of school social workers and school psychologists may help further strengthen the identity of professional school counselors.
Conclusion
Although role diffusion and role ambiguity may have negatively affected the profession of school counseling in the past, today’s professional school counselors and school counseling organizations have opportunities to clarify and advance the school counselor’s role. Focusing on the unique counseling skills of school counselors may be a critical next step for the profession. Ultimately, by addressing the effects of role diffusion, school counselors can distinguish and strengthen their professional identity and therefore have a more significant impact on the children and adolescents they serve.
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Randall L. Astramovich is an Associate Professor at the University of Nevada, Las Vegas. Wendy J. Hoskins is an Associate Professor at the University of Nevada, Las Vegas. Antonio P. Gutierrez is an Assistant Professor at the University of Nevada, Las Vegas. Kerry A. Bartlett, NCC, is a School Counselor at Basic High School, Henderson, NV. Correspondence can be addressed to Randall L. Astramovich, Counselor Education Program, University of Nevada Las, Vegas, 4505 Maryland Pkwy, Box 453014, Las Vegas, NV 89154-3014, randy.astramovich@unlv.edu.
Oct 15, 2014 | Article, Volume 3 - Issue 3
Wilma J. Henry
The purpose of this article is to assist mental health counselors and student affairs practitioners to gain a better understanding of the challenges 21st century Black college women may face in their attempt to develop intimate heterosexual relationships with Black men. Consequently, higher education leaders have the opportunity to support Black women in their quest to establish a healthy identity by providing educational opportunities within co-curricular and academic contexts to meet the needs of this unique population of students. The implementation of culturally relevant interactive workshops, case studies, and conversations focused on the positive contributions and value of Black women may aid them as they wrestle with relationship issues during the crucial process of developing a salubrious evolving identity. It is imperative that college counselors and student affairs professionals strive to augment appropriate multicultural awareness, knowledge and skills necessary to effectively assist Black women grappling with relationship issues as they move through the process of identity development.
Keywords: Black women, intimate relationships, heterosexual relationships, Black men, identity development
Most students choose to attend college in order to earn an academic degree, while others view the experience as an opportunity to identify a potential spouse for starting a family (Pew Research Center, 2010). Unfortunately, many 21st century Black college women face a myriad of problems when seeking a compatible mate. Some of the challenges these women encounter when attempting to develop intimate heterosexual relationships with Black men relate to the gender gap (i.e., gender ratio imbalance) that exists between Black women and Black men in college (Cuyjet, 2006). Because of this disparity, Black women grapple with issues such as the quest for a male partner with equal educational status, sexually related health risks, conflicts with interracial dating, and questions concerning dating significantly younger or older men (Henry, 2008). These types of issues can be quite daunting for young Black college women born into oppressive societal conditions and stigmatized with the burden of racism, sexism, and classism (Henry, Butler, & West, 2012). Unfortunately, these women may have little or no knowledge regarding the circumstances of their devalued status, nor the appropriate coping skills to survive the negative effects of their devaluation (Henry, 2008). Thus, some Black women may make poor dating decisions that lead to low self-esteem, negative self-efficacy, dysfunctional intimate relationships, academic failure, and an overall unhealthy identity, as well as lifelong physical and psychological health challenges (Hughes & Howard-Hamilton, 2003).
Women from other cultural groups also may face some of the same types of concerns and issues as Black women in the process of finding a mate; however, Black women in college are particularly challenged in the process of finding a mate because they have endured a long history of racism, sexism, and classism. This situation has perpetuated the educational gender gap, and strained intimate relationships between Black men and women. In fact, some researchers contend that the stress that exists in “Black love” relationships is primarily because of political, social, and economic oppression in America (Alexander-Floyd & Simien, 2006; Hill, 2005; hooks, 2001; Waters & Conaway, 2007). Thus, it is important to consider these phenomena when discussing Black love relationships among college students, because of their salient and intersecting influences on the identity development of Black men and women in this country. This article explores issues young Black college women face when seeking long-term intimate relationships with Black men during their college years.
Theoretical Framework
Identity development is a complex phenomenon because of both internal and external factors in the lives of individuals. According to Chickering and Reisser (1993), the college years are a critical time when young adults not only struggle with newfound freedom, but also must navigate the developmental trajectories of identity formation. The concept of identity has been defined as a set of qualities and/or characteristics that express who and what an individual is and desires to become (Cross, 1971). Schuh, Jones, Harper, and Associates (2011) described identity as a foundation from which a person’s image of self is derived.
Researchers studying women’s identity development have emphasized the significance of establishing intimacy and interpersonal relationships in the process of identity formation (Blackhurst, 1995; Chickering, 1969; Josselson, 1987, 1996; Taub & McEwen, 1991). Additionally, studies investigating intimate relationships between Black women and Black men have called attention to the effects of race, gender, and social class as constructs that influence their intimate interactions (Hill, 2005; hooks, 2001; Hughes & Howard-Hamilton, 2003). Inasmuch as the interplay of these constructs intertwines to influence identity development, it could be surmised that the dating decisions of Black women are influenced in part by their experiences at particular stages of racial and gender identity formation (Henry, 2008).
Racial Identity Development
Cross’ (1971) Black identity development model has been widely used as a framework to help contextualize the process of racial identity formation (Evans, Forney, & Guido-DiBrito, 1998). Cross contends that as Blacks move toward the development of a sound racial identity, they must reframe their sense of self from perspectives rooted in the dominant White culture to attitudes and beliefs based on their own Black cultural standpoint (Evans, Forney, & Guido-DiBrito, 1998). This is anchored in a series of racial identity stages: pre-encounter, encounter, immersion-emersion, and internalization (Cross, 1971). Thus, it seems that the dating decisions of Black women and men are influenced by their worldview at a certain stage of racial identity formation (Henry, 2008).
Womanist Identity Development
Janet Helms’ (1990) womanist identity development theory has been widely used in discussing the concerns and issues regarding women of color (Johnson, 2003). Helms’ model describes the process of identity formation according to the experiences of women as they move from an external, societal definition of womanhood to an internal, personally salient definition of womanhood. Helms’ theory parallels that of Cross’ (1971) Black identity development model and suggests that women move through the same four developmental stages that Cross proposed.
During the pre-encounter stage, women conform to societal views about gender and tend to display characteristics of gendered stereotypes (Helms, 1990). In the second stage, encounter, as a result of new information and experiences, the woman begins to question accepted values and beliefs (Helms). It is during this stage that a heightened sense of womanhood is developed. The immersion-emersion stage involves the idealization of women and the rejection of male-supremacist views of women in order to find a positive self-affirmation of womanhood (Helms). At the fourth and final stage, internalization, a positive definition of womanhood has emerged, which is based upon the woman’s own beliefs and values; the shared experiences of other women are valued as a source of information concerning the role of women, and there is conscious rejection of external definitions of womanhood (Helms, 1995).
The process of identity development among Black college women may significantly impact their dating decisions. For example, a woman in the pre-encounter stage may make very different dating decisions than a woman in the internalization stage. Within this context, the discussion that follows details the many challenges Black women face during their quest to date as they progress through college.
Many 21st century Black college women that are interested in finding a Black mate of similar academic status are not optimistic about their future for dating, marriage, and family (Henry, 2008). A review of relevant literature reveals several challenges that influence the dating decisions of Black women in college.
The Black Educational Gender Gap
While the total enrollment of minorities has been increasing, there are twice as many Black women attending college as men (“Census,” 2005). According to the National Center for Education Statistics (2007), females are enrolled in undergraduate institutions at higher rates than males across all racial and ethnic groups; however, the gender gap is largest among Blacks. A study conducted by the American Council on Education on the status of low-income minority students in higher education revealed that “among all ethnic groups except African Americans, as income increased the gender gap disappeared” (Bronstein, 2000, p. 4a). The Journal of Blacks in Higher Education (“Black women students,” 2006) noted that Black females make up 64% of the Black undergraduate student population on college and university campuses across the country. This trend is expected to continue as Black females are predicted to increase their college enrollment at a higher rate than Black males (Marklein, 2005; National Center for Education Statistics, 2007; Zamani, 2003). Unfortunately the campus dating scene for Black college students is grossly unbalanced (Cuyjet, 2006) and is projected to worsen.
As a result of the gender disparity on contemporary college campuses, Black women who aspire to find compatible, college-educated Black males are experiencing greater difficulty than women from other racial and ethnic groups (Offner, 2002). Black women generally outnumber Black men 60% to 40% on college campuses around the country (Foston, 2004). Even women that enroll at historically Black colleges and universities (HBCUs) with hopes of being in an environment where there are many Black college men do not find that their luck is any better (Henderson, 2006). According to Foston (2004) at Smith University, a small HBCU in Charlotte, North Carolina, in 2004 the enrollment of Black students was approximately 58% women and 42% men. At Florida A&M University in Tallahassee, Florida, the Black enrollment was approximately 58.5% women and 41.5% men. HBCUs with a higher ratio between women and men included Clark Atlanta University and Fisk University, both with a ratio of 70% women to 30% men (Foston, 2004). Similarly, Broussard (2006) purported that a significant percentage (39%) of Black college women would be left without a college-educated male partner if all the Black men in college were in a committed relationship with a Black woman. This suggests that many young, Black, college-educated women have a low probability of dating and marrying Black men of equal educational status (Furstenburg, 2001).
Reasons for the Black educational gender gap. A variety of factors related to race and socioeconomic status have been cited to explain why there are fewer Black men in college than Black women (Bronstein, 2000). Some of these factors include societal stigmatization and stereotyping, which often result in the disproportionate tracking of Black males in early grade school (Blake & Darling, 1994); under preparedness among many Black males that manage to graduate from high school (Townsend Walker, 2012); and high rates of violent deaths and incarceration among Black men (Swanson, Cunningham, & Spencer, 2003).
Ballard (2002) contends that Black males have been discouraged from earning a college degree by negative experiences they may have encountered in secondary school. For example, the disproportionate educational tracking (grouping students according to their academic abilities in classes categorized as approaching basic, honors or college prep) of Black males in elementary school has negatively affected their self-concept as well as their current and future achievement (Blake & Darling, 1994; Townsend Walker, 2012). In essence, because of educational tracking and the widespread underlying assumption that Black males cannot achieve academically, many of them graduate from high school lacking the academic skills, motivation or desire to pursue higher education. Additionally, as Murphy (2004) noted, “in the 15–30 age bracket, Black men have a mortality rate that is twice that of Black women” (p. 125). He attributes this to the fact that homicide and suicide are among the top three causes of death among Black men and that half a million of them are incarcerated. Hence, the large number of Black males who are not college bound directly contributes to the gender ratio imbalance that reduces the dating options of Black women in college and influences their dating decisions.
The Quest for Equal Status Among Mates
Black college women prefer to date men who are similar to them in education, occupation and social status (Henry, 2008). Consistent with the increasing number of women that are earning college degrees, more Black women are earning higher salaries than some of their Black male counterparts (“Census,” 2005), which makes it even more difficult to find a Black male partner of equal education, economic or social status (Furstenburg, 2001). Consequently, some 21st century Black women choose to remain single or postpone marriage until they can find a suitable Black male partner (Cuyjet, 2006; Henderson, 2006; Kitwana, 2002; Porter & Bronzaft, 1995). This dating decision may create undue stress for the Black woman due to family pressures and societal expectations regarding the importance of marriage (Henry, 2008). In addition, women who remain single may be left to contend with the negative characterizations of unmarried women in our society (e.g., old maid, spinster).
Sexually Related Health Risks
Many Black college women attempt to secure a long-term relationship with Black men by participating in promiscuous, risky sexual behavior (Foreman, 2003). Some of these behaviors include men having multiple female sex partners and women complying with men’s desire not to use a condom during sexual intercourse, which have increased the risk of HIV/AIDS among women and men on college campuses (Foreman). In fact, some students at HBCUs attribute the increasing number of Black women in college infected with HIV/AIDS to the gender ratio imbalance (Ferguson, Quinn, Eng, & Sandelowski, 2006).
The literature cautions Black women in particular to be aware of various reproductive health issues that exist within their cultural group (Ferguson et al., 2006). For example, during 2005, 66% of 9,708 Black women ages 15–39 were diagnosed with HIV/AIDS (Centers for Disease Control, 2007); in fact, HIV/AIDS has been reported as the number one cause of death among Black women ages 25–34 (Bullock, 2003). The rate of chlamydia among Black females is seven times higher than that among White females, and the rate of gonorrhea in Black women is nearly 20 times greater than that among White women (Jones, 2005).
Interracial Dating
Another way some Black women choose to address the gender ratio imbalance issue is to date and marry interracially. Because of the lack of college-educated Black males, Black females are dating outside of their race more than ever before (Hughes, 2003). Some Black women in interracial relationships have indicated that they were initially attracted to their White spouses because they could not find a Black mate of comparable social status and income level (Stanley, 2011). A study conducted by Knox, Zusman, Buffington, and Hemphill (2000) regarding the interracial dating attitudes among college students revealed that Blacks were twice as likely as Whites to report openness to involvement in an interracial relationship.
Much of the research regarding Black women’s dating preferences indicates that many do not desire to date outside of their race (Stanley, 2011). Black women who have observed immediate family members in devoted, long-lasting relationships seek that same type of commitment in relationships from men within their own race (Williams, 2006). It may be that these women wish to preserve their culture by producing a future generation of Black children. Thus, they hold firmly to the ideal of dating or marrying within their own race. Some Black women choose not to date interracially due to fear of opposition from their own family members, the family members of their racially dissimilar partner, and the Black community. Historically, there is a societal expectation that Black women should choose mates within their own racial group. These types of interpersonal challenges tend to create a great deal of stress in interracial relationships (Ortega, 2002).
Black men seem to be a bit more comfortable in crossing the color lines than Black women when it comes to dating and marriage. Banks and Gatlin (2005) reported that 13% of Black men are in interracial marriages, and census data revealed that 73% of all Black/White marriages are Black men with White women (Pew Research Center, 2006). As a result, Black women often find themselves competing for the attention of Black men who are already a limited pool of suitable mates. When Black men choose to date interracially, Black women are left feeling inadequate, particularly about their appearance (Stanley, 2011). Constant feelings of inadequacy may lead some Black females to adopt uncharacteristic behaviors, such as remaining in physically or emotionally abusive relationships with Black men.
Dating Younger Men
With the diminishing choices of mates for Black women in college, some have chosen to date much younger men (Henry, 2008). This phenomenon was first introduced into popular culture by Terri McMillan’s (1996) book How Stella Got Her Groove Back, which depicted McMillan’s real-life love encounter with a younger man while vacationing in Jamaica. McMillan’s plot has become a reality for many Black women. Several women who were asked to share their views on dating in an Ebony magazine article stated that they preferred to date younger men because these men were more vibrant (“The Stella thing,” 1998.) The article also indicated that because many Black men are incarcerated, married, gay, or dating interracially, Black women do not have many options; therefore, dating younger men has become an attractive alternative. It appears that some Black women are dispelling the notion that marrying an older Black man equates to social status, financial security and marital bliss. Similarly, Gilbert (2003) contends that many older women and younger men relationships among African American couples seem to work out well, with the most important factor in these relationships not being age, but rather compatibility. Many Black women in college who decide to engage in a love relationship with a younger man may endure potential hostility from family members, friends and the Black community in general.
Discussion
Dating for Black college women not only creates challenges in terms of finding a compatible Black mate, but also in finding and accepting one’s true self. Because of the educational gender gap, many Black women in college who are seeking long-term relationships with Black men believe that they must cater to the whims and wishes of men. According to Helms’ (1990) womanist identity development theory, young Black women in college who have not yet developed a healthy, internally based, positive definition of womanhood may make detrimental dating decisions. However, women who have progressed to the final stage of Helms’ model, internalization, may make better dating decisions, which are grounded in a positive self-identity. These women may have the courage to remain single, abstain from risky sexual behavior, date interracially, or date younger Black men. If Black women are supported in forming a positive self-concept, they may avoid making poor decisions as they seek intimacy in hopes of dating, marrying, and having a family; thus they will be less likely to experience poor long-term psychological and physical health.
Implications for Mental Health Counselors
Mental health professionals on college campuses are uniquely positioned to assist Black women in achieving a positive mature identity regardless of the challenges they may face in attempting to establish long-term intimate relationships with Black men. It is important for mental health counselors to be knowledgeable about the concerns, issues and needs of this unique population (Constantine & Greer, 2003). Although many Black women experience difficulties in adjusting to or dealing with college life, Constantine and Greer noted that they seek counseling for issues related to their personal dating dilemmas more often than is expected. In an article by Gabriel (2010), relationship concerns were listed as one of the most reported issues presented by ethnic minority counseling center clients on college campuses. This suggests that college counselors need the awareness, knowledge and skills necessary to effectively assist Black women grappling with relationship issues.
By studying and applying identity development models that illuminate the various stages of development that Black women encounter, counselors may begin to understand the dating struggles experienced by Black college women. For example, it is important for counselors to be aware of Cross’ (1971) Black identity development model and Helms’ (1990) womanist identity development theory, respectively, and to understand how race and gender oppression may influence Black college women’s ability to move successfully toward a positive and healthy self-identity. Clearly, an individual with a salubrious self-concept would be more likely to make good dating decisions.
Based on Cross’ (1971) identity development model, counselors may encounter a Black college woman who passed through the immersion stage and is in the process of emersion, taking on characteristics and behaviors of another race. Here it is critical for counselors to understand that the woman may be in denial as the emersion characteristics are antithetical to what the woman feels are appropriate behaviors for her race. Using Helms’ (1990) womanist identity theory, a Black college woman may be in search of a positive self-affirming definition of womanhood. Here it is critical for the counselor to understand the stage the client is in to support her appropriately.
Counselors must not only adopt a culturally relevant framework, but also must be aware of culturally appropriate counseling techniques in order to better serve Black college women (Bradley & Sanders Lipford, 2003). Chief among the strategies to assist Black women in achieving a healthy self-concept is a need for women-centered networks of emotional support (Williams, 2005) that provide Black women with “a place to describe their experiences among persons like themselves” (Howard-Hamilton, 2003, p. 25). According to Helms’ (1990) model, Black college women may use these encounters with other Black women to identify, question and reject the pervasive negative stereotypes that influence their self-concept. Group interventions such as “sistercircles” often provide Black college women with powerful support networks (Hughes & Howard-Hamilton, 2003, p. 101) that may assist them in making healthier dating decisions. These circles involve sharing experiences and discussing coping strategies and may be especially useful on predominantly White campuses, where the issues of Black women tend to be overlooked or marginalized at the periphery of campus life.
Implications for Student Affairs Professionals
Student affairs professionals who are well versed in student development theory also are uniquely positioned to assist Black college women in establishing healthy identities as they search for opportunities to engage in intimate dating relationships with Black college men. By providing Black college women with challenging, yet supportive educational opportunities within a variety of co-curricular and academic contexts, student affairs professionals can assist these women in reaping the psychosocial benefits of being involved in healthy intimate relationships and help them develop a positive sense of self. For example, interactive workshops, case studies, and conversations centered on the contributions and values of Black women may aid in positive identity development among young Black women in college. Based upon Helms’ (1990) womanist identity development model, the ability of these women to form positive identities may strengthen their self-concept and thus enhance the probability of them engaging in healthy intimate relationships.
In addition, student affairs programming should be structured to challenge (and support) Black college women to confront the wide array of “microaggressive” indignities (i.e., racist and sexist attitudes and behaviors) they encounter in their daily campus experiences (Howard-Hamilton, 2003, p. 23). These types of programs may help Black college women who are in Helms’ (1990) encounter stage explore and reformulate the dimensions of their self-concept, which are externally based.
Furthermore, student affairs professionals that are charged with facilitating leadership courses and co-curricular workshops who work to illuminate the strengths and values of Black women might be able to assist Black college women in establishing a healthy identity as they contend with a wide variety of difficult dating decisions. “Sistah to Sistah” programs facilitated by Black female faculty in conjunction with student affairs personnel may provide a forum in which Black college women can come to value the experiences of women like themselves and connect with these women to form a variety of deep interpersonal relationships. Helms (1990) cited the establishment and maintenance of relationships with other women as central in the process of constructing a positive, internally based definition of womanhood. By providing a combination of culturally relevant programs and activities, the process of Black women’s identity development may be improved and the quality of their college dating experiences enhanced.
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Oct 9, 2014 | Article, Volume 2 - Issue 3
Melissa Ng Lee Yen Abdullah, See Ching Mey
This study identified the fundamental lifestyles adopted by a university community in Malaysia. Rapid growth and expansion of higher education in Malaysia is inevitable as the country moves from a production-based economy to one that is innovative and knowledge-based, requiring the development of a highly skilled and knowledgeable workforce. Research universities in Malaysia are leading the way in the generation of intellectual property and wealth for the country, as well as enhancing the quality of life of its people. A case study approach found that the university community’s lifestyle is focused on recognitions. Implications for university personnel are discussed.
Keywords: Malaysia, higher education, university community, lifestyle, transformation, BeMIS
Higher education is one of the most dynamic and rapidly growing service sectors in many parts of the world
(Kapur & Crowley, 2011 Lee, 2004; Ministry of Higher Education, 2011a; “Transform Higher Education,”
2011 UNESCO, 2005; Varghese, 2009). In fact, the rapid growth and expansion of the higher education sector in Malaysia is inevitable, as the country is currently moving from a production-based economy to one that is innovative and knowledge-based and requires the development of a highly skilled and knowledgeable workforce (Arokiasamy, 2012). The shift toward a knowledge-based economy in the era of globalization also has contributed to the increasing demand for more and better quality graduates (Lee 2004; Varghese 2009). In order for higher education in Malaysia to remain relevant locally and competitive globally, it must undergo transformation (Levin 2001; “Transform Higher Education,” 2011). The push for excellence in research, innovation and commercial activities is particularly crucial to achieve the national agenda in Malaysia. As
a matter of fact, research universities in Malaysia are now leading the way to generate intellectual property and wealth for the country and to enhance the quality of life of the people (Ismail, 2007). With the changing landscape of higher education in Malaysia, local universities have imposed stricter key performance indicators (KPI) targets on the staff (Azizan, Lim, & Loh, 2012). KPI measures the performance of academic and
non-academic staff and also gauges their eligibility for promotion. The pressure to publish research papers, particularly in top-ranked journals, is an important facet of KPIs as it reflects recognition received by academics in local and international arenas. In addition, academic staff are encouraged to work together with industry and the community to leapfrog multidisciplinary knowledge creation to address social, economic, environmental
and health challenges of the nation or region (Gill, 2012). At the same time, student and staff mobility can be promoted via exchange programs and collaboration with international institutions, which is in line with the internationalization policy outlined by the National Higher Education Strategic Plan (PSPTN) in Malaysia
(Ministry of Higher Education Malaysia, 2011b). This implies that engagement with the local and international community through mobility, research and outreach activities are crucial.
Fundamental Lifestyle
Fundamental lifestyle is a way to segment people into groups based on three things: opinions, attitudes and activities (Harcar, Kaynak, & Kucukemiroglu 2004). As such, it measures peoples’ activities in terms of how they spend their time, interests, where they place importance in their immediate surroundings, and their views of themselves and the world which may differ according to socio-demographic factors (Plummer, 1974). According to Khan (2006), there are four main characteristic lifestyles:
• a group phenomenon that influences society
• influence on all life activities
• implies a central life interest
• affected by social changes in society
Studies have shown that lifestyle affects the performance of over 80% of employees in organizations (Robertson, 2012) and is a factor that should not be overlooked. Lifestyle can be divided into specific dimensions based on recognizable behaviors (Wells & Tigert, 1971). According to the Center for Credentialing and Education (2009), there are four types of fundamental lifestyles, namely (1) recognition, (2) introspection, (3) extroversion, and (4) introversion (see Figure 1). These lifestyles can be identified through one’s focus and preferred internal/external activities.
Recognition Lifestyle
People with a recognition lifestyle set clear goals, focus on achieving targeted recognition, and prefer external activity. They place importance on external stimulus and believe that recognition will follow suit when performance expectations are met. The recognition may come in the form of a pay raise, awards, promotion, and performance opportunities. These people also prefer external environments such as social activities with a high profile.
Introspection Lifestyle
People with an introspection lifestyle focus on internal activities such as clarifying personal goals and roles, self-reflection, motivation, and spiritual drive. They tend to look inward and constantly think about personal thoughts and feelings (Sedikides, Horton, & Gregg, 2007). They are capable of working independently and engage in high-level cognitive activities and are easily recognized as thinkers.
Extroverted Lifestyle
People with an extroverted lifestyle focus on external activities and rely on being in the company of other people. Extroverted individuals tend to be active, gregarious, impulsive and fond of excitement. They like socialization and perceive it as a source of motivation. As such, a small social network may lead to psychological problems (Grainge, Brugha, & Spiers, 2000). People with such lifestyles also do not often focus on specific external stimuli such as tangible rewards.
Introverted Lifestyle
People with an introverted lifestyle focus on internal activities and prefer to work on their own without relying on the company of others. Hence, a lack of large social networks may be of less concern (Grainge et al.,
2000). People with such a lifestyle also do not often depend on internal processes such as clarifying personal
goals and roles, self-reflection, motivation and spiritual matters.
Figure 1. Descriptors of Lifestyles (Source: Adapted from the Center for Credentialing and Education, 2009).
Lifestyles in University Communities
Currently there is a lack of literature on the fundamental lifestyles of university communities during institutional transformations. Transformation measures undertaken in higher education in Malaysia aim to foster the development of academic and institutional excellence so that higher education institutions (HEIs) can fulfill their roles in meeting the nation’s developmental needs and build its stature both at home and
internationally (Ministry of Higher Education Malaysia, 2011b). Stricter KPIs are being imposed on university staff (Azizan, et al., 2012). The pressure to publish research papers, particularly in top-ranked journals, is an important facet of KPIs as it reflects recognition received by academics in local and international arenas. It is, however, unclear to what extent recognition (such as the push for publication and emphasis on KPIs) plays a role in shaping the lifestyle of the university community in Malaysia. Literature reviews show that emphasis
on external stimuli may create an unhealthy culture as “everyone is rushing to publish papers to meet the KPI… they want to be recognized internationally” and published in top-ranked journals (Azizan, et al., 2012, p.1). For this reason, empirical studies are needed to explore the types of lifestyles adopted by university communities. Investigations also need to examine the variation that may exist among the different categories of university
communities, namely higher administrators, academics, administrative officers, support staff, postgraduates and undergraduates. Such data are vital in helping HEIs keep track of staff and students’ development during higher education transformation. Based on the findings, strategic planning at the institutional level can be implemented accordingly. To fill in the literature gap, this study aims to identify the lifestyle of the university community
as a whole and also describe the lifestyle adopted by the different categories of the community. The research objectives were (1) to identify the lifestyle of the university community, and to (2) describe the lifestyle of administrators, academics, administrative officers, support staff, postgraduates and undergraduates.
Methodology
An exploratory case study method was used to conduct the investigation at a research-intensive university in Malaysia. Based on a list of staff and students at this institution, 520 targeted participants were randomly chosen as shown in Table 1. Official invitation letters, general information about the research and consent forms were sent out to all targeted participants.
Table 1
Participants in the Study
|
Participants |
|
| Categories |
Targeted |
F
|
|
% |
| Higher Administrators |
40
|
39
|
|
11.27 |
| Academic Staff |
100
|
59
|
|
17.05 |
| Administrative Officers |
100
|
38
|
|
10.98 |
| Support Staff |
100
|
68
|
|
19.65 |
| Postgraduate Students |
100
|
80
|
|
23.12 |
| Undergraduate Students |
100
|
62
|
|
17.91 |
| Total |
520
|
346 |
|
100.00 |
A total of 346 respondents voluntarily agreed to participate in this study; 39 higher administrators, 59 academic staff, 38 administrative officers, 68 support staff, 80 postgraduate students and 62 undergraduate students.
The Behavioral Management Information System (BeMIS), an online assessment and reporting tool, was used as the instrument to identify the lifestyle of the university community. The underlying instrument includes the Adjective Check List (ACL), which comprises of 300 adjectives commonly used to describe
traits that a person subscribed to and these traits can be grouped into four major lifestyles, namely recognition, introspection, introverted or extroverted (Gough & Heirbrum; 1980, 1983, 2010; Measurement and Planned Development, 2010).The validity of the instrument is well established in the literature and has been adopted
in nearly 1,000 research reports (Essentials, 2010). The reliability of the instrument was pilot tested and
established before the study began. Results showed that the satisfactory reliability with Cronbach’s alpha values ranged from 0.74 to 0.97. The BeMIS system is capable of plotting lifestyle into a four-quadrant graph (Center for Credentialing and Education, 2009). The report presents the participants’ real- and preferred-self lifestyle. Real-self refers to one’s current lifestyle while the preferred-self indicates the person’s desired lifestyle.
The data collection was completed via an online system. Each participant was provided with a password to access the BeMIS website. As such, the participants could provide responses and submit them online. The data were analyzed using BeMIS proprietary software and the results are presented as standard scores. The acceptable ranges of scores range from 40 to 60. Any score that exceeds 70 or is less than 30 is considered too extreme and reflects dissatisfaction with life (Gough & Heilbrun, 2010).
Results and Discussion
The results of this study are presented and discussed according to the two main objectives of the study, which were to identify the lifestyle of the university community as a whole and to describe the lifestyle adopted by the different subgroups of the university community.
Lifestyle of the University Community
The four-quadrant graph reveals that the university community’s lifestyle (real-self) is at the recognition quadrant whereby recognitions such as pay raises, awards, promotions and performance opportunities are very much the focus of life. The university community’s preferred lifestyle indicates that they seek higher recognition. There are indications that the community’s focus may be moving towards the introspection
quadrant (see Figure 2). As a whole, the university community is likely to set clear goals and focus on achieving targeted recognitions. Their external lifestyle also suggests that the community is currently active in social and community activities.
The scatter plot in Figure 2 demonstrates that there are variations in lifestyle adopted by the university community. Most of the respondents’ scores are within the acceptable range of 40–60, with a few notable outliers. To further examine the findings, there are needs to examine the lifestyles of the university community according to the six subgroups of participants; higher administrator, academics, administrative officers, support staff, postgraduates and undergraduates.
Lifestyle of Higher Administrators
The four-quadrant graph shows that as a whole the higher administrators’ real-self lifestyle is within the recognition quadrant (see Figure 3). Their focus on recognition is slightly above the score of 60, indicating an emphasis on recognition. Recognition may come in the form of pay raises, awards, promotions and performance opportunities. Nevertheless, the higher administrators are sociable and likely to have high profiles among the university community. Higher administrators’ focus on recognition seems to be lower in the preferred lifestyle which indicates they prefer to lower their focus on recognitions.
The scatter plot in Figure 3 demonstrates that even though there are variations in the lifestyle of higher administrators, their scores are still within the acceptable range of 40–60, except for a few outliers located at the recognition and introversion quadrants. These outliers indicate that a small number of the higher
administrators may be focusing too much on recognition. This could potentially cause dissatisfaction in life if their expectations are not met (Gough & Heilbrun, 2010). One of the higher administrator’s scores is considered extreme in introverted behavior, implying that this individual prefers to work alone, does not often self-reflect or self-motivate, and is not keen on social activities.
Figure 2. Fundamental Lifestyle of the University Community
Figure 3. Lifestyle of Higher Administrators
Lifestyle of Academics
The four-quadrant graph shows that as a whole, the academics’ lifestyles, both real and preferred-self, are located at the recognition quadrant (see Figure 4). They are likely to set clear goals and focus on achieving recognitions like pay raises, awards, promotions and performance opportunities. Their emphasis on recognitions is still within the acceptable range of 40–60 and is unlikely to cause any negative impact on psychosocial wellbeing (Gough & Heilbrun, 2010). In addition, academics’ focus on an external lifestyle suggests they are active in social and community activities.
Figure 4. Lifestyle of Academics
The scatter plot in Figure 4 further demonstrates that even though academics may adopt different lifestyles, their scores are within the acceptable range of 40–60 (except for a few notable outliers).
Their extreme scores are found in the recognition and introverted quadrants. These outliers indicate that a small number of academics are focusing too much on recognition, which could potentially cause dissatisfaction in life if their expectations are not met (Gough & Heilbrun, 2010). One of the academic staff is extreme in introverted behavior suggesting that this professor prefers to work by himself, is not keen on social and community activities, and is often not engaging in introspective activities such as self-reflection, self- motivation and spirituality.
Lifestyles of Administrative Officers
The four-quadrant graph shows that as a whole the administrative officers’ real and preferred lifestyle is located at the recognition quadrant (Figure 5). Their focus on external stimuli suggests that recognitions such as pay raises, awards, promotions and performance opportunities are important sources of motivation. Their emphasis on recognitions is still within the acceptable range of 40–60, thus it is unlikely to cause negative impact (Gough & Heilbrun, 2010). Figure 5 also reveals that the officers’ lifestyle is rather external in nature.
In other words, they engage more in external activities and rely on being in the company of other people. Nevertheless, their preferred lifestyle indicates that they wish for lesser external activity.
Figure 5 shows that the administrative officers’ lifestyle distribution scattered in four different lifestyle categories. Generally, the scores for all four different lifestyles are within the acceptable range of 40–60, except for a few outliers found in the recognition and introversion quadrants. These outliers indicate that a small number of administrative staff are focusing too much on recognition which could potentially cause dissatisfaction in life if their expectations are not met (Gough & Heilbrun, 2010). One of the administrative
officers is extremely introverted in his or her lifestyle, suggesting that the officer likes to work by himself, is not keen on social or community activities, and is not much involved in self-reflection or self-motivation.
Figure 5. Lifestyle of Administrative Officers
Lifestyles of Support Staff
The four-quadrant graph shows that as a whole, the support staff’s real and preferred lifestyle is within the recognition quadrant (Figure 6). Nevertheless, the support staff appear to be active in social activities and seem to prefer higher level recognition.
The scatter plot in Figure 6 reveals that most of the support staff’s scores are within the acceptable range of 40–60, except for a few outliers located at the recognition, introspection and introverted quadrants. These outliers indicate that a small number of support staff are focusing too much on recognition which could potentially cause dissatisfaction in life if their expectations are not met (Gough & Heilbrun, 2010). Support staff with rather extreme introversion and introspection behaviors are those who prefer to work by themselves and do not like to socialize or engage in introspective activities (e.g., self-reflect).
Figure 6. Lifestyle of Support Staff
Lifestyles of Postgraduate Students
The four-quadrant graph shows that as a whole the fundamental lifestyle of the postgraduate students falls into the recognition quadrant (Figure 7). The findings suggest that academic achievement, awards and recognition are important sources of motivation for the majority of students at the postgraduate level. In fact, they prefer higher recognition, as indicated by their preferred self-scores.
Figure 7 also reveals that the score distributions recorded by the postgraduate students clustered around the acceptable range of 40–60 with a slight tilt toward the introverted quadrant. A high number of postgraduate students with introverted behavior may suggest that the students tend to work in silos when seeking recognition, and students with extreme scores are not actively socializing with others. In fact, they also do not engage
much in introspective activities (e.g., self-reflection). Such a scenario may not be considered as positive in that
postgraduate students are expected to be learners who engage actively in thinking and research activities.
Lifestyles of Undergraduate Students
The four-quadrant graph shows that as a whole the undergraduate students’ lifestyle (both real- and preferred-self) is within the recognition quadrant (Figure 8).The findings suggest that academic achievement, awards and other forms of recognition are very important for the majority of undergraduate students.
The scatter plot in Figure 8 reveals that most undergraduate students’ scores clustered around the acceptable range of 40–60; however, a number of the students’ scores tilted toward the introverted quadrant. This
result shows that some undergraduate students are introverted in their lifestyle and do not engage much in
introspective activities (e.g., self-reflection).
Figure 7. Lifestyle of Postgraduate Students
Figure 8. Lifestyle of Undergraduate Students
Summary and Conclusion
The lifestyles of the university subgroups are summarized in Figure 9. The findings reveal that the distribution of scores for three groups of participants, namely support staff, postgraduate students and undergraduate students, tilt more toward the introverted quadrant. Their inclination toward introverted behaviors seems to be higher than those holding administrative and academic positions such as administrative officers, academics and higher administrators.
In conclusion, recognitions such as pay raises, awards and promotion are very much the focus of
the university community. Past studies have indicated that recognition has a significant impact on one’s performance. It is an external stimulus to achieve a targeted goal (Ali & Ahmad, 2009; Deci, 1971; Gomez- Mejia & Balkin, 1992). Therefore, the pay system can be utilized as a mechanism to direct employees toward achieving the organization’s strategic objectives (Gomez-Mejia & Balkin, 1992). In fact, employees’ job satisfaction is significantly related to recognitions like pay raise and promotion (Ali & Ahmed, 2009). Ch’ng, Chong, and Nakesvari (2010) found that the job satisfaction of lecturers in Malaysia is related to salary and promotion opportunities. Since the appraisal and promotions system at local HEIs are based on KPIs (Azizan et al., 2012), the university staff can strategically align their goals toward achieving the institution’s targets. The implementation of KPIs can indeed create a new mindset among academic and non-academic staff (Kaur,
2012), particularly when the focus of the university community is on recognitions. In other words, it is possible to move the university community as a concerted force to attain the institution’s KPIs.
Even though recognitions can be a positive external stimulus to directly enhance the job performance of members of the university community, overemphasis on recognitions can result in dissatisfaction among staff and students if expectations regarding recognitions are not met (Gough & Heilbrun, 2010). In fact, the pressure to publish research papers, particularly in top-ranked journals, and the push to place Malaysian universities among the top 100 worldwide have caused concerns among academia (Lim & Kulasagaran, 2012). However, academia is more than publishing in journals; teaching and learning are equally crucial. Academics play
a central role in stimulating intellectual discussions and mentoring students. They must have passion and genuine interest in teaching as well as conducting research activities, and not just be driven by KPIs to achieve recognition. In order to do so, academic staff must possess internal motivation such as interests and the passion to teach, conduct research, disseminate knowledge and create innovations.
In addition, this study found that the university community prefers an external lifestyle. They are active in social and community activities, which is in line with the institution’s move toward industry and community engagement. For instance, research and consultation projects aim to fulfill societal needs. The external lifestyle also contributes to collaborative research and industrial and community engagement. Even so, there are still members of the university who are extremely introverted in their lifestyles. They prefer to work and study in silos, not becoming active in social and community activities, apart from not looking much into their inner-
self in order to self-reflect, self-motivate and self-improve. This situation is more pertinent among support staff, postgraduate and undergraduate students. These findings are not encouraging, particularly among the postgraduate students, as they are expected to be active and engaging learners.
Finally, the university should take measures to address the development of its staff. Support services need to be made available for those who feel isolated and have more introverted behaviors. Mental health support systems and counseling services also are crucial to sustain the well-being of the university community during institutional transformations.
Figure 9. Lifestyles across the Subgroups of the University Community
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Melissa Ng Lee Yen Abdullah is a Senior Lecturer and See Ching Mey is Deputy Vice-Chancellor at the Universiti Sains Malaysia. Correspondence can be addressed to 1180 USM, Pulau Pinang, Malaysia, melissa@usm.my. Acknowledgement: The authors would like to acknowledge the financial support from RU Grant (1001/PGURU/816144) and also the assistance received from Dr. Daniel R. Collins and Dr. J. Scott Hinkle, as well as the contribution of all the AURA team members, in conducting this study.
Oct 9, 2014 | Article, Volume 2 - Issue 3
Jeffrey S. Lawley
The use of technology in counseling practice is constantly expanding, offering new tools for communication and record-keeping. These tools come with significant legal and ethical risks for counselors as well as counselor educators and supervisors. Rules from HIPAA and HITECH are discussed in relation to counselor practice. Guidelines for electronic records and communication are suggested.
Keywords: counselor education, ethical risks, supervision, technology, electronic records
In April 2005, the Security Rule of the Health Insurance Portability and Accountability Act (HIPAA; 2007) went into effect for all health care providers. New security standards (which specifically address protection of access to medical records, as opposed to privacy standards which address issues related to sharing of medical records with other entities)
are now enforced for any professional that handles electronic Protected Health Information (ePHI), including professional counselors. Some aspects of the impact of HIPAA on individuals who are practicing as independent clinicians have been addressed previously (See Benefield, Ashkanazi,& Rozensky, 2006, and Brendel & Bryan, 2004 for examples). However, many discussions of HIPAA have been aimed at other types of practitioners.
HIPAA’s rules have since been amended in a number of ways by the Health Information Technology for Economic and Clinical Health (HITECH) act, which was passed in 2009 and went into effect in February 2010. HITECH (2009) makes changes to some HIPAA rules regarding electronic security and access to ePHI. In comparison to discussions of other technological issues regarding counseling, such as online counseling (Richards, D., 2009; Rummel & Joyce, 2010), electronic security is a relatively new and sparse area in the counseling literature. The shifts in law regarding ePHI have direct effects on the way that some current counseling practices, such as e-mail interactions with clients (McDaniel, 2003), must be pursued. The question of practical implications of changing laws is made more complex by the fact that many
of these rules are written with large organizations or medical practices in mind. This can leave the individual or small group practitioner without the resources of larger practices feeling overwhelmed. Regardless, counselors are required to be aware of not only important aspects of the HIPAA security rule, but also the ways in which it is amended by HITECH. Awareness of laws regarding practice and the use of technology is part of the American Counseling Association’s (ACA;
2005) ethical guidelines regarding limitations to confidentiality and privacy in the counseling process. Counselors may wish to discuss limitations specific to electronic medical records as part of this process (Richards, M., 2009).
ePHI is defined as any Protected Health Information (PHI) that is stored on any form of electronic media, or which
is transmitted in any electronic form (e.g., fax or Internet). This would include scanned records or correspondence that
is written on a computer and then printed (Freeny, 2007). This does not include ePHI in educational records, which falls separately under the Family Educational Rights and Privacy Act (HIPAA, 2007). The security rule requires that medical professionals take measures to keep ePHI confidential and to protect it from disclosure. Additionally, counselors are
to safeguard ePHI from any “reasonably anticipated threats or hazards to the security or integrity of such information” (HIPAA, 2007, §164.306 (a) (2)).
Poorly maintained ePHI systems are a significant legal and ethical risk for counselors for a variety of reasons. This risk involves a breadth of information typically kept by counselors, including reports, case notes, billing materials, correspondence, personal notes, and research kept on electronic devices including computers, smartphones, and other electronic devices (particular issues related to smartphones and similar devices are discussed below). This is due to the expanded definition of protected health information (PHI) that HIPAA creates—virtually anything that could be traced back to a client that confirms their treatment. HIPAA defines PHI as material in any format that “relates the past, present, or future physical or mental health or condition of an individual” (HIPAA, 2007, §160.103(2)[definition of individually identifiable health information]). It also covers information that is involved in payment for these services. In order to
be categorized as ePHI, the information must be used to identify an individual—that is, de-identified information is not covered under this definition.
HIPAA includes requirements for both physical and electronic safeguarding of ePHI (or computers that store ePHI). Physical security includes access to devices on which information is kept. Tools and procedures related to physical security involving access to records will probably be familiar to most counselors. Typically, this refers to basic practices such as antivirus software and other technical practices, but additionally refers to specific access and data management practices as discussed below. Concerns related to electronic security are somewhat more complex and come with
broader implications. For example, there is little information to help counselors determine what counts as a “reasonably anticipated” (HIPAA, 2007, §164.306 (a)(2)) electronic threat.
Note that there are other areas where HIPAA may affect mental health practice in ways that may conflict with generally
accepted standards of practice or ethical guidelines, such as the fact that communication for continuity-of-care or insurance billing purposes no longer legally requires a release. This discussion falls out of the area of focus of this article, which is on the specific effects of the security rule on counseling practice. (A general discussion of HIPAA issues affecting counselors can be found in Freeburg & McCaughan, 2008).
Ethics, Law and Client Files
Counselors will be happy to learn that there are few significant conflicts between counseling ethics (ACA, 2005) and law in regards to ePHI. Differences are typically found when ethics codes within the mental health profession do not address issues that are addressed by HIPAA and HITECH. For example, general guidelines for the protection of client records are discussed in the most recent ethics code of the American Counseling Association (ACA, 2005). However, these guidelines focus more on a general need to keep confidentiality and possible reasons for breaking confidentiality. The code does not suggest specific guidelines for keeping electronic records, but only notes that “records are kept in
a secure location and that only authorized persons have access to records” (ACA, 2005, Standard B.6.a). No specific measures regarding ways to manage confidentiality, security or privacy of ePHI are offered. HIPAA and HITECH lay out a number of details in addition to this general rule.
Data Backups
One primary concern not applicable to paper records is the legal requirement to keep an easily accessible, but equally secure and encrypted, backup of all ePHI (HIPAA, 2007, §164.308, (7)(ii)(a): an entity must “establish and implement procedures to create and maintain retrievable exact copies of electronic protected health information”). Since this guideline is meant as part of a disaster recovery plan, assuming loss of all data in a counselor’s office, this backup may often be kept offsite. That is, an additional secure location outside of the office is now necessary. With this rule and the advent of nominally secure and easily accessible cloud backup services, the variables defining a “secure location” have changed significantly since HIPAA was established.
Counselors may be tempted to use an online backup service as an offsite backup, and can be aided by provisions of HIPAA and HITECH in making a choice between an offsite physical backup in an additional secure location and the use of an online backup service. Under HIPAA and HITECH, the appropriateness of online backup can be somewhat murky. Separate encryption of data on the local computer (as required by HITECH, see below) before sending the data over an encrypted connection to an online service may alleviate this concern. Before using any cloud backup solution, counselors
should determine whether the company meets a brief checklist of requirements (see Table 1). There are a number of online backup services, marketed towards healthcare professionals, which describe themselves as “HIPAA-compliant.” However, this does not have a technical meaning—there is no certification for HIPAA compliance regarding client data backup services. It is the responsibility of the counselor or designated individual in a group practice to ensure that online backup meets HIPAA and HITECH requirements.
Table 1
Quick Checklist for Online Backup
HIPAA and HITECH require the counselor to be able to access accurate and current copies of all ePHI at any time, even in
the event of a disaster that destroys copies located in a counselor’s office. Some forms of cloud storage may be an option
if they meet the following minimum requirements, which can typically be ascertained by reading a site’s terms of service:
• Data is monitored for changes and backed up immediately
• Client-side software can be set up in such a way that unauthorized individuals cannot access data
• Data is transmitted over an encrypted connection (e.g., https connections)
• Documentation of physically secure storage; some services have multiple backup locations
• Data cannot be accessed by staff at storage site under any circumstances, including a court order
• Data is encrypted before transmission with at least 256-bit encryption (e.g., encryption is automatically performed client-side by the client software). Alternatively, data can be encrypted manually by the counselor before backup
• (optional) Two-factor authentication (requiring a USB key or other secondary “token” to access archived data)
Most popular cloud storage services advertise secure online backup with varying levels of encryption. However, these services are not all created equally and in many cases their process does not meet minimum standards. While transmission is typically encrypted as required by HIPAA, information stored by these services is not necessarily secure. Information may be encrypted at a physically secure site, but some services do have the technical ability to access any ePHI that is stored with them. For example, the terms of service at Dropbox, a popular backup and syncing service, state that:
We may disclose to parties outside Dropbox files stored in your Dropbox and information about you that
we collect when we have a good faith belief that disclosure is reasonably necessary to (a) comply with
a law, regulation or compulsory legal request; (b) protect the safety of any person from death or serious bodily injury; (c) prevent fraud or abuse of Dropbox or its users; or (d) to protect Dropbox’s property rights. If we provide your Dropbox files to a law enforcement agency as set forth above, we will remove Dropbox’s encryption from the files before providing them to law enforcement. However, Dropbox will not be able to decrypt any files that you encrypted prior to storing them on Dropbox (Dropbox, 2011, section 3, para 4).
This means that someone other than the counselor or a designated individual could access ePHI. For example, if a counselor is involved in a lawsuit, a court order could cause the online storage company to disclose unencrypted ePHI without input from the counselor. However, as noted, they are not able to decrypt any information that the counselor encrypts before backing up, as suggested by HITECH. In most cases, counselors must ensure that data is encrypted before being sent to any such service. Counselors also are cautioned to pay close attention to the privacy policies at any backup service that they might use; many are less specific than the example above but still allow for the possibility of decrypting and releasing data with a court order.
Counselors also should note that there are other backup services that offer what is called user or client-side encryption. ePHI is encrypted before it leaves the counselor’s computer, and no individual at the physical storage site can access the information. This protects the counselor, as they cannot provide any information about data that they are storing for the counselor. It is important to note that this does not mean that information on the counselor’s own computer is encrypted.
Communication of Client Information
HIPAA also addresses the transmission of ePHI via electronic methods such as e-mail. The law states that medical professionals must have some sort of measure to “guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network” (HIPAA, 2007, § 164.312(e) (1)) such as the Internet. Similar language regarding secure electronic communication is found in the ACA ethics code. It is important for counselors to be aware of this requirement, as communication with clients via e-mail or other online
communication is likely to become more common for general communication as well as therapeutic tasks. As an example, McDaniel (2003) discusses the benefits of having clients e-mail weekly journals to their clinicians. This work was published before the HIPAA security rule went into effect and the general idea is certainly no less useful today. However, the online transmission of identifiable material directly related to clinical work certainly falls under the legal guidelines discussed here. While in most cases clients are clearly giving permission for counselors to correspond via e-mail or by other means such as videoconferencing or online chat (Haberstroh et al., 2008), the laws regarding secure electronic transmission still apply. It is important to note that the counselor is not liable for encryption or safety of material on
the receiving end of the transmission (HITECH). This problem could be solved by using an e-mail service that forces encryption before transmission, an option available through most e-mail services. As indicated in the ACA ethics code,
if online communication is utilized by a counselor, they should indicate the limitations of this method of communication in regards to the possible insecurity of online communication and encourage the client to take similar precautions when sending messages to the counselor.
Loss of Data or Involuntary Breaches of Confidentiality
One aspect of the care of ePHI that is not completely addressed by HIPAA or the most recent ethical codes is what should happen when ePHI is accessed inappropriately. For example, there is no specific guideline in the ACA ethics code indicating that clients should be notified when their files are accessed. It is up to the individual counselor to determine what to do if a client’s paper file is stolen. HITECH has changed this in regards to ePHI, however. The law requires medical professionals to have a specific plan in place to notify affected clients in the case of a breach of unprotected (e.g., unencrypted) electronic information—and to immediately notify the Secretary of Health and Human Services (HHS) if
the breach involves more than 500 individual clients. At first glance this may seem like a large number, especially for an individual in private practice. However, any practicing individual who has used electronic records for some time will have at least this many case files over the lengthy period (often at least seven years) in which documentation may be kept. This means that if an unprotected backup of ePHI is stolen, the counselor is responsible for notifying every individual whose identity may be compromised within 60 days. There are no ethical or legal requirements for disclosure after the loss of encrypted data, leaving it to the counselor to choose whom to notify.
Case Notes and Assessment Data
Another important ethical question that presents itself regarding ePHI involves unique types of medical information that are typically handled by counselors. Counselors may handle some types of information that have differing practical and legal status than “traditional” medical records, including case notes and testing material. Case notes have historically enjoyed nearly absolute privacy protection in the United States (Mosher & Swire, 2002) and are specifically addressed
in HIPAA. They continue to retain expanded protection under current law, requiring a separate release when they are accessible at all (see Hixson & Hunt-Unruh, 2008). These include the type of separate notes that some counselors keep separately from the patient file and specific to the counseling process. They include observations, inferences and conceptualizations of the client; however, typical case notes including such information as diagnosis, prognosis, and changes in symptoms, etc. are not covered under this expanded protection (HIPAA, 2007).
The case of assessment records, particularly raw data, is somewhat murkier. The general idea is that data may be misused or misinterpreted by individuals who are not trained in interpretation of test data, in addition to concerns about
the security of test instruments themselves (Committee on Legal Issues, 2006). Given the historical view of the fields of psychology (Committee on Legal Issues, 1996) and the current view of counseling (ACA, 2005) on the security of test data, particularly raw data, one might expect assessment data to be separated in a manner similar to case notes in regards to release of the information. However, rules in HIPAA regarding test data state that a client can choose to sign their entire medical record (sans case notes) to any third party (HIPAA, 2007). While HIPAA allows the medical professional to exclude certain information based on client safety, or if the counselor obtained the information under separate release from another practice, possible misuse of test data is not an acceptable reason to exclude portions of a counselor’s
record (Erard, 2004). There are no stipulations in HITECH that change this. However, ACA’s 2005 ethics code is clear in its statement that “[test] data are released only to persons recognized by counselors as qualified to interpret the data” (Standard E.4). This is the most significant difference between the ACA ethics code and current law.
Online assessment and treatment is another activity that counselors may not have considered when reviewing the impact of law on their practice. A growing number of therapists, for example, are using online tools for various tasks such as career assessment (Gysbers, Heppner, & Johnston, 2009), and are starting to pursue online counseling activities (Haberstroh et al., 2008). This information is typically stored on computers that belong to the test owner, not the counselor, and the counselor is not directly responsible for information on these machines. However, counselors have an ethical responsibility to ensure the integrity of the website that a client may use for such an assessment. The ACA ethics
code specifically addresses this issue by stating that counselors should be aware of the limitations of online activities and
share this information with the client. It also discusses guidelines for supervision of online activities (ACA, 2005). This is a relatively new area of practice that is not covered by HIPAA or the more recent HITECH. However, the same care should be taken with any information downloaded from these sites as with any other ePHI.
A Note About Smartphones
It also is important to note that as “alternative” (and easily lost) computing devices such as smartphones and tablet computers become more common, counselors are likely to use these to monitor and keep client records as well. Most cloud storage systems offer mobile applications for smartphones, or have websites that may be accessed by smartphones. Additionally, there are a number of smartphone tools designed to assess symptoms or help a client keep a journal. As a part of informed consent in treatment, clients should be reminded of the risk of keeping such information on their phone. At the current time, it is not advisable to use smartphones or tablet devices to access ePHI unless it is being accessed
over a secure network and then deleted (e.g., information is accessed through a local network or virtual private network). Often, information such as this may be cached on the device and accessible if the device is stolen or lost. Counselors also should be encouraged to utilize a passcode on these devices, as required under the rules regarding computer access under HITECH.
Finally, counselors should take care to monitor the security of any messaging that they use on their phone. While
secure e-mail can be configured on most smartphones, there is no way to secure a text message and clients must be informed of this risk if text messaging is used as a form of communication between counselor and client. (For good examples of situations where text messaging may be a productive tool in counseling, see Agyapong, Farren, & McLoughlin, 2011, and Suffoletto, Callaway, Kristan, Kraemer, & Clark, 2012).
Practice Guidelines
Access Policies and Documentation
Counselors are responsible for a number of procedural issues regarding “live” practice. The organization is required to have a designated individual who is responsible for ensuring the practice meets legal guidelines regarding records as well as other issues. In solo practices, this would mean the individual counselor. In group practices, this person needs to
be readily identifiable and does not have to be a licensed individual, or someone who is an active counselor in the practice. The practice also must have a manual of procedures regarding such things as password policies, access policies, standards regarding computer security, instructions for encryption and storage of files, and documentation that everyone in the office has been kept up to date on these policies. This is not an exhaustive list, but indicative of the types of information that
need to be covered and readily available in the case of an audit. “Case notes” also are required for this list of procedures,
documenting changes to these policies as they are made (HIPAA, 2007).
Not only must counselors have general physical safeguards in place, there must be policies specific to physical access
to any computers that can access or modify records. Controlled access to individual machines is required, including user-specific logins with passwords and automated logoff in case an individual leaves their desk and forgets to log off. Counselors should be encouraged in particular to pay close attention to their password policies (see Proctor, Lien, Vu, Schultz, & Salvendy, 2002).
Ideally, in small group practices each individual will have their own computer which is only accessible using their personal login. If more than one counselor uses a computer, the counselor must be able to show that individuals who should not be able to access certain information are not able to do so. For example, in many situations graduate counseling students might access services through a college counseling center. If some of their peers work at this site, steps would need to be taken to ensure that they do not have access to these files. In another case, in many areas with less access to counseling services, an individual with a close relationship to one counselor may be seeing another individual in the practice. Depending on the nature of a practice’s electronic records, keeping a separate individual paper file may be
easier than modifying ePHI procedures to account for this type of issue. Another alternative might be to keep a file on a
counselor’s individual computer, if records are kept on a central storage device or server.
Encryption
Although not specifically addressed by ethical standards, encryption of electronic files is encouraged by relevant law. This concerns not only local files, but also offsite backups. According to HIPAA, an electronic file had to be kept in such a way that it was not able to be modified by unauthorized individuals. This could be interpreted as encryption, but controlled access to computers technically counted as this type of protection. HITECH, however, encourages medical professionals
to encrypt all local data. In addition to the required notification discussed above, fines of up to $50,000 (per incident) have been instated for loss of client data. As noted, notification of clients or the department of HHS is not legally required for the loss of adequately encrypted data, and it is up to the counselor to create a policy regarding notification to clients of
loss of encrypted data. The current ACA ethics code does not specifically address encryption or backup of ePHI.
Additional HITECH Practice Guidelines
There are other changes in HITECH that will affect counseling practice that are not specifically related to the use of electronic records. HIPAA and HITECH also have guidelines regarding what are labeled as “business associates.” Counselors may occasionally share information regarding clients with other individuals or agencies in order to assist with such activities as billing or collections. This information is part of a client’s PHI. As such, it is the responsibility of the counselor to create a contract with this “business associate” that includes language stating that the associate also will maintain HITECH-compliant security (similar to HIPAA, but including rules regarding encryption, etc.) related to any
information that the counselor shares with this agency. The counselor is presumably, but not specifically, also responsible for ensuring that the other agency has some awareness of security requirements for ePHI. The counselor is not, however, responsible for monitoring this other agency and is not responsible for data lost by this other agency (HIPAA, 2007; HITECH, 2009).
HITECH has made some changes in regards to the provision of records to the client and to insurance companies. Clients must be provided with a complete copy of their records upon request at “reasonable” cost—if the counselor charges any amount for release of records, ePHI must be shared with only a reasonable cost of labor. Clients also have the right to records about the sharing of records with other entities for up to three years. This means that in addition to typical record-keeping, counselors also must keep some sort of receipt or other notes indicating exactly what information has been shared with others, such as providers or insurance companies.
Finally, while this was an existing ethical requirement (ACA, 2005), counselors are now legally allowed to share only the minimum necessary amount of information in order to meet the needs of the other agency or individual who is requesting the information. For example, records shared with another entity such as an insurance company should involve only the information necessary for the insurance company to be able to appropriately bill for services. HITECH clarifies
that the counselor is the individual who is allowed to make the determination of the minimum amount of necessary information. The counselor might find it helpful to have a few treatment summary templates for sharing with other entities such as schools, where all of the information in a child’s file is not necessarily relevant to the other entity. Additionally, counselors may, at the client’s request, withhold treatment information from insurance companies if the client pays out
of pocket for services. For example, if the client wishes that their insurance company or employer not know about their treatment for a specific issue (e.g., substance abuse), the counselor may see the client at any rate they choose and keep this information secure (HITECH, 2009).
Summary and Implications for Professional Counselors
While most counselors are at this point aware of changes necessary to remain in compliance with the HIPAA security
and privacy rules, HITECH has changed some aspects of practice again, in some cases significantly. Of particular impact for counselors are rules involving encryption, fines for loss of unencrypted data and changes in rules regarding communication with other individuals involved in a client’s care. It is notable that rules regarding ePHI are in many ways more restrictive than those involving management of traditional paper files, requiring encryption, offsite backups and other safeguards that were not even possible with paper. However, it can be argued that ePHI carries significantly more risk of loss than traditional paper records, as it is much easier to obtain large amounts of information off of an unguarded computer than from a file cabinet. It also is important to note that as of yet, aside from a few prominent cases involving the loss of data, there is little or no case law regarding the specifics of HIPAA implementation—that is, even the best guides are not yet able to state the best way to do this “right.” For example, there are no specific encryption standards, although there are industry standards that can be used as a rough guide. Significant implications for counselors are summarized in Table 2.
Table 2
Significant Implications for Counselors, Counselor Educators, and Supervisors
HITECH, the cloud, and electronic records modify the meaning of technological competence in counseling in many ways.
Below are some significant practical implications for practice and training in counseling:
• Continuing education programs and graduate coursework need to address ePHI and the differences between requirements for electronic and paper records; even counselors who do not utilize electronic records likely utilize electronic communication with clients
• Awareness of technological issues, such as the limitations of cloud backup, strong password generation, and the basics of how encryption works, is crucial for counselors
• Counselors need to be able to explain to clients the limitations of electronic communication and include any relevant limitations on their statements of practice and other informed consent materials
• Mobile technology such as SMS (text messaging) is coming into greater use in counseling, but ethical and legal guidelines for these methods do not yet exist. SMS in particular may not technically meet legal requirements but is utilized with good effect in recent research (Aguilera & Muñoz, 2011)
• If counselors use smartphone apps in their practice, they need to be able to explain ways to keep clients’
smartphones secure (e.g., instructing a client in how to create a PIN lock on an iPhone or iPod).
• Existing ethical guidelines need to specifically address electronic tools that are used in counseling
• “Current best practice” in technology changes much faster than in counseling. Limiting one’s exposure to changes in technology to an occasional CE program is not advisable.
• Supervisors have added responsibility, as they can be seen as the best way to propagate this information
• Counselors may find it helpful to seek out a dependable “technology supervisor” with whom they can
consult on issues related to technology
There appear to be few conflicts between the new law and the current ACA ethics code. In fact, the law addresses
some things that the current ethics code does not. The next revision of the ethics code would do well to cover some issues related to electronic communication and record-keeping in addition to its guidelines on the use of online counseling services and tools. Counselors would benefit from guidelines regarding whom to notify in the case of data loss, and may be well advised to pursue encryption of any ePHI that they handle within their practice. Counselors also would benefit from guidelines regarding awareness of current issues regarding electronic security, such as good password policies and the use of “smart” handheld devices for data access. Guidelines regarding the backup of ePHI may be of assistance to counselors who are attempting to utilize online services.
Finally, CACREP (2009) guidelines for counselor training include the need of counselor educators to show that they are teaching their students about the ways that technology is changing counseling. Discussion of issues regarding ePHI should be clearly evident in training programs, specifically in ethics courses, practica, and internship. For counselor educators, these points may be easiest to integrate into existing ethics courses. While these discussions are often centered on the use of online tools as described in the current ethics code, the growing use of ePHI in the medical and mental health communities may be the most important change that technology has yet brought to the field.
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Jeffrey S. Lawley is an Assistant Professor at Louisiana State University-Shreveport. Correspondence can be addressed to Jeffrey S. Lawley, Louisiana State University-Shreveport, 1 University Place, BE Building 348, Shreveport, LA 71115, jslawley@gmail.com.
