Aug 26, 2025 | Volume 15 - Issue 3
Brandi M. Sawyer, Edith Gonzalez
The global health and economic disaster caused by the coronavirus (COVID-19) pandemic has intensified mental health needs and subsequent demands on helping professionals. Counselors, in general, are at risk of experiencing both shared traumatic realities with clients and exacerbation of occupational stressors. For rural mental health counselors, who already face enhanced stressors related to rural service provision, the impact of COVID-19 is generally unknown. Through transcendental phenomenology, this study explores the experiences of 11 rural mental health counselors practicing in Texas during the COVID-19 pandemic. Two themes emerged, revealing experiences of systemic limitations as well as counselor growth and resilience. Findings provide implications for mental health counselor training, clinical practice, and advocacy.
Keywords: COVID-19 pandemic, rural, mental health counselors, transcendental phenomenology, resilience
With over a million deaths in the United States alone (Centers for Disease Control and Prevention [CDC], n.d.) the novel coronavirus (COVID-19) pandemic created a mental health crisis that includes long-term fear, trauma, grief, isolation, and negative social patterns (Czeisler et al., 2020; Eisma et al., 2021; Elbogen et al., 2021; Prati & Mancini, 2021). The influx of mental health needs meant that practitioners had to meet the demand of providing quality counseling services for those struggling with COVID-19 pandemic–related symptoms. Mental health counselors and related professionals experienced significant increases in caseloads and the clinical severity of presenting symptoms (Czeisler et al., 2020) that added increased pressure to workload, risk of burnout, and compassion fatigue, all of which are natural occupational hazards even under typical circumstances (Litam et al., 2021; Posluns & Gall, 2020; Sprang et al., 2007).
Increases in service demand were especially problematic when considering the vast preexisting shortage of mental health service availability worldwide (Wainberg et al., 2017). For rural mental health counselors, who ordinarily experience increased mental health service shortages (Breen & Drew, 2012; Slama, 2004), these demands and lack of resources were likely more intensely highlighted as lockdowns and shelter-in-place orders further reduced service access while simultaneously increasing the need for it (Panchal et al., 2023; Prati & Mancini, 2021). Mental health professionals were suddenly forced to transition to teletherapy services, a modality not frequently used prior to the COVID-19 pandemic (Burgoyne & Cohn, 2020; Pierce et al., 2021).
Teletherapy completely reshaped the provision of counseling services and required practitioners to consider and navigate various concerns, including accessibility and advocacy issues for vulnerable populations, quality of therapeutic engagement, ethical and legal matters, financial issues, treatment effectiveness, experience limitations, and training limitations (Maurya et al., 2020). This was likely a greater adjustment for rural practitioners, as they were less likely to use this modality than their urban counterparts prior to the COVID-19 pandemic (Pierce et al., 2020). Teletherapy has its disadvantages and advantages. The disadvantages include increased complexity of ethical issues such as privacy, information security, and maintaining a professional environment and professional relationships (Burgoyne & Cohn; Pierce et al., 2021). However, teletherapy provides client accessibility to services, overcoming the most notable barrier of local practitioner shortages experienced more often by rural residents (Tarlow et al., 2020). Through teletherapy, rural residents can connect to counselors in larger populated areas, but internet connectivity to do so has been a challenge historically (Handley et al., 2014).
Rural Mental Health
Practice and clinical topics related to rural populations are relatively sparse in empirical counseling literature, and this is especially true regarding rural mental health counselors during the COVID-19 pandemic. Existing research has established the enhanced hardships faced by rural populations, including more significant mental health presentations caused by mental health stigma (Slama, 2004) and a significant lack of mental health, medical, and transportation resources (Breen & Drew, 2012; Pullen & Oser, 2014; Slama, 2004). For rural counselors, this often means bulging caseloads, professional isolation, and more complicated cases than their urban counterparts.
Although not specific to COVID-19, Fruetel et al. (2022) documented the experiences of school and clinical mental health counselors responding to crises in rural areas. Findings indicated significant hardships such as isolation and lack of crisis stabilization resources. This highlights the fact that rural counselors continue to face significant mental health challenges in the community with limited institutional and professional support, placing further demands on existing providers and thereby increasing the risk of burnout and attrition (Litam et al., 2021; Sprang et al., 2007). To further complicate matters, the COVID-19 pandemic has exacerbated practitioner experiences of vicarious trauma, fatigue, and emotional disconnection as well as feelings of incompetence (Aafjes-van Doorn et al., 2020), which likely has a compounded effect for rural mental health counselors, who face additional geographic and cultural stressors (Breen & Drew, 2012; Pullen & Oser, 2014; Slama, 2004).
Trauma and Resilience
For many counselors involved in trauma and crisis work, occupational hazards such as burnout, compassion fatigue, and vicarious trauma have been documented (Posluns & Gall, 2020; Sprang et al., 2007), but less is known about the complexities of sharing trauma and crisis simultaneously with clients. Bell and Robinson (2013) posited that such experiences evolve into a compounded experience for counselors, in which the interplay between both vicarious and direct trauma—known as shared traumatic reality—enhances the post-traumatic exposure counselors experience. The shared traumatic reality of the COVID-19 pandemic has likely intensified existing occupational hazards of stress, burnout, and compassion fatigue (Litam et al., 2021; Posluns & Gall, 2020; Sprang et al., 2007).
Examining only the negative experiences associated with long-term trauma and crisis work would be unidimensional, inaccurate, and ignoring the potential value in such meaningful work. Additionally, this one-sided position ignores the presence and value of resilience among practicing counselors. Resilience has been represented as the ability to adapt and maintain well-being during unfavorable conditions (Clauss-Ehlers, 2008) and more specifically, taking deliberate actions to sustain health during hardship (Litam et al., 2021). Fostering resilience is imperative for mental health counselors who often face vicarious trauma. Without self-care and the ability to cope positively, these professionals risk burnout and impairment (Posluns & Gall, 2020), the latter of which has strong ethical implications because it poses an emotional risk to clients (Bell & Robinson, 2013).
Lambert and Lawson (2013), who studied counselors providing services during Hurricanes Katrina and Rita, found that counselors treating survivors of those disasters experienced compassion fatigue and burnout at no greater rates than counselors in general. Interestingly, those counselors who were both survivors and treatment providers experienced compassion satisfaction and post-traumatic growth, positive counterparts to compassion fatigue and post-traumatic stress, respectively. Similarly, Litam et al. (2021) found comparable results for counselors during the COVID-19 pandemic. Although occupational hazards such as compassion fatigue, vicarious trauma, and burnout were apparent for counselors in the sample, resiliency was a positive mitigating factor. It is important to note, however, that neither study examined multicultural issues as variables, and Litam et al. noted the absence of rural counselors as a significant limitation of their study.
Although not a study conducted with counselors, Wang et al. (2021) compared coping and adjustment in rural and urban individuals in North America. Despite adverse experiences among both groups, Wang et al. found several strengths in rural populations that were undetected in their urban counterparts, including enhanced coping and adjustment. These findings imply a cultural element to trauma and disaster response. In studies specific to counselors, Crumb et al. (2021) found strengths among rural school counselors providing disaster mental health services that included deepened empathy because of co-experience; Imig (2014) also found that despite difficulties, rural counselors found meaning in difficult work.
At the time of this study, we did not find additional research examining stress, resilience, or other quantitative or qualitative inquiries of rural mental health counselors’ experiences during the COVID-19 pandemic. This paucity of literature necessitates our study, which aims to fill a gap in understanding the interplay of rural mental health constraints and COVID-19 response. Learning how rural mental health counselors manage the complexities of limited mental health and medical resources, increased service demand, and vicarious trauma is imperative to better prepare for future mass disasters while maintaining the health and well-being of practitioners. Additionally, this study provides a much-needed voice for rural counselors and can further advocacy efforts for rural communities.
Method
The purpose of this study was to explore the experiences of rural mental health counselors during the COVID-19 pandemic and to develop a distinct picture of this population during long-term stress and disaster. We utilized a postpositivism paradigm, which allows for the acknowledgement of multiple perspectives while also striving for empirical rigor, to explore the universal experience of rural counselors during the COVID-19 pandemic (Guba & Lincoln, 1994; Hoshmand, 1996). To facilitate this exploration, we utilized a transcendental phenomenological methodology to capture the essence or true meaning of the phenomena of interest, the overall experiences, and the responses of the sample who share elements of an identity under similar conditions (Moustakas, 1994). Although postpositivism and transcendental phenomenology originate from different epistemological assumptions, one that emphasizes a reality that can be approximated through empirical observation and the other focusing on the essence of lived experience through subjective exploration, this study intentionally combined both to balance rigor and depth. Transcendental phenomenology and postpositivism have been found to complement each other through acknowledging multiple perspectives and having a top-down approach to research (Henderson, 2011; Hoshmand, 1996; Moustakas, 1994), and additional studies have utilized this paradigm and methodology (Eryaman et al., 2013; Hall et al., 2016). Nevertheless, to address potential incongruences, we utilized bracketing techniques to mitigate researcher bias and to ensure that the participants’ experiences remained central to the study. In alignment with transcendental phenomenology, we aimed to explore the lived experiences of rural mental health counselors during the COVID-19 pandemic, focusing on the perceived impacts and responses. The research questions guiding this exploration were:
- RQ1: What were the experiences of rural mental health counselors during the COVID-19 pandemic?
- RQ2: What impacts, if any, did COVID-19 have on the lives of rural mental health counselors?
- RQ3: How did rural mental health counselors respond, if at all, to the COVID-19 pandemic?
Site and Sample Selection
The sample criteria included Licensed Professional Counselors of all rankings—Licensed Professional Counselor-Associates (LPC-As), Licensed Professional Counselors (LPCs), and Licensed Professional Counselor-Supervisors (LPC-Ss)—who provided mental health counseling services in rural regions of Texas between March and December 2020. Texas was selected as a matter of convenience sampling (both Brandi M. Sawyer and Edith Gonzalez reside in Texas and are familiar with public license information) and because 76% of the state is considered fully rural. Additionally, Texas, like most other states, experienced government-mandated lockdowns, restricted social gatherings, and shuttered schools for most of 2020 (Friend, 2021; Limón, 2020), indicating that Texans experienced significant adversity from the pandemic. The criteria for rural regions were determined by the fiscal year 2022 definitions set forth by the Federal Office of Rural Health Policy (Health Resources and Services Administration, Federal Office of Rural Health Policy [FORHP], 2025).
Following approval for this study by the IRB, we obtained a list from the FORHP (2025) of counties in Texas with a completely rural status for fiscal year 2022 as an initial guide for sampling. Once the counties were identified, we used the Texas Behavioral Health Executive Council’s online search tool to obtain the names of eligible participants. This information was then used in a Google search to find addresses and emails for potential participants. In sum, we compiled a list of LPCs from 198 of 200 counties. Two counties were eliminated, as Sawyer had worked extensively in these rural counties and the likelihood that she knew potential participants was significantly increased. Email addresses, when available, were the first method of contact for recruiting participants. When not available, paper flyers were mailed to available addresses. Participants who completed the study and the final member-checking procedure received a $50 Amazon gift card. All participant recruitment and data collection took place in August and September of 2022.
Participants
Following recruitment procedures, 12 individuals volunteered to participate in this study, 11 of whom completed individual interviews. Saturation of data, when no new themes emerged during interviews and analysis (Ando et al., 2014), was reached within the 11 participants; no additional participants were needed. Eight participants identified as female, two participants identified as male, and one participant identified as transgender male. Eight participants identified as White and three identified as Hispanic or Latino. Nine of the 11 participants had master’s degrees and two held doctoral-level degrees. Years in counseling practice ranged from 1.5–30. Years in rural counseling practice also ranged from 1.5–30. Working environments varied across the 11 participants and included seven in group and private practice, three in agency and nonprofit settings, and one in an educational setting fulfilling a mental health counseling role. The sample consisted of the following current license categories: nine LPCs, one LPC-A, and one LPC-S.
Data Collection
Exploratory questions were designed to holistically capture the perceived impact of the COVID-19 pandemic, including the related thoughts, emotions, and behavioral responses as they align with the research questions exploring general experience, impact, and response. Participants chose personalized pseudonyms for anonymity and engaged in a 45–60-minute semi-structured, open-ended interview exploring their experiences working during the COVID-19 pandemic. The interview protocol included the following questions:
- What was it like to provide rural mental health counseling during the COVID-19 pandemic?
- How did you respond to the COVID-19 pandemic?
- What feelings do you experience about providing rural counseling during the COVID-19 pandemic?
- How did the COVID-19 pandemic impact your personal life?
- How did the COVID-19 pandemic impact your professional life?
- What was it like providing teletherapy during the COVID-19 pandemic?
- What is it currently like providing teletherapy?
- What is your perception of rural mental health counseling during the COVID-19 pandemic?
- How do you see your rural mental health work in the future following the COVID-19 pandemic?
Interviews were conducted and recorded via Zoom. Transcripts were first generated through a transcription application, Otter, and then verified for accuracy.
Data Analysis Procedures
Following the procedures set forth by Moustakas (1994), we used thematic analysis to evaluate data using two cycles of inductive coding. Engaging in multiple levels of inductive coding allowed us to explore themes within participant experiences while minimizing preconceived biases, a process known as epoche. The steps of coding and analysis first included preliminary horizontalization, which involved reducing narrative data into smaller units but not yet grouping data based on shared meanings. Using a spreadsheet, we achieved this by taking participant transcripts line by line, summarizing them, and placing them into columns. The next step in analysis, phenomenological reduction, involved clustering data relevant to the research questions into categories of corresponding themes and considering these from a variety of perspectives. Clustering data was done first to efficiently manage the data in order to better recognize recurring themes. We evaluated the horizontal data in the spreadsheet and clustered data from textural descriptions in various statements until no new groupings emerged. Ancillary information irrelevant to the research questions was eliminated from further coding. The final coding procedure generated the broadest themes, which were grouped based on shared meaning derived from phenomenological reduction using imaginative variation. We evaluated and interpreted the context of all codes achieved in reduction until the final themes emerged.
Strategies for Establishing Trustworthiness
We took steps to ensure trustworthiness of the findings according to Lincoln and Guba’s (1985) five tenets of trustworthiness: credibility, authenticity, transferability, dependability, and confirmability. Credibility and authenticity were achieved through in vivo and post-interview member checking to ensure accurate understanding or credibility of participant reports and by using two methods, providing ample opportunities for clarification. Another credibility validation tool, prolonged engagement, was achieved by having Sawyer interview, transcribe, check for accuracy, and conduct analysis, resulting in heightened awareness and understanding of the data. Triangulation with Gonzalez, who has different professional and personal identities, aided in furthering the inductive and methodological nature consistent with transcendental phenomenology (Moustakas, 1994).
Transferability was achieved through inductive procedures and obtaining rich details about study findings. Dependability was achieved through a rigorous methodology as outlined in Moustakas’s (1994) framework, which lends itself to examining multiple realities from an objective position. Multiple coding cycles additionally aided in dependability because they reduce abstract and biased findings. These same procedures also helped to achieve confirmability, enhancing objectivity in this qualitative research. We reduced researcher bias in interviewing and analysis through multiple coding cycles with rigorous methodology and triangulation (Lincoln & Guba, 1985).
Reflexivity
Bracketing was used to achieve reflexivity as a means to isolate and understand participant experiences apart from existing presuppositions. Sawyer has a professional identification aligning with that of rural mental health counselors. For 14 years, she has practiced mental health counseling in rural Texas, and since the onset of the COVID-19 pandemic, has provided teletherapy. She is an LPC-S and National Certified Counselor (NCC) who lives in Texas and has roots in rural Texas. Sawyer led all aspects of the research study. Gonzalez served as an external auditor for data analysis and assisted with manuscript writing. She is a counselor educator, researcher, and LPC with extensive experience in qualitative research and previous teaching experience in a rural setting. Based on Sawyer’s positionality, there were some apparent internal assumptions existing prior to the study. We assumed, based on personal and professional experiences, that participants would likely identify some hardships with rural service provision. Based on Sawyer’s work with often resilient rural clients during the last 14 years, we assumed some strengths related to rural populations would likely be identified.
In addition to bracketing, Sawyer reviewed interview questions and reflected on their cognitive reactions to the questions prior to conducting the interviews in an attempt to be aware of and set aside suppositions about the topic. Following each interview, Sawyer again reflected on personal cognitive responses to the topics, making notes as needed, and regularly reflecting on potential biases and enhancing trustworthiness with Gonzalez to counter them. As a result of such reflection, during thematic analysis, we did line-by-line coding to minimize interpretive assumptions, yielding the most objective view of sample experiences possible.
Findings
Thematic analysis rendered two themes as distinctly capturing the rural mental health counselor experience: systemic limitations and counselor growth and resilience. The codes within these themes had a 100% endorsement from the sample.
Systemic Limitations
The theme of systemic limitations was defined by participants as resource limitations within their rural communities, including significant shortages of mental health and medical services as well as services for basic needs such as food, housing, and financial assistance. Furthermore, a large majority of these clients characterized resource limitations as being both preexisting as well as exacerbated by the pandemic. For many participants, COVID-19 conditions greatly impacted their ability to provide face-to-face counseling in already resource-limited communities. Internet connectivity deficits in rural communities, which are already dealing with limited resources, were also included in this theme.
Mental health care prioritization and a lack of mental health care availability for rural clients were among the most prominent topics in participant reports. Participants shared the idea that because basic health care and other needs remained unmet in their communities, mental health care was a lower-ranking priority during the COVID-19 pandemic. One noted that “mental health had to take a second seat because their basic needs were not being met.” Another described that although mental health “maybe needed more,” other responsibilities took priority because the “importance of [mental health] was not there.” Additionally, one participant further addressed not just the need for mental health counseling services but the impact of the loss of services during the COVID-19 pandemic. She emphasized that these impacts were “more keenly” felt in rural areas due to baseline counseling resource limitations. Furthermore, one participant shared this perspective by noting the need for financial support for ongoing focus on parity in rural mental health care. Although this participant acknowledged the attention garnered by the COVID-19 pandemic for rural communities, she worried that the focus was waning too quickly.
In addition to mental health shortages, medical shortages were also prominent with rural clients. One participant, whose caseload was heavily comprised of transgender individuals, compared his experiences between metropolitan and rural areas, emphasizing the rural-specific difficulties for his clients. He went on to describe how the COVID-19 pandemic shutdowns led to a temporary loss of gender-affirming care in his community. He identified this experience as “particularly rough” for his clients who were “dealing with worrying about whether they would ever be able to access their gender-affirming health care or [have] it delayed a long time.” Limitations in resources for basic survival were also impacted during the COVID-19 pandemic, as one participant described the deepened scarcity of financial and housing assistance as well as food bank supplies. He went on to describe his community as “one of the poorest in Texas, where poverty is pronounced,” to emphasize the impact these resource shortages made in rural communities during this time.
In addition to health and other wellness services, internet connectivity deficits greatly impacted the ability for rural counselors to reach and provide services to rural clients. Nearly all participants identified geographical and/or financial barriers in rural communities obtaining internet connectivity necessary for everyday life during the COVID-19 pandemic. For those who could afford internet service, rural geography made consistent connectivity difficult. Some participants had to resort to primarily phone usage early in the COVID-19 pandemic. It was also noted that difficulties in connectivity impacted “already thin” mental health resources in rural communities and that “Wi-Fi is not as fast as it is in metro areas.” Even when some counselors attempted to have face-to-face services, they were met with difficulties in sustainability. In describing the changes to her private counseling practice, one participant described having to shutter her face-to-face business, which never rebounded after the period of shutdown between March and June 2020, and begin providing teletherapy only. This meant that there was one less in-person practice operating in a rural area where mental health resources were already limited.
Counselor Growth and Resilience
The theme of counselor growth and resilience was defined as rural counselors’ abilities to overcome significant adversities related to COVID-19 pandemic conditions in the context of their rural identification. Specifically, growth was defined as the ability to not only manage difficult circumstances but also to experience a change in themselves as an outcome of that experience. Resilience was defined as an ability to rebound or cope quickly in the face of adversity and, in the case of the COVID-19 pandemic, traumatic circumstances. Among the 11 participants, over half detailed a clear alignment between rural-specific deficits, as noted in the theme of systemic limitations, and the need to respond in resilient ways. Two participants, for example, adjusted quickly to phone counseling without face-to-face contact when rural internet connectivity and Wi-Fi availability fell short. Relatedly, another provided face-to-face services throughout the COVID-19 pandemic as the only practitioner in her area who could meet this need.
All participants described significant adverse experiences, up to and including vicarious trauma, but also an ability to cope with or make meaning of the circumstance. Collectively, participants leaned into their challenges, and many described a sense of empowerment in meeting them. For example, one participant, like most other counselors in this study, struggled significantly with the idea of teletherapy service delivery. She had difficulty adjusting treatment for her caseload, which included children coping with trauma and their families. Despite the stress described, she grew to enjoy meeting these new demands. She not only described that she “likes a challenge” but also discussed a process of using cognitive flexibility in providing herself “grace” and coping with the sudden need to learn a new skill set.
Although the ability to pivot typical practice styles during desperate times was a notable element of rural counselor growth and resiliency during the COVID-19 pandemic, so was the ability to alter beliefs and personal philosophies in order to adapt to changing times. Participants described a shift in viewpoints and flexibility to teletherapy as a modality. Although initially and fundamentally opposed to the practice, one participant reflected on the ability of professionals to shift their views. In speaking on the revolution of teletherapy in counseling, she stated that an in-person counseling modality is “not the only practice . . . we have to be flexible . . . we can’t be as old school anymore.” Similarly, another participant, also speaking on behalf of himself and rural mental health counselors, described a positive component of the pandemic: trying new things and learning that they are beneficial. He illustrated this by describing his “work–life balance” since his employers retained remote working allowances initially issued during lockdown and stay-at-home orders.
Participants illustrated cognitive flexibility in response to changes within their working world, but cognitive flexibility only represented part of the growth and resiliency among this sample. As depicted in the theme of systemic limitations, most participants provided services to clients with intensely limited resources, which naturally impacted how they typically provide counseling. In efforts to be therapeutic for his often crisis-affected clients, a participant noted that most of his work in the early months of the COVID-19 pandemic was “just letting people know that however they’re feeling is okay,” and further described, “I am good at remaining calm when the person in front of me is not . . . and appear to have at least a reasonably soothing presence.” Another participant closely mirrored these concepts in her statement that “it was, for me, a lot of just providing this space for people to have whatever feelings they had about it. And for that to be okay.” Additionally, two more participants reflected the change in focusing on immediate needs versus long-term or abstract concepts in counseling. Both described staying abreast of current events to help clients process their concerns.
As mentioned earlier, a majority of the participants noted a direct connection between rural-specific resource deprivation and the need to respond with resilience. Consequently, many participants found themselves becoming an integral part of resource seeking and attainment, which was described as a notable deviation from their typical counseling role. One participant described responding by actively providing help to clients who needed food when there were shortages due to already limited resource closures. She described this process as case management and assumed an active role in ensuring resources were obtained, including “trying to find people that could go pick up groceries and drop off at their porches.” Another similarly reflected that she did “a lot more social work . . . more connecting people with resources and that sort of thing.” She went on to note that as she adjusted her typical role from mental health counseling, the clients felt “cared for” and subsequently experienced a renewed encouragement to keep moving forward with counseling. Another participant additionally noted that gender-affirming care was already “quite difficult to find” in his rural community but became even more difficult to access due to the COVID-19 pandemic. In response, he sought out “updates through newsletters and Facebook connections with professionals” to ensure clients that the medical community was working to resolve the deficit. Collectively, these participant reports indicated that this sample of rural mental health counselors possessed the ability to shift their work and adapt to rapidly changing circumstances during the COVID-19 pandemic.
Discussion
The study explored the experiences of rural mental health counselors during the COVID-19 pandemic, revealing that participants experienced both preexisting and exacerbated systematic limitations in addition to growth and resilience during the early and more impactful phases. Systemic limitations identified by participants spanned the spectrum of human needs from food, financial, medical, transportation, and housing resources to a near absence of mental health services in their respective rural communities. Unique to rural counseling, the mass implementation of teletherapy was met with limitations involving lack of connectivity and financial means to remain online. For many participants, connectivity concerns have persisted. Unfortunately, the dearth of services for basic needs also meant an increase in the need for mental health services to cope with those hardships.
The descriptions of rural resource and funding deprivation extend and support the findings of the rural counselor hardships from other qualitative studies (Breen & Drew, 2012; Imig, 2014). The findings from this study show that despite nearly a decade, systemic changes that would otherwise bolster the quality of life or resource availability in rural communities have not been actualized. Naturally, this has created enhanced stressors for this sample of rural mental health counselors who perceived these otherwise typical limitations in their work as being grossly exacerbated during the COVID-19 pandemic.
The findings related to growth and resiliency in this study align with previous findings on counselors’ work in mass disasters (Lambert & Lawson, 2013). Most recently, Litam et al. (2021) found that counselor resiliency was associated with post-traumatic growth and compassion satisfaction, states that are in contrast with post-traumatic stress and compassion fatigue, which cause burnout. We suggest that finding one’s purpose is critical for growth, which aligns with the descriptions provided by this sample of participants. Much like the rural counselors in this study, Posluns and Gall (2020) found that maintaining awareness, finding balance, and having a flexible coping style were key to overcoming hardship. Additionally, Pow and Cashwell (2017) found that emotion-focused coping skills such as mindfulness and emotional regulation techniques were effective at mitigating the traumagenic effects of disaster work among a sample of disaster mental health counselors. The findings, combined with those on resilience practices in the current study, strongly support counselors and clients emphasizing a greater role in resilience and positive coping during disasters.
Participants also described resilience in the form of strong personal and professional support from family, friends, and colleagues, which validated findings that both personal and professional support were important for coping with adverse conditions and experiences during the COVID-19 pandemic (Aafjes-van Doorn et al., 2020). This finding is interesting in light of prior research showing that rural counselors experience isolation (Breen & Drew, 2012; Imig, 2014). They are, however, consistent with the findings of Wang et al. (2021), which showed that social connections helped rural individuals cope better than their urban counterparts during COVID-19, and Crumb et al. (2021), which indicated that social connection and rural community collaboration are helpful in coping after disaster.
Though not a theme that is uniquely tied to the rurality of the mental health counselor sample, it was evident that participants experienced intense levels of negative affect vicariously with their clients, especially during the earlier and more impactful parts of the COVID-19 pandemic. Such experiences included anxiety, uncertainty, depression, trauma, and helplessness. Findings from this study included echoes of prior research related to broader populations (Czeisler et al., 2020; Eisma et al., 2021; Elbogen et al., 2021; Prati & Mancini, 2021). In our study, these vicarious experiences intensified the natural occupational hazards (Lambert & Lawson, 2013; Litam et al., 2021) associated with professional health counseling practice and created a shared traumatic reality caused by mass disaster (Bell & Robinson, 2013). Additionally, uniquely rural hardships such as immense systemic limitations no doubt exacerbated these pandemic-related stressors as described by nearly all participants. This in turn necessitated the growth and resilience demonstrated by most of this sample in their descriptions of responding in creative and resilient ways.
Implications
Exploring the experiences of rural counselors during the COVID-19 pandemic reveals important training, clinical, and advocacy implications to consider. The findings emphasize the need for rural mental health counselors to adopt a more comprehensive approach that extends beyond traditional counseling roles. To effectively respond to sudden mass disasters or crises, like the COVID-19 pandemic, counselors must develop enhanced skills in case management, crisis intervention, referral coordination, and social service networking. Given the compounded challenges in rural settings, cultural competency training is vital for addressing the unique needs of these populations.
Mental health counselors should proactively familiarize themselves with available community resources and remain adaptable to extending services beyond conventional counseling modalities during crises. Counselors may consider expanding their training by attending workshops on advocacy and referral strategies and being more involved in networking with non-counseling resources within their clients’ communities. For those providing teletherapy services across their state or in several states, there are a few issues to consider. In addition to consulting and abiding by state laws related to interstate practice, mental health counselors should consider the location of their remote clients and at least generally link them to resources in their own communities.
Although teletherapy has proven beneficial, relying solely on virtual services is not a comprehensive solution for rural communities that lack consistent broadband access. Federal funding for increasing rural internet connectivity has been explored, as the National Telecommunication and Information Administration (n.d.) has allocated over a quarter of a million dollars to aid in increasing broadband accessibility in rural areas. However, until broadband for all is an established reality, continued advocacy is necessary to ensure rural connectivity remains a national priority.
Rural mental health counselors can further support rural clients by promoting culturally relevant resilience practices that emphasize mindfulness and emotional regulation (Pow & Cashwell, 2017) as well as self-awareness, balance, and cognitive flexibility (Posluns & Gall, 2020). For rural clients, aiding in establishing social support may better foster resilience development. Counselors can help rural clients explore, develop, and strengthen their involvement across multiple systems, including family, church, school, and the broader community to increase their capacity to cope with adversity. Further, counselors can help rural clients identify and leverage existing community strengths to mitigate the impact of resource limitations.
Advocacy and leadership are needed for promoting systemic change to drive policy and clinical practice shifts in the counseling profession (Lee & Rodgers, 2009). Advocacy efforts should prioritize systemic changes at local, state, and national levels that target funding allocations, service accessibility, and infrastructure development in rural areas. Addressing chronic resource limitations in rural areas involves advocating for increased mental health and medical funding, expanding access to basic needs, and sustaining broadband infrastructure initiatives. Prioritizing mental health care includes boosting resources, reducing stigma, and ensuring that mental health services are affordable and accessible. In these efforts, counselors can collaborate with community leaders, social service agencies, and advocacy organizations to elevate rural mental health priorities within broader policy discussions.
Finally, rural mental health counselors should recognize and enhance personal cultural strengths to overcome natural occupational hazards associated with counseling work as well as the enhanced challenges that coincide with rural practice. To maintain their own well-being amid ongoing crises, rural counselors should also engage in professional development that fosters their resilience. Implementing peer support programs, attending networking events, and participating in supervision groups can provide essential emotional support and guidance. Additionally, involvement in local, regional, and state counseling associations can further reinforce counselors’ sense of connection and reduce the isolation often associated with rural practice. This comprehensive approach will empower rural mental health counselors to better navigate the challenges they face and enhance their ability to support their clients.
Limitations and Future Research
Despite providing rich phenomenological data to understand the experiences of this sample during the COVID-19 pandemic and contributing to a relative paucity of research on this population, this study was not without limitations. Defining rurality is complex with no single definition capturing the multifaceted nature of such a culturally intricate group (Imig, 2014), and our study is no exception. For the purpose of generating accurate findings, a categorical and geographically based definition was selected. While the FORHP’s (2025) fiscal year 2022 classifications were used and represented an enhanced and more accurate definition of rural areas compared to previous definitions, it neglected to consider the descriptive or cultural aspects of rurality. Defining COVID-19 and its parameters was also a limitation. Participants, much like society, have navigated the uncertain, mutating, and episodic nature of viral outbreaks; therefore, it is difficult to define as either a historical or current event 4 years later. At the time of the study, however, participants largely viewed the most impactful degree of the COVID-19 pandemic as having occurred in earlier phases, which is helpful in ameliorating this limitation. Conversely, the length of time between the identified impactful phases in 2020 and interview time in 2022 is an additional limitation. With the passing of nearly 2 years, retrospective reflections may impact the accuracy of participants’ accounts of their experiences.
This study brings about several recommendations for future research. Future studies should continue to explore counselor experiences during mass and prolonged disasters. Despite being several years removed from the devastation of the COVID-19 pandemic, lessons of preparation and adaptability linger. In the last year, the United States has experienced Hurricane Helene in North Carolina and the Los Angeles wildfires, among hundreds of other disaster declarations (Federal Emergency Management Agency, n.d.). It is important to understand how counselors can care for their clients and themselves while navigating shared traumatic realities. Learning ways to foster resilience and post-traumatic growth is necessary to prevent counselor burnout and, ultimately, improve client care. For rural research specifically, replications of this study and related inquiries should continue to seek the most robust definition of culture; developing mixed methods approaches to capturing rurality would most likely overcome some limitations present herein. Rural cultural resilience should be a continued exploration, as much research has highlighted primarily barriers and challenges with less emphasis on resilience (Fruetel et al., 2022; Imig, 2014; Pullen & Oser, 2014; Slama, 2004; Sprang et al., 2007). Lastly, comparative analyses should be done in the future to further determine the uniqueness of rural counselor growth and resilience, as identified as a theme in this study.
Conclusion
The COVID-19 pandemic intensified mental health challenges in the United States, further straining an already overburdened health care system. Rural communities, which already experience fundamental disparities in resources and mental health care, were no exception. This study revealed both the struggles and resilience of rural mental health counselors in navigating the impacts of the COVID-19 pandemic in their communities. Identifying both exacerbated resource limitations and the need to cope and adapt with creativity and strength provides lessons for all counselors in the face of inevitable mass disasters. The findings underscore the importance of self-care, resilience-building, and leveraging community support during crises. Counselors should be well-versed in local resources and adopt broader roles. Given persistent disparities in rural health care access, ongoing advocacy remains essential.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Brandi M. Sawyer, PhD, NCC, LPC-S, is an assistant professor at Bellevue University. Edith Gonzalez, PhD, NCC, LPC, is an associate professor at the Hazelden Betty Ford Graduate School. Correspondence may be addressed to Brandi M. Sawyer, 1000 Galvin Rd. S., Bellevue, NE 68005, bsawyer@bellevue.edu.
Aug 26, 2025 | Volume 15 - Issue 3
Andie Chilson, Melissa Mecadon-Mann, Rebecca Gwira, Loidaly G. Rosario-Singer
This scoping review examines 12 years of research on body image ideals and eating disorder (ED) pathology in Black American women. The authors synthesized the aims, methods, and results of 10 studies to outline the specific body image ideals within this population and the relationships between these ideals and ED risk. The findings from this review provide important insights to inform counseling and integrated care approaches for working with Black American women struggling with body image and disordered eating. This study highlights the existing evidence on body image and EDs in this understudied population and points to critical directions for future investigation.
Keywords: body image ideals, eating disorders, Black American, women, counseling
Body image as it relates to disordered eating has been a widely researched topic within the medical and psychology fields (Blostein et al., 2017; Brandsma et al., 2019; Jung & Forbes, 2012; Malachowski & Myers, 2013; Mölbert et al., 2018; Reslan & Saules, 2013). Researchers have explored racial and cultural differences in disordered eating pathology and identified specific body image ideals among racial and ethnic communities (Aldalur & Schooler, 2019; Capodilupo & Kim, 2014; Goel et al., 2021). Disordered eating research has primarily focused on Western European, White body image ideals. Therefore, a scoping review was warranted to achieve a comprehensive view of this underexamined topic. According to Arksey and O’Malley (2005), there are four commonly cited reasons to warrant a scoping review: to examine the extent and nature of existing research on a topic; to discern whether a full systematic review is necessary; to summarize and disseminate key findings; and to identify gaps in the existing literature. We have observed a dearth of research on the intersection of body image ideals and eating disorders (EDs) in Black American women and, therefore, endeavored to summarize and disseminate key findings and identify gaps in the existing literature.
Research is limited on the most effective modalities to treat disordered eating in minoritized populations. Cognitive behavioral and dialectical behavioral therapy are among the most popular counseling treatments for disordered eating in clients who are striving for a thin body ideal (Federici et al., 2012; Fursland et al., 2012). However, the body image ideals for Black and African American women differ from their White, Asian, Latine, and Native American peers (Smith et al., 2020; Talleyrand, 2012). Therefore, counseling modalities centered around the thin ideal are not the best fit for Black and African American clients who present with EDs. For example, Labarta and Bendit (2024) suggested a relational–cultural approach to ED treatment that provides space for the decolonization of traditional treatment models. As such, this scoping review was driven by the following research question: What are the most common body image ideals (as they relate to body weight/shape) for Black women living in the United States and how does this impact their risk for/presentation of disordered eating?
Body Image Ideals in Black Women Living in the United States
Studies have shown that Black women may feel less pressure to be thin than their White peers (Awad et al., 2020). Historically, the Black community has seen larger bodies as resilient, healthy, and a symbol of wealth. Awad et al. (2015) identified a thick/toned/curvy body shape as optimal for Black women. Some Black women exercise not to lose weight but to achieve a large backside and a small waist. However, when in a majority White community, the pressure to conform to the thin ideal is still present (Awad et al., 2015). In these instances, diet (or not eating at all) and exercise are emphasized.
The ideal body shape for Black American women also includes acceptance of a larger body size, or what some call the curvy ideal (Boutté et al., 2022; Cotter et al., 2015; Gitau et al., 2014; Hunter et al., 2017; Parker et al., 2022; Scott, 2019). The curvy ideal, sometimes described as a Coke-bottle figure (Hunter et al., 2017), consists of a large bust, a small waist, and a large backside. It has been stated that because Black women have wider acceptance of a larger body size or the curvy ideal, they experience body dissatisfaction less than their White peers (Boutté et al., 2022). It is important to note that the curvy ideal is not necessarily more attainable or healthy than the thin ideal (Scott, 2019). The curvy ideal is also related to body dissatisfaction and can be associated with body monitoring or body checking (Shafran et al., 2003). Body checking, or continual monitoring of weight, waist size, and body measurements, can be a risk factor for developing bulimia nervosa (BN) and anorexia nervosa (AN; Shafran et al., 2003).
Eating Disorder Prevalence and Risk/Protective Factors in Black American Women
The scope of the existing research on ED pathology in Black and African American individuals is extremely limited. The most recent comprehensive study examining the prevalence of EDs in Black Americans was conducted in 2007. The study found that binge eating disorder (BED) was the most common ED among Black adults, comprising 2.24% of participants, and AN was the least common, with 0.17% of adults meeting diagnostic criteria (Taylor et al., 2007). Although this study is extremely useful in providing a point of reference for the prevalence of eating pathology in Black Americans, updated research on the topic is needed.
According to Cotter et al. (2015) and Hunter et al. (2017), Black women have similar rates of disordered eating to their White peers. Many Black women feel an expectation to be thin and/or fit into a specific body ideal; however, there is a lack of research specific to Black women and ED pathology. Additionally, the research that does exist is highly focused on body mass index (BMI) and obesity rates, which have been proven to be poor indices of physical health (Rasmussen, 2019) and fail to address the underlying cause(s) and risk factors of disordered eating in Black communities (Hunter et al., 2017). Black women are often categorized as overweight and/or diagnosed as obese while EDs are likely undiagnosed or underdiagnosed in this demographic (Boutté et al., 2022).
Racial identity development can act as a protective factor against disordered eating (Capodilupo & Kim, 2014; Rakhkovskaya & Warren, 2014). Capodilupo and Kim (2014) found that identification with the majority culture leads to higher levels of disordered eating, while Black women who identify with Black culture have lower levels of body dissatisfaction. As one works through racial identity development, they tend to identify more with cultural norms and push away from the body ideals of White culture and influence. The Black community emphasizes beauty ideals beyond size and shape (attitude, self-confidence, hair; Rakhokovskaya & Warren, 2014). Therefore, rejecting White beauty ideals through racial identity development may protect some women from disordered eating behaviors.
Present Investigation
This scoping review was inspired by a review published by Harris (2015), which explored three different strata of research on EDs in Black American women from 1980–2015. The first stratum of research discusses the clinical implications of the exclusion of Black women from ED research in the 1980s. Harris demonstrated that as ED presentations in Black women became increasingly recognized, the rate of treatment for Black women with EDs similarly increased. However, ED research and treatment at this time still largely centered around economically advantaged White women and the Eurocentric beauty ideals with which they aligned (Harris, 2015).
The second stratum of research highlighted by Harris (2015) emphasizes an expanded definition of body image to include affective, psychological, and behavioral facets, thus creating a more nuanced and inclusive dialogue around the implications of body image concerns for Black women. This expanded definition of body image also opened up the conversation for cultural variables related to body image that could be precursors to EDs in Black women (Harris, 2015).
The third and final stratum of research examined by Harris (2015) saw an increase of within-group studies of Black American women compared to the between-group studies with White and Black women that dominated ED literature up to that point. This stratum of research also identified strong ethnic identity as a protective factor against EDs in Black women, and low ethnic identity as a risk factor for BED and BN symptomatology (Harris, 2015). In the conclusion of the paper, Harris called for further investigation into risk factors associated with eating pathology in Black American women.
The goal of the present investigation, therefore, is to bridge the gap between the findings of the Harris (2015) study and the existing body of research. We endeavored to accomplish this in three ways: first, identify the most common body image ideals for Black women living in the United States; second, identify what relationship (if any) exists between body image and disordered eating in Black women living in the United States; and third, identify implications for counselors based on the research findings of the first two objectives. The language “Black” and “African American” was utilized to capture as many ethnic identities as possible, including those that did not originate in the United States. When articles specified ethnic identities in their demographics, we indicated as such.
Methods
Author Positionality
There were four authors for the present investigation. It is critical to acknowledge that the first and second authors, Andie Chilson and Melissa Mecadon-Mann, are White women who have learned, only as outsiders, about the intersecting experiences of body image challenges and eating disorders in Black American women. Chilson has benefited both directly and indirectly from systemic racism, particularly as it pertains to adherence to Eurocentric beauty ideals and the inherent protection provided in identity. She has extensive experience working with eating disorders and body image challenges in women from diverse racial backgrounds. The second author, Mecadon-Mann, identifies as a cisgender White American woman in a large body. She has experience working with adolescents and emerging adults with diverse ethnic backgrounds and varied body image ideals and disordered eating behaviors. The third author, Rebecca Gwira, identifies as a first-generation, cisgender, Black woman in a mid-sized to large body. She also has experience working clinically with diverse eating disorder patients across demographic characteristics and levels of care. Her research centers marginalized voices, specifically Black women’s eating and body image concerns and intersectional stress. The fourth author, Loidaly G. Rosario-Singer, identifies as a cisgender Puerto Rican woman; she has benefited from some aspects of Eurocentric body ideals because she has had a small to mid-sized body the majority of her life. She has experience working with multilingual children and families with a focus on health equity and reproductive justice.
Methodology
The following research questions guided this scoping review:
RQ1: What specific body ideals are most commonly endorsed by Black American women, and how do these ideals differ from or align with the thin ideal traditionally emphasized in ED research?
RQ2: What (if any) relationship does the existing literature identify between culturally specific body image ideals and the manifestation of different types of disordered eating behaviors in Black American women?
RQ3: Identify implications for counselors based on the research findings of the first two objectives.
Our systematic search was conducted based on the guidelines put forth by the PRISMA extension for scoping reviews (PRISMA-ScR), a 22-item checklist aimed at helping readers develop a better understanding of the terminology and key concepts reported in scoping reviews (Tricco et al., 2018). The checklist was created by a panel of 24 expert members and two research leads and was informed by the published guidelines of the EQUATOR (Enhancing the QUAlity and Transparency Of Health Research) Network (Tricco et al., 2018). A five-step scoping review process was undertaken, including 1) identifying the research question and objectives; 2) defining the scope of the review; 3) selecting the records; 4) charting the data; and 5) summarizing the results. Inclusion and exclusion criteria were identified a priori and documented in a protocol.
Eligibility Criteria
The eligibility criteria for inclusion were based on population (P)—Black American women; exposure (E)—body image ideals; and outcome (O)—disordered eating. To attempt to capture all relevant literature published after or around the time of Harris (2015), articles published in English between 2013 and 2025 were eligible for inclusion in this review. Sources examining a pediatric population (under 18 years) or research conducted outside of the United States were excluded from the review.
Information Sources
Inclusion and exclusion criteria were established a priori with the assistance of a public health librarian at Western Carolina University. These criteria were used to develop a standard checklist for study eligibility for screening titles/abstracts and subsequently full-text sources. All stages of the screening process were conducted using Covidence, an online software tool used to organize records in the systematic or scoping review process and to blind the results between the researchers. Study selection was conducted independently by Chilson and Mecadon-Mann based on the preestablished checklist. All decisions were automatically recorded via Covidence. Conflicts between the authors were resolved through discussion. Records were identified through searching the following electronic databases: Academic Search Premier, Biological & Agricultural Index Plus (H.W. Wilson), Business Source Premier, Child Development & Adolescent Studies, CINAHL Plus with Full Text, Communication & Mass Media Complete, eBook Collection (EBSCOhost), Education Source, ERIC, Gender Studies Database, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE Complete, Mental Measurements Yearbook with Tests in Print, Military & Government Collection, Philosopher’s Index, APA PsycArticles, APA PsycInfo, APA PsycTests, SocINDEX with Full Text, SPORTDiscus with Full Text, and Ebony Magazine Archive.
Search
To achieve an extensive review on the topic, literature from the past 12 years was included in the search. Because of limitations with access to sources outside of Western Carolina University, reference mining was not conducted as part of the present study. The search strategy was created by a public health librarian at Western Carolina University in collaboration with Chilson. The search strategy was checked for comprehensiveness and errors against the PRESS Peer Review of Electronic Search Strategies Guidelines. The specific search terms utilized were as follows: (Black OR Blacks OR African American*) AND (female* OR woman* OR women* OR lady OR ladies* OR gyn* OR girl*) AND (“eating disorder*” OR “disordered eating” OR anore* OR “binge eating” OR bulimi* OR purging OR purgeing OR “restrictive eating” OR orthore* OR overeat* OR pica) AND (body OR personal) AND (image OR perception OR satisfaction OR dissatisfaction OR psychosocial OR societ*).
Data Charting Process
A data extraction template in Covidence was used to record key characteristics and relevant information from eligible records, including study design, research purpose, study participants, and research findings/results. Chilson and Mecadon-Mann independently charted the data, discussed the results, and regularly updated the data extraction form in Covidence.
Data Items
Chilson and Mecadon-Mann abstracted data on article characteristics (i.e., country of origin, publication date, language), sample characteristics (i.e., race, gender, and age), and constructs/outcomes examined (i.e., body image ideals and EDs). Gwira subsequently vetted all the extracted articles based on the same criteria.
Critical Appraisal of Individual Sources of Evidence
An in-depth examination of the unique body image ideals held by Black women and their influence on the risk for EDs is lacking in the current literature. Therefore, we endeavored to explore the link between specific body image ideals of Black women and their correlation with EDs. We also aimed to identify the most common body image ideals for Black women living in the United States as an independent construct. Individual articles were screened for eligibility using the systematic review management tool, Covidence. Chilson and Mecadon-Mann independently screened the articles against inclusion/exclusion criteria, which were established a priori. We then screened articles at the abstract level for general relevance and subsequently conducted full-text screenings. Articles included in the full-text screening were assessed to determine if sources examined Black American women, specifically; examined body image ideals, specifically, or body image ideals as an independent variable and ED as a dependent variable; and examined an adult sample (18 years or older) from the United States. After reviewing at the full-text level to determine that Black American women, specifically, were examined, Chilson and Mecadon-Mann looked for language such as Black American, African American, Caribbean American, and Haitian American to encompass the full spectrum of Black American women. Also at the full-text level, we screened for clearly identified body image ideals, which required reference to a preferred size/shape of a specific body part (e.g., Coke-bottle waist; Hunter et al., 2017) or preferred shape of the body, generally (e.g., curvy ideal; Scott, 2019). If the intersection of an ED was present, Chilson and Mecadon-Mann screened for either general reference to ED (e.g., “ED pathology”; Siegfried, 2021) or specific reference to an ED diagnosis (e.g., anorexia and bulimia; Hunter et al., 2017). Gwira screened each source separately against the established inclusion/exclusion criteria and charted assessments in an Excel spreadsheet. Gwira and Rosario-Singer reviewed the manuscript for accuracy and offered feedback for Chilson and Mecadon-Mann’s consideration.
Synthesis of Results
The synthesis included quantitative analyses (e.g., means, standard deviation) to summarize the characteristics of included records, body image ideals in Black women, and any ED intersection noted. The results are presented in both a table and a descriptive format that aligns with the review’s objectives of identifying the most common body image ideals for Black women living in the United States and identifying the relationship between body image and disordered eating in Black women living in the United States.
Results
The record identification process is outlined in Figure 1. A total of 501 records were identified through the initial search process. After removing all duplicates (n = 301), the authors were left with 200 records for screening. Next, 107 records were excluded based on criteria such as examination of a pediatric population (under age 18), women outside of the United States, and a lack of focus on Black women. There were 93 records then screened for eligibility, 83 of which were excluded because of patient population, type of publication, and lack of access. This process resulted in 10 records selected for inclusion.
Figure 1
PRISMA Flow Diagram for Scoping Reviews

Note. Adapted from Page et al., 2021.
Characteristics of the Sources of Evidence
Included records examined Black women living in the United States. One study (Bruns & Carter, 2015) also examined White women, and another study (Siegfried, 2021) examined Hispanic/Latina/x women in addition to Black women. Participant ages ranged from 18–73 years and there was no discernible trend in the age selection of the included records. Only one study specifically examined a sample of women 25 years and older (Talleyrand et al., 2016). The majority of records included the age range with mean/standard deviation, except two papers, which only reported the age range and not the mean/standard deviation (Bruns & Carter, 2015; Siegfried, 2021).
Included study designs were qualitative research (n = 4), randomized controlled trial (n = 2), cross-sectional (n = 2), mixed methods (n = 1), and exploratory factor analysis (n = 1). The 10 included records presented data from sample sizes ranging from 11 to 232. Two studies (Awad et al., 2015; Hollier, 2019) were conducted with women enrolled in universities across the United States. One study (Talleyrand et al., 2016) was conducted in the greater Washington metropolitan area. The other seven studies did not specify where they were conducted within the United States.
Four studies utilized focus group questions aimed at identifying common themes pertaining to beauty ideals specific to Black women. Two studies used the Eating Disorders Inventory – 3 (Garner, 2004) to determine specific body image ideals and assess for the presence of ED pathology. Two studies employed the Eating Attitudes Test – 26 (Garner et al., 1982) to measure disordered eating behaviors. Other instruments utilized in the included studies were the Contour Drawing Rating Scale (n = 2; M. A. Thompson & Gray, 1995), The Skin Color Satisfaction Scale (n = 1; Falconer & Neville, 2000), The Reese Figure Rating Scale (n = 2; Patt et al., 2002), the Rosenberg Self-Esteem Scale (n = 2; Rosenberg, 1965), Family Experiences Related to Food Questionnaire (n = 1; Kluck, 2008), Family Food Experiences-Black Questionnaire (n = 1; Hunter et al., 2017), Body Image Disturbance Questionnaire (n = 1; Cash et al., 2004), Visual Analog Scale- Body Satisfaction (n = 1; Heinberg & Thompson, 1995), The Curvy Ideal Silhouette Scale (n = 1; Scott, 2019), Curvy Ideal Questionnaire (n = 1; Scott, 2019), The Sociocultural Attitudes Towards Appearance Questionnaire—3rd Edition (n = 1; J. K. Thompson et al., 2004), The Sociocultural Attitudes Towards Appearance Questionnaire—4th Edition (n = 1; Schaefer et al., 2015), Objectified Body Consciousness Scale (n = 1; McKinley & Hyde, 1996), Body Shape Questionnaire (n = 2; Cooper et al., 1987), Eating Disorder Examination-Questionnaire (n = 1; Fairburn, 2008), and Gormally Binge Eating Scale (n = 1; Gormally et al., 1982).
Table 1
Results of Individual Sources of Evidence
Author(s), Publication Date |
Aim of Study |
Study Participants |
Study Design |
Body Image Ideals |
Eating Disorder Intersection |
Awad et al., 2015 |
Examine the issues that arise pertaining to AA women’s conception of beauty and body image, identify body image themes, and identify the sources of the body image messages received and internalized. |
Female AA students enrolled in a large Southwestern university in the United States between the ages of 19–25 |
Qualitative research |
Thick/toned/curvy as optimal
(n = 33) |
Yes |
Bruns & Carter, 2015 |
Examine how model ethnicity and body shape impact body dissatisfaction. |
Women self-identifying as African American or Caucasian between the ages of 18–45 |
Randomized controlled trial |
Thin ideal and plus-sized ideal |
No |
Capodilupo
& Kim, 2014 |
Explore how race and gender interact and inform body image ideals. |
Women between the ages of 21–35; identified as African American (n = 10), Black American (n = 4), Caribbean American (n = 4), and Haitian American (n = 2); six women did not specify their ethnicity |
Qualitative research |
Large breasts, shapely hips, and full backside |
No |
Hollier, 2019 |
Examine body dissatisfaction and self-esteem factors that contribute to BEDs among Black female students. |
Black college women currently enrolled in a private or public university in the United States between the ages of 18–54. All participants self-identified as “Black,” but 3.2% of the participants identified as “other” and “multi-racial” under this umbrella |
Cross-
sectional |
Thighs, breasts, waist/hip ratio |
Yes |
Hunter et al., 2017 |
Explore family food experiences (FFEs) of AA women and develop a measure of FFEs related to disordered eating. |
Studies 1 & 3: AA women from two National Pan-Hellenic Council sororities at a Southeastern university; Study 4: AA women from across the United States younger than 25 |
Mixed methods |
“Boobs and booties” (Study 1) and “Coke-bottle figure” (Study 3) |
Yes |
Author(s), Publication Date |
Aim of Study |
Study Participants |
Study Design |
Body Image Ideals |
Eating Disorder Intersection |
Javier, 2017 |
Increase understanding of body image and eating behaviors in AA and Asian American women. |
Study 1: AA women between the ages of 18–30 who reported body image problems |
Qualitative research |
Curvy and thin ideals |
Yes |
Scott, 2019 |
Examine the effect of exposing Black women to rap lyrics that promote the curvy ideal on their level of body image dissatisfaction. |
Black women between the ages of 18–34 who had access to audio output (e.g., headphones, speaker); all participants identified as AA, 2.1% also identified as American Indian/Alaska Native, and 4.2% also identified as White |
Randomized controlled trial |
Curvy ideal |
No |
Siegfried, 2021 |
Increase understanding of the ways cultural values and pressure impact the development of EDs in Black and Latinx women in the United States. |
Black, Hispanic/Latina/x, and Afro-Latina/x women between the ages of 18–25 living in the United States; 125 participants (49.2%) identified as Black, 107 (42.1%) identified as Hispanic or Latina/x, and 22 women (8.7%) identified as Afro-Latina/x |
Cross-sectional |
Thin ideal |
Yes |
Talleyrand et al., 2016 |
Explore the phenomena that impact body image ideals, eating behaviors, and appearance in AA women over the age of 25 who report body/weight concerns. |
AA/Black women in the greater Washington metropolitan area; seven women identified as African American, two identified as Black, and two identified as African American/Black. |
Qualitative research |
Thin, sculpted “ripped” arms, and “sistah girl” hips |
No |
Wilfred & Lundgren, 2021 |
Assessing the psychometric properties and validity of a body image assessment
for Black women. |
Women between the ages of 18–73 who identified as African American (73.4%), African (8.5%), Afro-Latina (3.5%), Caribbean (1.5%), Caribbean American (1.5%), other Black descent (3.0%), and multiple racial identities (8.5%) |
Exploratory factor analysis |
“Slim-thick,” thin, and muscular |
Yes |
Main Study Outcomes
The most salient findings of the current study were twofold: first, the identification of specific body ideals held by Black women living in the United States; and second, the identification of a relationship between specific body image ideals and the presence of ED behaviors in Black women living in the United States. The first predominant body image ideal identified was a thick/slim-thick/curvy ideal. The majority of the included records indicated a striving for the curvy ideal (i.e., large breasts, shapely hips, and large backside) as opposed to the more commonly cited thin ideal. Four studies identified specific body parts that were highlighted as part of the curvy ideal. For example, Hunter et al. (2017) discussed “boobs and booties” (p. 29) as two specific body parts on which Black women focused their attention when striving for the curvy ideal.
Although the curvy ideal was the predominant body shape ideal that was identified in the included records, the influence of the thin ideal was also present. Five studies highlighted the influence of the thin ideal on their sample populations, either on its own or in conjunction with the curvy ideal (e.g., Bruns & Carter, 2015). The final body image ideal noted in the included records was the muscular/toned ideal. Both Talleyrand et al. (2016) and Wilfred and Lundgren (2021) identified being visibly fit, toned, or muscular as desirable qualities for Black women. Talleyrand et al. described the desirability of Michelle Obama’s “ripped” arms, stating that she was the ideal combination of curvy and healthy. Wilfred and Lundgren identified a similar muscular internalization, specifically regarding having a toned abdomen as a desirable physical trait for Black women.
The second major finding was that the majority of included records reported a relationship between specific body image ideals and the presence of an ED. More specifically, six out of the 10 included records noted this positive relationship (see Table 1 for specific studies). Hunter et al. (2017) identified an increased risk for AN and BN among Black women in a sorority who idealized being curvy, but only in certain places. Additionally, Awad et al. (2015) described the relationship between experiencing discrimination and the presence of disordered eating behaviors. Both Awad et al. and Javier (2017) found that a disconnect between one’s cultural heritage and the ideals of the White dominant group often led to disordered eating behaviors. If one perceives that they are divergent from the ideals of the dominant group (i.e., the thin ideal), they are likely to engage in potentially harmful disordered eating patterns. Finally, Wilfred and Lundgren (2021) found that the experience of a double consciousness (i.e., the pressure to adhere to two separate cultural ideals) increased ED pathology, specifically BED, among Black women.
Several of the included articles correlated variation in skin tone with positive/negative body image and ED pathology. Wilfred and Lundgren (2021) and Hollier (2019) noted that pressure to meet White body image ideals, including a fair complexion, increase the risk for ED behaviors, BED in particular. Similarly, Awad et al. (2015) determined that women who experienced discrimination stress, dissonance between the dominant culture and their culture of origin, or identification as a devalued group by the majority culture were at an increased risk for ED pathology. Awad et al. (2015) used the example of having a darker complexion to illustrate this, noting that if a woman was darker complected than her peers, and felt devalued because of it, she was more likely to engage in ED behaviors. Capodilupo and Kim (2014) discussed the influence of skin tone in a similar manner, asserting that women who are lighter complected are more likely to be desired by Black men and are more frequently and positively portrayed in the media, decreasing their risk for poor body image and ED behaviors.
The authors also examined moderating factors such as level of education, profession, and socioeconomic status, and found that only one study (Siegfried, 2021) examined the relationship between education and body image/ED pathology and determined that there was no substantial correlation with any of the measures. However, significantly, Siegfried (2021) determined that higher income was highly correlated with lower levels of acculturative stress as well as lower levels of internalization of the thin ideal but noted that there was no predictive factor between income and ED pathology.
Discussion
This scoping review centered around four objectives: first, to identify the most common body image ideals for Black women living in the United States; second, to identify what relationship (if any) exists between body image and disordered eating in Black women living in the United States; third, to bridge the gap between the findings of the Harris (2015) study and the current body of research; and fourth, to identify implications for counselors based on the research findings.
Common Body Image Ideals
Although some Black women in the United States are driven by the thin ideal, many describe a thick, toned, or curvy body shape as ideal. Most of the examined studies identified the thin ideal in combination with the curvy ideal as most desirable among the examined population. For example, Wilfred and Lundgren (2021) identified a “slim-thick” figure, high muscularity, and thinness as the predominant body ideals for Black women. Only one study, Siegfried (2021), identified thinness alone as the predominant body ideal. It is notable, however, that 50% of the included records highlighted thinness as a prominent body ideal for Black women. Although it has previously been assumed (Bruch, 1966) that Black women did not value thinness, the present findings indicate that this is not the case. Although Black women overwhelmingly value thinness in conjunction with the curvy ideal, thinness alone is still emphasized as a desirable quality.
Black American Body Image and Disordered Eating
Black women have lower rates of body dissatisfaction than their White peers but comparable rates of disordered eating. However, Black women have also been associated with disordered eating behaviors that center around culturally specific ideals or factors. For example, Siegfried (2021) described the positive relationship between acculturative stress and the internalization of the thin ideal, which then positively predicts an increased risk for ED pathology. Siegfried further identified a relationship between the internalization of the thin ideal and the development of BN, specifically.
One of the overarching messages regarding the relationship between specific body image ideals and disordered eating in Black American women was that being discrepant from one’s identified cultural ideals was a significant risk factor for disordered eating behaviors (Awad et al., 2015; Hollier, 2019; and Javier, 2017). For example, if an individual strongly identifies with a culture that emphasizes the curvy ideal and they naturally have a curvy figure, they are less likely to engage in disordered eating behaviors to alter their body shape. If an individual with the same curvy figure has a low degree of cultural identity, or identifies more strongly with another culture that emphasizes the thin ideal, they would be at increased risk to engage in disordered eating behaviors. Additionally, women who feel pressured to conform to the body ideals of two cultures are at an increased risk for eating pathology. This experience is referred to as double consciousness (Du Bois, 1903), which in this context means being made to feel like one needs to adhere to the beauty ideals of both mainstream (White European) culture and Black culture.
Gaps in Existing Literature
Although the included records identified general body image ideals that are emphasized by Black American women, there was a dearth in the existing literature surrounding specific ED diagnoses that are linked with certain body image ideals. In the present investigation, only three of the included records identified a specific diagnosis that is linked with certain body image ideals in Black American women. Therefore, future research is warranted surrounding specific ED diagnoses and the associated prevalence rates in this demographic. We also identified that many Black women perceive beauty through a wider lens than simply body shape/size, including elements such as skin tone, hair (length, style, neatness), self-esteem, and attitude. Further investigation into these ideals will deepen the conceptualization of beauty and attractiveness ideals in Black women living in the United States today. Finally, the authors also identified a gap in recent literature examining moderating factors such as level of education and profession that may serve as risk/protective factors for ED behaviors. Further investigation into these factors is warranted to broaden the conceptualization of ED presentations in Black women.
Additionally, there is a gap in the current research surrounding disordered eating and body image ideals in Black LGBTQ+ women, specifically. The studies included in the present investigation either excluded discussion of sexuality entirely or conceptualized it in relation to the male gaze. Therefore, further research into the relationship between sexuality and body image ideals/disordered eating in Black American women is warranted. Another identified gap in the existing literature centers around the influence of the Black/White male gaze on Black women’s self-identified body ideals. More specifically, research is warranted surrounding whether there are different body image ideals for Black women who identify more closely with the body shape/size preferences of Black men compared to White men, and any eating pathology associated with these ideals.
Implications for Counseling and Integrated Care
Traditionally, there has been a limited focus on Black women and ED behaviors outside of the thin ideal. Counselors and care providers must be aware of the culturally embedded protective factors (e.g., racial identity development) that can support healthy eating patterns as well as potential risk factors. It is common for Black women to have higher body weight and BMI, but this does not mean they are immune from disordered eating. It is important to explore how stress and trauma may affect restriction and eating patterns (Small & Fuller, 2021). Boutté et al. (2022) suggested that care providers utilize strengths-based interventions that are holistic rather than interventions focused solely on diet and exercise. It is important, also, to assess for disordered eating before making recommendations to lose weight or form a weight loss plan. Counselors and other helping professionals should consider the implications of skin tone when supporting Black women. As previously noted, darker complected women who exist in a dominant White culture may be at a higher risk for poor body image and ED behaviors (Awad et al., 2015; Capodilupo and Kim, 2014; and Wilfred and Lundgren, 2021). The influence of White, Eurocentric beauty standards on Black women of varying skin tones should be accounted for when conceptualizing treatment plans.
Labarta and Bendit (2024) suggested the use of an integrated relational–cultural approach to ED treatment. Relational–cultural theory (RCT) is rooted in feminist and multicultural theory with a central goal of connection, mutuality, and relationship (Jordan, 2017). RCT approaches to ED treatment allow the care provider and client to work in mutuality, break down power differentials, and repair relationships with food and the body. This framework provides space for discussion and healing focused on racial and social marginalization and how it affects body dissatisfaction, thus building self-image and resilience and empowering clients to live authentically. Further, Labarta and Bendit suggested a self-compassion approach to help clients build knowledge and skills about self-compassion, common humanity, and mindfulness. These factors are helpful in building resilience and can serve as protective factors for people from marginalized communities.
Lastly, care practitioners should be trained in holistic approaches and cultural humility (Matthews et al., 2021). One way practitioners can do this is through expanding care services into the communities where marginalized people live and work. For example, community outreach partnerships can be made with organizations that promote Black female health and wellness. Additionally, practitioners should read literature and attend professional development presented by Black women. One suggested book is Treating Black Women with Eating Disorders (Small & Fuller, 2021).
Strengths and Limitations
This review outlines research spanning a 12-year timeframe, providing a bridge to the anchor article written by Harris (2015). Because of reasons outside of our control, there were a handful of articles that were inaccessible. Furthermore, because of these constraints, we did not conduct reference mining as part of the search strategy. These articles may have added to the findings of the present study. We utilized Covidence software to review articles and lessen the chance of reviewer bias. After consensus was reached between Chilson and Mecadon-Mann, Gwira and Rosario-Singer provided insight into the articles and cultural implications of the research. However, bias is still a possibility in identifying terms and phrases that allude to body image satisfaction or dissatisfaction. An additional limitation is that this review only examined cisgender women. Research examining body image ideals and eating disorder prevalence in individuals outside of the gender binary is needed. The most substantial limitation is the dearth of research specifically focused on body image and EDs in Black women. Therefore, the authors identified a need for ED research and practice publications specifically focused on treating Black women in the United States.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Andie Chilson, MS, LGPC, is a psychotherapist at Greenhouse Psychotherapy. Melissa Mecadon-Mann, PhD, NCC, LPC, LSC, is an assistant professor at Western Carolina University. Rebecca Gwira, PhD, is a clinical postdoctoral fellow at the University of North Carolina at Chapel Hill School of Medicine. Loidaly G. Rosario-Singer, PhD, NCC, LCMHC-A, is Founder and Mental Health Consultant of De Colores Family Wellness. Correspondence may be addressed to Andie Chilson, 1519 Connecticut Ave NW, Washington, DC 20036, andie@greenhousepsych.com.