Aug 26, 2025 | Volume 15 - Issue 3
Kathleen L. Grant, Alyson Pompeo-Fargnoli, Melissa A. Alvaré
The climate crisis is having a significant impact on development and wellness. Young adults face challenges that no earlier generation has experienced, impacting their path toward wellness and thriving. This hermeneutic phenomenological study endeavored to illuminate the experiences of a group of environmentally aware young adults through semi-structured interviews. Thematic analysis, analyzed through Arnett’s theory of emerging adulthood, illustrated participants’ experiences of fear for the future, anxiety, and loss; limited coping strategies for dealing with climate-related emotions; and a perceived tension between their desire to make life choices aligned with their environmental values and a financially stable career. Recommendations for counselors to best serve this population included increasing counselors’ mental health literacy, developing specific strategies to support resilience, and exploring counselors’ ethical responsibilities as advocates.
Keywords: climate crisis, young adults, phenomenological, environmental values, resilience
The climate crisis is expected to have a profound impact on human life in the 21st century (Wuebbles et al., 2017). Evidence of the changing environment is evident everywhere, including historic storms, catastrophic wildfires, record-breaking heatwaves, and severe droughts (Intergovernmental Panel on Climate Change [IPCC], 2023). Americans increasingly believe that the climate crisis is impacting their mental health, with 57.9% of 16–25-year-olds very or extremely worried about climate change, and 38.3% indicating that feelings about climate change negatively impact their daily life (Lewandowski et al., 2024). The consequences of the climate crisis are predicted to continue profoundly impacting mental health (Clayton et al., 2021; Hickman et al., 2021; Sturm et al., 2020).
Definition of the Climate Crisis
The climate crisis poses a significant threat to the future of human civilization. Each day, millions of tons of man-made greenhouse gases, including carbon dioxide (CO2) and methane, are released into the atmosphere (Wuebbles et al., 2017). Burning fossil fuels, such as oil and natural gas, to fuel modern lifestyles is one of the most significant sources of pollution that contributes to global warming (IPCC, 2023). As greenhouse gas emissions rise, global temperatures exhibit a corresponding increase, leading to sea level rise, heat waves, floods, droughts, and severe storms (IPCC, 2023). In 2014, the United States Department of Defense reported that climate change “will likely lead to food and water shortages, pandemic disease, disputes over refugees and resources, and destruction by natural disasters in regions across the globe” (Banusiewicz, 2014, para. 3). By 2050, anywhere from 200 million to 1 billion people will be displaced from their homes, communities, and possibly countries because of climate-related events such as extreme heat, flooding, and famine (IPCC, 2023). For over three decades, the scientific community has warned of the grave danger of global warming and climate change (Borenstein, 2022). Despite the dire warnings, global greenhouse gas emissions continue to increase (World Meteorological Organization, 2020). Young adults are inheriting a world full of unprecedented and complex challenges (Hickman et al., 2021).
Impact of the Climate Crisis on Young Adults
A growing body of literature is documenting the impact of the climate crisis on mental health and wellness, particularly among young people and young adults (Clayton et al., 2021; Hart et al., 2014; Hickman et al., 2021; Sturm et al., 2020). Youth, as defined by the United Nations, encompasses individuals aged 15–24, although this definition may vary (United Nations, 2025). This age range also consists of those emerging adults in the unique developmental period of transitioning from adolescence to adulthood (Arnett, 2000). According to a large study (N = 10,000) published in The Lancet, 77% of young people (aged 16–25) surveyed reported that they think the future is frightening, and 45% indicated that their feelings about climate change had a negative impact on their daily lives (Hickman et al., 2021). Research illuminates how experiencing the direct impact of climate change, such as exposure to wildfires, floods, and displacement, can lead to acute anxiety-related responses and chronic and severe mental health disorders (Clayton et al., 2021; Watts et al., 2015).
Climate change and related disasters can cause direct anxiety-related responses and chronic and severe mental health disorders (Pihkala, 2020). A 2018 meta-analysis found an increased incidence of psychiatric disorders and psychological distress in populations exposed to environmental disaster (Beaglehole et al., 2018). Flooding and prolonged droughts have been associated with elevated anxiety levels, depression, and post-traumatic stress disorders (Hickman et al., 2021). Even among members of the population who have not been directly exposed to the impacts of climate change, such as environmental-related disasters, a simple awareness of the problem may evoke feelings of anger, powerlessness, fear, and exhaustion (Moser, 2007).
Emerging research has highlighted the mental health impact of the indirect effects of the climate crisis, such as climate anxiety (Clayton et al., 2021; Hickman et al., 2021; IPCC 2023). Climate anxiety is a response to the current and future threats of a warming planet (Clayton et al., 2021; Hickman et al., 2021). The associated feelings can include grief, fear, anger, worry, guilt, shame, and despair (Clayton et al., 2021; Doherty & Clayton, 2011). It is essential to acknowledge that scholars recognize anxiety as a natural condition of living and acknowledge its potential benefits, as it can motivate individuals to take action and effect change (Hickman et al., 2021). Climate anxiety, although it can be a complex and intense experience, can also be viewed as a congruent response to the dangers and challenges that global citizens will face now and in the future (Hickman et al., 2021).
Young people with marginalized identities will face the most devastating impacts of climate change (Watts et al., 2015). Low-income and Black, Indigenous, and other communities of color are often the most vulnerable to the worst impacts of climate change, such as flooding, drought, fire, and extreme heat (IPCC, 2023). Furthermore, because of intersectional marginalization, some individuals will be at even greater risk for severe impacts and negative mental health consequences (Hayes et al., 2018). Marginalized communities may lack access to mental health resources after traumatic weather-related events or to process the ongoing challenges associated with climate change (Hilert, 2021). The cultural stigma that reduces help-seeking behavior and lack of access to mental health services may also lead marginalized groups to suffer more from poor mental health outcomes (Priebe et al., 2012).
Research indicates that young people are particularly vulnerable to the adverse effects of climate change, largely because of their ongoing physical and mental development, their dependency on adults, and their likelihood of repeated exposure to climate-related events over time (Hart et al., 2014). However, there is a need for more research on the impact of climate change on mental health, especially as it impacts young people (Hickman et al., 2021). The counseling literature has a paucity of studies in this area (Hilert, 2021; Mongonia, 2022). As the impacts of the climate crisis continue to grow more severe, the profession must deepen its understanding of the climate crisis’s effects on young adults and explore paths toward resilience and wellness (Hickman et al., 2021).
Climate-Aware Counselors
There is a growing need for counselors who are aware of and trained in the mental health impacts of the climate crisis, including climate anxiety (Hilert, 2021). This form of counselor competency includes identifying clients who are experiencing climate-based distress and anxiety (Mongonia, 2022). Although climate anxiety has yet to receive a formal classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM), it is well accepted by counselors as a fear of impending environmental collapse that elicits strong and sometimes debilitating anxiety (Thomas & Benoit, 2022). Counselors must be able to assess and understand how to treat those who present with clinically significant levels of climate anxiety that interfere with functioning and developmental tasks (Pihkala, 2020). Treatment modalities often include teaching resilience and coping skills and increasing support systems (Baudon & Jachens, 2021). Counselors are called upon to support not only their clients through their environmental action but also to take action themselves (Thomas & Benoit, 2022).
Environmental Action
One intervention that can promote positive mental health outcomes for young adults concerned about the climate crisis is climate activism or sustained efforts to effect positive change (Gislason et al., 2021). Young people have been at the forefront of creating new U.S. climate policy (see Sunrise Movement; Bauck, 2022) and driving action (Rashid, 2023). Climate action can positively bring about necessary social change and provide mental health benefits (Hart et al., 2014). Research suggests that young people engaged in climate action experience several benefits, including increased resilience, agency, a sense of purpose, and community, all of which support positive mental health outcomes (Gislason et al., 2021). However, focusing on the climate crisis can also expose individuals to difficult feelings, such as fear, sadness, loss, and hopelessness (Hickman et al., 2021). It is common for people to employ defense mechanisms, such as denial and minimization, to maintain more positive feelings and a more optimistic view of the future in response to the realities of a changing world (Doherty & Clayton, 2011).
Environmentally Aware Young People
Environmental awareness can be broadly characterized as a level of consciousness concerning the importance of the natural environment and the impact of humans’ behavior on it (Ham et al., 2016). Environmental awareness often leads to a deeper understanding of the severity of climate change and the urgency to address it (Orunbode et al., 2019). Youth awareness of the climate crisis is associated with a range of emotional and mental health impacts, such as climate anxiety and feelings of grief, loss, anger, guilt, and existential dread (Hickman et al., 2021). However, environmental awareness can also lead to increased action, a sense of purpose, and resilience building (Clayton et al., 2021).
In the 2024 American Climate Perspectives Survey, Americans aged 18–24 reported the highest levels of environmental concern among all age groups (over 80%; Speiser & Ishaq, 2024). Concern over the environment drives some young adults to action, but not all. Scholars suggest that to prevent the most severe consequences of climate change, humans must take action and alter their ways of life (IPCC, 2023; Wuebbles et al., 2017). Environmental awareness and action will be increasingly important as the impact of the climate crisis grows more pervasive and severe (IPCC, 2023). Young adults, in particular, may need to take steps to adapt to the rapidly changing planet. This study involves young people who are aware of the climate crisis, are motivated to act, and have taken a step toward creating change.
Aims of Study
This study focuses on the experiences of U.S.-based environmentally aware young adults who are moved to take action, aiming to understand their lived experiences as they transition from adolescence into adulthood. This is a significant period in life, as many young people are culminating their educational experiences and choosing who they want to be as adults, both personally and professionally (Arnett, 2014). The research questions guiding this study are: What are the lived experiences of environmentally aware young people as they transition to adulthood? How have their experiences impacted their mental health and understanding of themselves and their roles? How are their environmental experiences influencing their actions and aspirations for their futures (e.g., familial and career goals)?
Method
Hermeneutic phenomenology is a constructivist approach that scrutinizes individuals’ subjective experiences and their interpretations of those experiences, asking “what is the nature of this experience from the individual’s perspective?” (Moustakas, 1994; Ramsook, 2018). The study focused on interpreting the meaning of the lived experiences of the participants, which is crucial given that the experience of entering adulthood during the climate crisis is novel and new structures to understand the nature of this experience may be necessary. Climate engagement for emerging adults involves layered emotions, developmental stage influences, and societal pressures (Arnett, 2010; Clayton et al., 2021; Ogunbode et al., 2019). Hermeneutic phenomenology is well suited to context-rich experiences that cannot be separated from the social, political, and developmental realities in which they occur (Ramsook, 2018; van Manen, 1997). This method enabled us to explore not only what the participants said, but also how they understood themselves in this particular life stage.
Theoretical Framework
Arnett’s developmental theory of emerging adulthood provided the framework for this study. According to this theory, between the ages of 18 and 29, young people consolidate their identity and explore career paths (Arnett, 2000, 2014). This is a time of possibility, in which multiple futures are open, and instability, as individuals transition from the structure provided by their family of origin and formal education and endeavor to make career and personal choices aligned with their values and aspirations (Arnett, 2000). Social and cultural factors also influence young people as they crystallize their identities and career paths (Arnett, 2010). This theory was selected because we were interested in the dynamic interactions among experiences, emotions, and actions within a critical developmental period and how these factors shape participants. Arnett’s theory and hermeneutic phenomenology both emphasize process, interpretation, and the evolving nature of identity within a specific context.
Participants
Twelve interviewees, aged 20 to 25, participated in this research. All participants viewed climate change as an important issue and engaged in environmental action, although their methods for addressing it varied. There were seven female and five male interviewees. The majority identified as non-Hispanic White Americans, but two individuals described multiracial identities: one as South Asian and White, and the other as Asian Pacific Islander and White. All but one of the 12 participants were from a middle-class background; one described growing up in a working-class family. Eight participants were residents of New Jersey or Pennsylvania at the time of data collection, while the other four were residents of New Mexico, Colorado, Texas, and Washington, D.C.
Data Collection
To be included in this study, participants had to be aged 18–25, view climate change as an important issue, have actively engaged in some form of environmental action for at least 6 months, reside in the United States, be able to communicate in English, and consent to participate in an audio-recorded interview lasting 60–90 minutes. Following IRB approval, we contacted key informants—academics in the climate movement who are recognized as leaders because of the reach of their speaking engagements and publications, and with whom we (Kathleen L. Grant and Melissa A. Alvaré) had a prior relationship—to recommend individuals who met the selection criteria. We also utilized social media platforms, including Facebook and Instagram, and posted an IRB-approved recruitment flyer on our personal and publicly accessible sites. Snowball sampling was used, as several respondents recommended their peers for interviews. Recruitment emails described the research study, detailed the interview procedures, and invited people to contact us if they were interested in participating. Once individuals responded to these emails, they were screened to see if they met the inclusion criteria. If so, they were asked to read and sign an informed consent document and complete a demographic questionnaire before scheduling the interview.
Interview questions were designed to elicit rich descriptions of participants’ lived experiences and perspectives. We utilized Arnett’s theory of emerging adulthood, specifically the five features of identity exploration, instability, self-focus, feeling in between, and possibilities/optimism, and considered how these factors would appear in climate awareness and action (Arnett, 2010, 2014). We drew from the existing literature to develop our initial interview guide, first drafting broad, open-ended domains. Then, we met to revise them with a critical eye, working to ensure that we were not asking leading questions or probes that were overly influenced by our own biases and expectations. Taking a phenomenological approach, we also ensured that our questions were crafted to go beyond eliciting descriptions to allow us to explore the meanings participants attached to phenomena of interest (e.g., climate change and career trajectories). We then sent a draft of our interview instrument to a renowned scholar in the field of climate justice, who made recommendations for further revisions.
All interviews were conducted and recorded over Zoom by one of the three authors. In line with the phenomenological tradition and our intentions to explore topics introduced by participants, we used semi-structured interviews. The semi-structured format promoted fluidity, allowing the informal dialogue to emerge and take unexpected directions, as respondents could discuss the topics most meaningful to them (Hesse-Biber & Leavy, 2010). The interview guide included questions such as: “How has learning about the environment impacted you personally, if at all?” “Has your environmental awareness had any impact on your life goals and/or career plans?” “When you think about the future, what feelings come up for you?” and “How, if at all, do you think you have changed as a result of your involvement in environmental action?”
We asked follow-up questions based on participants’ responses and probed—when appropriate—to gain clarity and delve deeper into their experiences and viewpoints. Interviews ranged from 55 to 75 minutes in length, and participants received $15 gift cards as compensation for their time and participation. The audio files from the recorded Zoom videos were sent to a professional transcription service.
Analysis
Given our hermeneutic phenomenological design, the analysis followed van Manen’s (1997) approach, which involves a cyclical process of reading, reflecting, and writing to uncover thematic structures. Researchers (a) turn to the nature of lived experience, (b) investigate experiences as lived, (c) engage in hermeneutic phenomenological reflection, (d) engage in hermeneutic phenomenological writing, (e) maintain a robust and oriented relation, and (f) balance the research while exploring the parts and whole (van Manen, 1997, pp. 30–31). As Starks and Trinidad (2007) wrote, in coding data from phenomenological inquiries, “specific statements are analyzed and categorized into clusters of meaning” with close attention to “descriptions of what was experienced as well as how it was experienced” (pp. 1375–1376). Transcripts were divided among us for an initial pre-coding of each interview. We each engaged in preliminary note-taking, marking repeated phrases and themes, and memo writing on potential codes and sub-codes during this stage. We then met to discuss initial interpretations of interviews, emergent themes, and perceptions of the powerful and insightful stories shared by participants. At that time, we also devised an initial inductive code and created a codebook and color scheme for the next coding round. We then re-divided the transcripts and each coded four transcripts in shared Microsoft Word documents. Once all 12 interviews were coded, we met again to discuss our analyses and refine and collapse codes. We repeated this process with each reading, using four new transcripts to examine our coding processes and contribute to our analyses with the new code list and interpretations of the data.
Trustworthiness
Our research team consisted of two counselor educators and one sociologist. We identify as White, middle and upper–middle-class women, aged 35–45, with shared concerns about the climate crisis. We engaged in ongoing discussions about how our social positions, interests, and privileges influenced all phases of the research process.
Trustworthiness was established primarily through prolonged engagement, critical reflexivity, and peer debriefing. We reviewed the audio recordings and transcripts for months. Both listening to the participants’ voices in the audio recordings of interviews and prolonged engagement with the transcripts is crucial for establishing trustworthiness, as it enables the researcher to see the world from each participant’s perspective and pick up on the richness and nuance of the narratives and ensures a thorough understanding of the participants’ statements, all of which are essential for phenomenological analyses (Moustakas, 1994). We were committed to maintaining an open stance and curiosity toward participants’ experiences. Each member of the team engaged in memo writing to document our emerging interpretations and consider how personal preconceptions and backgrounds might be influencing our interpretations. These memos were shared among the team and served as starting points for critical dialogue. We responded to each other’s memos, posing alternative perspectives and challenging probes to push one another to examine how personal biases might be shaping interpretations of the data. We also met regularly to engage in reflexive practice, unpacking the data collectively, scrutinizing our codes and emerging themes, seeking data that did not support the themes that were emerging, and interrogating how personal expectations and life experiences could be influencing our analyses. Whenever we found inconsistencies in our interpretations and/or data categorization schemes, we conducted thorough discussions to reach a consensus and ensure a uniform coding process.
Findings
This study aimed to gain a deeper understanding of the experiences of young adults engaged in environmental action during the transition from late adolescence to early adulthood. In particular, this study focused on the impact of environmental awareness and action on the participants’ development, personally and professionally, as they transition into adulthood. Through a hermeneutic phenomenological analysis of the 12 in-depth interviews, three key themes emerged from the participants’ narratives: 1) Fear for the Future, Anxiety, and Loss; 2) Limited Coping Strategies;
and 3) Tension Between Making a Difference and Making a Living.
Fear for the Future, Anxiety, and Loss
The environmentally aware participants expressed fear for the future, anxiety, and loss throughout their narratives. Most discussed pervasive anxiety and fear for the future related to the climate crisis. In contrast, other participants were triggered by specific situations, such as a severe weather-related event (locally or globally) or a climate change–related news item (i.e., the release of a UN report on the climate crisis). One participant, Theodora, also reflected on the present-day harm that communities are experiencing: “And it’s here right now, and increased natural disasters are not a future thing; they’re happening. . . . It’s definitely impacted my mental health.” Mary discussed how the climate crisis is causing a “collective trauma” in her generation. She said, “I think it’s really impacting everybody because individual action feels so futile. I think we’re just feeling really lost.” Many of the participants discussed a fear for their future as adults.
The participants specifically shared their fears about the future in light of the climate crisis. They raised questions about where they will live, whether they should have children, and the state of the planet. Brianna stated that it is a “daunting and terrifying idea, if we don’t start to get it [global warming] worked out, just how much of an impact it can have on our future.” Amy stated, “I could say that the climate crisis has negatively impacted mental health . . . [I experience] anxiety and worry about the state of the planet, now and in the future.” Briana described:
It’s pretty hard to feel hopeful, especially since all of us live here in Colorado now, where fires are a big problem and stuff like that. We often have conversations where we’re like, “So the West is going to be on fire, and the Southwest won’t have water, and the coastlines are going to be flooded. Where can we live?”
Three participants (25%) discussed, without specific prompting, whether or not to have a child, as the climate crisis would profoundly impact their child’s life. Nancy stated, “I feel like my generation . . . is not the biggest about having kids. . . . There’s not going to be a good place for us to live.”
Several participants used the terms eco-anxiety and climate grief to discuss their emotional experiences related to climate change. Nancy indicated that reports of natural disasters trigger her eco-anxiety, and Carol stated that she started psychiatric medication partly because of her eco-anxiety. Evan discussed his feelings of climate grief, helplessness, and powerlessness.
Limited Coping Strategies
The participants discussed various coping strategies for dealing with their intense climate-related emotions. The main strategies were adopting a positive mindset and ignoring or withdrawing from climate information/action. These two strategies are discussed below, after which the remaining strategies are briefly discussed.
The majority of the participants discussed choosing to stay optimistic about the future as a coping strategy. They discussed thinking about all the people, including themselves, who are engaged in climate action to make a difference. Alex discussed guarding against negative feelings by avoiding getting “too down on myself” or adopting “too negative of an outlook” and engaging in individual action as a coping strategy. Participants elaborated on the challenges they faced in maintaining a positive perspective, especially as they age and see an increasing number of negative climate-related events. Jackson stated that it is “more and more of a struggle” to maintain a positive attitude and be motivated to take climate action.
Participants also shared examples of ignoring or withdrawing from climate-related information or action as a means of coping with negative feelings or protecting themselves. Daniel stated, “I have taken an approach of doing the most that I can in my community while choosing to stay a little ignorant on what’s happening globally.” Sarina shared, “I felt pretty stressed and sort of want . . . to give up on trying to help environmental problems because a lot of them are so far gone that it can be pretty discouraging to read about.” Mary elaborated on her emotional experience:
And it almost teaches you, I’ve found, not to feel your feelings. So in a sense, I find myself becoming more apathetic because you’re desensitized to it. You’re seeing it all the time, but you can’t feel it all the time because no one wants to stare into the impending doom of environmental decay or whatever.
Three of the participants discussed connecting with their community as a means to address their fears and concerns about the climate crisis. All three of these participants reported connecting with others who are environmentally minded or engaged in climate action. One participant discussed therapy as a strategy: “I do see a therapist occasionally. . . . She’s not trained on the eco-side of things. So she tries to understand and gets tools and whatnot, but definitely, it’s not her main area of concern. But she’s been helpful anyways.”
Two participants discussed being in nature, specifically hiking, as a coping mechanism. Mary stated, “Life outside and living a life that is environmentally based actually brings me a lot of joy, and that component of it doesn’t stress me out and give me anxiety.” Sarina shared that she does not have a clear coping strategy:
So even though me and my friends . . . are people who are trying to work towards improving things, I would say we all can feel pretty hopeless about the situation, especially [when] the current government-level response is not very strong. . . . I want to be hopeful, but I would say from a scientific perspective, it can also be pretty hard to feel hopeful for the future. Yeah, I don’t really have an answer. . . . it can be pretty overwhelming, and you just kind of have to try to think about something else. Because I guess I can remind myself I’m already working to try to increase knowledge, and that’s useful. So, I guess I’m playing some positive part, and so I can try to relieve myself with that information. But yeah, I guess I don’t really have a good way to feel better about it.
Tension Between Making a Difference and Making a Living
The participants in this study were all in a transition period between adolescence and adulthood. In their narratives, many of the participants (n = 7) expressed the tensions between their environmentally based values and the need for a job that would provide economic security. These tensions emerged as the participants struggled to make choices congruent with their stated values and career choices that might have long-term impacts, both individually and for their communities.
The role of money and financial stability was not directly probed for in the interview protocol; however, participants often brought it up when asked what prevents them from engaging in environmental action. Jackson stated, “You can either pursue this as a passion and as an ideal and as a thing to do, or you can . . . make money and have a stable life.” He went on to state:
And so I grew up with a lot of that type of thinking, of like, eventually, you’re going to have to kind of settle your own goals and ideals in order to survive in the world on your own and provide safety nets to your family later on. And so I always kind of grew with that . . . in the back of my mind, and that became more present in college. . . . I think those have been the biggest kind of like detractors . . . like “You have to choose one or the other.” Like, they [parents] weren’t necessarily discouraging my passion or any of that, they were just kind of like, “It’s one or the other.” Most people fall for the latter, and that’s kind of why we have the issues in the first place.
Evan discussed grappling with either getting paid with a traditional job or engaging in more meaningful environmental activism on a volunteer basis. He shared:
I guess, unfortunately, money is a factor. I found more ways to get paid for teaching than for volunteering my time. You have to think about, “What’s the balance of that going to be?” I need to be able to support myself, and so when I can, I will dedicate time to being active in my community and engaging with environmental issues. So, finding a balance.
Brianna, who was in law school studying environmental law, discussed the tension as she sees it:
Society . . . pins people against environmental work because it’s not lucrative, or they paint it not to be lucrative because I think people can make a decent living and know that they’re doing something beneficial. But I would say that there’s still a stigma in society just surrounding environmental work, and that if you want to make money and you want to live decently, that’s not the field to go into. I fully don’t believe in that anymore, but I think that that played a role in my choices.
Although most participants indicated that financially providing for themselves was a significant detractor from an environmentally focused career, several participants had alternative narratives. Amy, an environmental educator at a nonprofit land trust, discussed the importance of taking time in college to discover her identity and selecting a career aligned with her values, even if it was not financially lucrative. However, her financial realities were still infused into her thinking, reflected by her parents’ repeated refrain: “My parents, from day one, always said, ‘Pursue your passion, do what you love, and the money will come.’” Other participants were exploring careers in academia and research as methods to bring about change and did not mention finances as an impediment to an environmentally oriented career.
Discussion
This study aimed to gain insight into the lived experiences of environmentally aware individuals as they transition from adolescence into adulthood. Specifically, Arnett’s developmental theory of emerging adulthood was utilized to frame these experiences, as it considers the dynamic interactions among experiences, emotions, and actions within this critical developmental period between adolescence and adulthood (Arnett, 2000). In particular, Arnett’s theory provides insight into the tension and instability that young adults experience during this transition, particularly in terms of identity, career, and emotional development.
Three main themes emerged from the participants’ narratives, including feelings of fear for the future, anxiety, and loss; limited coping strategies; and tension between making a living and making a difference. Each participant described fear for the future, anxiety, and loss. These findings align with past research exploring mental health concerning the climate crisis (Gislason et al., 2021; Hickman et al., 2021; Ojala et al., 2021; Sanson et al., 2019). The depth and breadth of the participants’ descriptions of fear and anxiety suggest that thoughts, feelings, and experiences around the climate crisis impact their daily lives. Some participants reported powerful emotional responses to negative news about the climate. They were pondering significant life choices because of the climate crisis (e.g., questions about where to live and whether to have children). As previous researchers have suggested, these responses appear appropriate given the realities of the climate crisis and the expected impact it will have on their lives and those of future generations (Hickman et al., 2021). However, although participants expressed and communicated these fears and anxieties, few seemed to have comprehensive structures (psychological, behavioral, or relational) to act on their pervasive and legitimate concerns. Participants often managed complex feelings and plans independently in the absence of communities informed about their fears and realities for the future, which could help them navigate the challenges and possibilities of a life and a future heavily impacted by the climate crisis.
Although all participants experienced a range of emotional reactions to the climate crisis, they also employed various strategies to manage their feelings. The participants generally appeared to have limited strategies for dealing with challenging climate-related feelings. Most of the strategies were individualistic, and young people had to figure out how to manage their deep and complex emotions independently. Several participants discussed being optimistic as a coping strategy but also voiced that this strategy is ineffective and exhausting. Although keeping a positive attitude in the face of adversity can be beneficial, doing so without acknowledging or feeling the vast array of emotions associated with the climate crisis and their fear for their futures may be ineffective. This finding aligns with the conclusions of Hickman et al. (2021), which demonstrate that young people are facing unique stressors arising from the climate crisis that can impact their development.
Several participants discussed ignoring aspects of the climate crisis or the climate crisis itself to protect themselves. Denial is a common psychological defense to reduce climate-related distress (Doherty & Clayton, 2011). Participants noted that they disengaged from environmental action to avoid challenging feelings related to climate change. These individuals may benefit from positive strategies to manage their emotions, allowing them to take care of themselves and continue to be active citizens working toward change. Finally, participants shared coping strategies, including spending time in nature and engaging in therapy, as strategies to support their mental health. Participants also engaged with environmental communities as a coping strategy, which can be a significant influence during such a developmental period. Social and cultural factors have been shown to influence young people during the development of emerging adulthood as they crystallize their identities and career paths (Arnett, 2010). As the future will include increasingly complex and challenging climate crisis–related issues, individuals in this study may benefit from additional coping strategies, which will be further discussed in the Implications for Counseling section.
The final theme illuminated by the participants is the tension between making a difference and making a living. Participants discussed the challenges inherent in creating environmental change, often in low-paying or volunteer capacities, and the desire to support themselves financially. Although the participants were interested in environmental action, both professionally and personally, they often struggled to create a life in adulthood where they could enact their values. Participants described examples of their engagement in environmental causes in high school and college but had a more challenging time maintaining action as they transitioned to adulthood. Although part of the challenge seemed to be the lack of clear, viable paths for the participants to engage in environmental action and careers as adults, financial realities also shaped their choices. Participants viewed jobs in the environmental sector as less lucrative than others, and they would not be able to support themselves or their future families on this salary, especially if they wished to maintain the same socioeconomic level as they were offered. Additionally, the participants saw this tension as a dichotomy; they could either have a well-paying career or engage in environmental action.
Implications for Counseling
Young adults are increasingly experiencing mental health impacts of the climate crisis (Hickman et al., 2021). This study offers insight into the developmental and emotional experiences of young adult participants as they navigate the transition to adulthood, exploring how to make sense of their environmental concerns and act to create change. Counselors, including school counselors, college counselors, career counselors, and clinical mental health counselors, can play a crucial role in supporting mental health and wellness in the context of the climate crisis. Both the National Board for Certified Counselors (NBCC; 2025) and the American Counseling Association (ACA; Sturm et al., 2020) have issued statements emphasizing the need for counselors to advocate for climate action and educate themselves and others on the mental health implications of climate change.
The findings of the current study support the need for counseling services because of climate change impacts on mental health. Findings reveal that participants were experiencing challenging emotions related to the climate crisis and had limited strategies to cope with the changing world. Three implications for counseling are discussed below: increasing counselors’ climate change mental health literacy, supporting resilience, and the ethical responsibility of counselors as advocates.
Recommendation 1: Increase Counselors’ Climate Change Mental Health Literacy
Counselors must practice “within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience” (ACA, 2014, Section C.2.a.). Many counselor education training programs do not cover the unique experiences and challenges individuals face because of the climate crisis, resulting in a void in counselor education training (Heiman, 2024; Hilert, 2021). Therefore, to ethically assist clients with this need, counselors must continue their education and, where necessary, seek additional supervision to treat this population. As a first step, counselors can consider learning more about the nature of the climate crisis, including the impacts on future generations (Doherty & Clayton, 2011). Publications such as the American Psychological Association’s 2021 report, Mental Health and Our Changing Climate: Impacts, Inequities, and Responses (Clayton et al., 2021), provide a comprehensive overview of the nature of the climate crisis and strategies for mental health practitioners. Counselors can also seek support, training, and consultation through membership in the Climate Psychology Alliance of North America, a community of mental health professionals who educate climate-aware practitioners (https://www.climatepsychology.us).
Participants in this study noted that their mental health practitioners were not adept at addressing their climate anxiety and trauma in sessions. Individuals may not directly broach the topics of climate anxiety, eco-grief, and weather-related PTSD; therefore, counselors must address these topics directly with clients. Climate-aware counselors must facilitate the expression of clients’ emotions about the climate crisis and help them further explore and articulate their experiences (Doherty & Clayton, 2011). Counselors can consider using interventions that facilitate emotional expression and create opportunities for adaptive behaviors (Doherty & Clayton, 2011). Interventions can also include existential therapy, particularly exploring how to find meaning, peace, joy, and hope in the face of ecological collapse and climate-related disasters (Barry, 2022; Frankl, 2006). Finally, eco-therapy is a promising modality for clients that centers healing through nurturing a stronger relationship with nature and the physical environment (Delaney, 2019). As such, it is recommended that counselors expand their knowledge of the climate crisis and its impact on mental health to serve their clients better as well as any supervisees.
Recommendation 2: Supporting Young Adult and Client Resilience
This study found that participants lacked comprehensive structures to address their climate anxiety and fears about the future. Many participants felt overwhelmed by the climate crisis, which impacted their ability to take action in the climate movement. As a coping strategy to protect themselves from difficult feelings associated with climate change, some participants withdrew from climate information or action. As challenging weather-related events and the impact of the climate crisis are expected to increase in the coming years, young adults must develop both internal and external resources to survive and thrive in a changing world (Gislason et al., 2021).
Fostering resilience is an effective strategy for supporting the mental health and well-being of young adults, including those affected by the climate crisis (Clayton et al., 2021). Resilience can be fostered through the development of both internal and external resources, and counselors can play a crucial role in this process. Internal resources can include increasing self-efficacy or young adults’ belief in their ability to overcome the stress and trauma associated with climate change. Research suggests that those who believe in their ability to withstand the challenges associated with climate change have more positive psychological outcomes than those with lower self-efficacy (Clayton et al., 2021). Belief in one’s resilience is also correlated with fewer symptoms of depression and PTSD after natural disasters (Ogunbode et al., 2019).
Counselors can support young adults in developing external resources that enhance resilience, such as fostering social connections. Social connections to peers and those of different generations can be a vital source of emotional, informational, logistical, and spiritual support (Center for the Study of Social Policy, 2019). Individuals’ ability to withstand trauma and adversity increases when they are connected to strong social networks (Clayton et al., 2021).
Finally, this study found that participants did not have clear paths to enact their environmental values in their adult lives. They faced financial and cultural pressures to choose careers that would allow them to make a living. Although this study highlights that some participants may not have had the internal and external resources to cope with the emotional stressors of engaging in climate-related work, a viable career or civic path was elusive. All counselors who work with young adults, especially school and career counselors, have the opportunity to provide resources about the wide array of jobs available in the green economy, as well as methods to include civic involvement (i.e., participation on local environmental commissions, participation in activist groups, leadership in local government advocating for green policies) when planning one’s adult life. Models of adults who engage in environmental action, both personally and professionally, must be provided to young people as examples of possible paths in adulthood. As taking action is seen to have numerous mental health benefits, specifically as it builds agency, counselors must support clients in developing the attitudes, skills, and behaviors necessary to engage in activism and advocacy (Gislason et al., 2021; Sanson et al., 2019).
Recommendation 3: Ethical Responsibility of Counselors as Climate Advocates
Counselors are ethically responsible for advocating for the well-being of their clients, as stated in the ACA Code of Ethics (2014): “When appropriate, counselors advocate at individual, group, institutional, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients” (Section A.7.a.). The climate crisis is and will continue to significantly negatively impact the growth and development of clients, with young clients and clients from historically marginalized populations such as people of color and people with low incomes among the most vulnerable (IPCC, 2023; Watts et al., 2015). Counselors’ ethical responsibility is to advocate for local, state, and national policies and practices to prevent the most dire climate outcomes and support a livable future for all. This includes the counseling profession’s call for counselors to be active in policy initiatives and advocacy related to climate change (NBCC, 2025). Such policies may consist of those that support a just transition away from fossil fuels and to renewable sources of energy; agricultural strategies that reduce emissions, shift toward more sustainable diets, and reduce food waste (United Nations Environment Programme, 2020); and nature-based solutions such as stopping deforestation and ecological degradation and moving toward ecosystem regeneration (United Nations Environment Programme, 2020). As the impacts of the climate crisis are felt most significantly in communities of color (who are more likely to be situated in floodplains, heat islands, downwind from fossil fuel-burning plants, etc.), there is an added ethical responsibility to advocate for the well-being of the most vulnerable.
Limitations and Future Research
This study had several limitations. First, the majority of participants identified as White and middle class. The study would have benefited from a greater diversity of participants to gain a broader perspective on cultural differences as they relate to the experiences of climate change, development, and mental health. Additional research is necessary to gain insight into the experiences of young adults across the intersections of identity, specifically focusing on those who will suffer the greatest impacts of the climate crisis, such as individuals from the global majority and low-income households. Secondly, all participants in this study were currently or had been previously engaged in some level of environmental action. The results of this study may not be applicable to those who are concerned about climate change but not actively engaged in taking action. Finally, although a sample size of 12 was suitable for the goals of this research and the standards of hermeneutic phenomenology (van Manen, 1997), the nature of qualitative research limits the ability to generalize these findings.
The participants in this study struggled with diverging from the status quo to make choices aligned with their values. In particular, values associated with individualism and capitalism frequently appeared as roadblocks, such as pressure to make a certain financial living and engaging with problems and solutions from an individualistic perspective. More research is needed to understand how young people challenge and resist dominant cultural values that prevent them from taking action to bring about environmental change and may contribute to poor mental health outcomes.
Conclusion
This study sheds light on the lived experiences of environmentally aware young people. Commensurate with previous findings, participants expressed fear for the future, anxiety, and loss (Hickman et al., 2021). This study highlighted the limited comprehensive strategies available to young people for addressing their climate-related emotions, which affected their ability to remain engaged in climate action. Additionally, participants felt significant cultural and financial pressure to make a living, which stood in contrast to their ability to engage in personal or professional environmental action. Counselors can support young adults by enhancing their climate-related mental health literacy, offering climate-specific interventions to increase their resilience, and engaging in social change through advocacy.
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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Kathleen L. Grant, PhD, NCC, is an associate professor at The College of New Jersey. Alyson Pompeo-Fargnoli, PhD, NCC, LPC, is an associate professor at Monmouth University. Melissa A. Alvaré, PhD, is a lecturer at Monmouth University. Correspondence may be addressed to Kathleen L. Grant, 2000 Pennington Rd, Ewing Township, NJ 08618, grant24@tcnj.edu.
Aug 26, 2025 | Volume 15 - Issue 3
Julie C. Hill, Toni Saia, Marcus Weathers, Jr.
Ableism is often neglected in conversations about oppression and intersectionality within counselor education programs. It is vital to expand our understanding of disability as a social construct shaped by power and oppression, not a medical issue defined by diagnosis. This article is a call to action to combat ableism in counselor education. Actionable recommendations include: (a) encouraging professionals to define and discuss ableism; (b) including disability representation in course materials; (c) engaging in conversations about disability with students; (d) collaborating with, responding to, and supporting disabled people and communities; and (e) reflecting on personal biases to help dismantle ableism within counselor education. Implications for counselor educators highlight the ongoing need for more ableism content within the profession.
Keywords: ableism, disability, counselor education, representation, biases
Disability is rarely examined through intersectionality and critical consciousness, despite its deep connections to race, class, gender, and other social identities (Berne et al., 2018). As the United States becomes increasingly diverse, the need for counselors who can competently address the complex, intersecting needs of disabled people has never been more urgent (Dollarhide et al., 2020). Disabled people are the largest and fastest-growing minority group, with approximately 60 million people reporting some form of disability (Elflein, 2024). Despite this increasing prevalence, ableism, known as the systemic discrimination and exclusion of disabled people, remains persistent in our society. Slesaransky-Poe and García (2014) further discuss ableism as the belief that disability makes someone less deserving of many things, including respect, education, and access within the community.
Ableism and ableist beliefs have profoundly shaped how society perceives and interprets the disability experience. Historically, the medical model has framed disability as an inherent defect within the individual, requiring treatment, rehabilitation, or correction to restore “normal” functioning (Leonardi et al., 2006). This deficit-based perspective, reinforced by legal definitions, has shaped societal attitudes and policies, often prioritizing intervention over community integration. In contrast, the social model of disability shifts the focus from the individual to the broader societal structures, emphasizing how inaccessible environments, exclusionary policies, and ableist attitudes create disabling conditions (Bunbury, 2019; Friedman & Owen, 2017; Shakespeare, 2006). This model asserts that disability is not simply a medical issue, but a social justice concern requiring systemic change to remove barriers and promote full participation. Within counselor education programs, the biopsychosocial model is often taught as a more integrative framework that acknowledges disability as a complex interplay of biological, psychological, and social factors. Although medical interventions may be necessary for some individuals, this model emphasizes addressing environmental and attitudinal barriers contributing to marginalization. By adopting this holistic approach, counselors can better advocate for equity, inclusion, and meaningful accessibility for all.
This article provides an asset-based framework that views disability as a valuable aspect of diversity rather than a deficit or limitation. This approach recognizes the strengths, perspectives, and contributions that disabled people bring to communities and educational spaces (Olkin, 2002; Perrin, 2019). By embracing disability as an aspect of diversity, this framework challenges societal norms rooted in ableism, which often prioritize conformity and cure over anti-ableism (Bogart & Dunn, 2019). Through this lens of power and oppression, disability is celebrated as a source of innovation, creativity, and cultural richness, encouraging practices that empower disabled individuals to thrive both in the classroom and in the community. To reinforce this shift in thinking to disability as an asset, we use identity-first language, recognizing that many disabled people prefer it as a positive affirmation of their lived experiences and their connection to the disability community (Sharif et al., 2022; Taboas et al., 2023).
Intersectionality and Disability
Scholars recognize intersectionality as an analytical tool to investigate how multiple systems of oppression interact with an individual’s social identities, creating complex social inequities and unique experiences of oppression and privilege for individuals with multiple marginalized identities (Collins & Bilge, 2020; Crenshaw, 1989; Grzanka, 2020; Moradi & Grzanka, 2017; Shin et al., 2017). The topic of disability is often absent in conversations regarding power, oppression, and privilege (Ben-Moshe & Magaña, 2014; Erevelles & Minear, 2010; Frederick & Shifrer, 2018; Mueller et al., 2019; Wolbring & Nasir, 2024) despite the potential for disability to intersect with other marginalized identities (e.g., racial/ethnic identity, gender identity, socioeconomic status, religious and spiritual beliefs, citizenship/immigration status) that lead to intersectionality-based challenges that conflict with the marginalization of being disabled (Wolbring & Nasir, 2024). For example, Lewis and Brown (2018) condemned the lack of accountability in reporting on disability, race, and police violence, which often irresponsibly neglects the coexistence of disability in conversations of experienced violence. Using the framework of intersectionality responsibly in disability discourse within counselor education holds significant potential for the professional development of counselors to work toward unmasking and dismantling ableism.
Challenges and Gaps in Anti-Ableism in Counselor Education and Training
How counselor educators teach about disability is crucial to dismantling ableism, yet history reveals a troubling lack of cultural humility in educational approaches. Cultural humility is a process-oriented approach that continuously emphasizes the counselor’s openness to learn about a client’s culture and invites counselors to consistently incorporate self-reflective activities to enhance their self-awareness (Mosher et al., 2017). Although cultural humility may be well intended, it may also have a harmful impact and fall flat if inherent biases go unrecognized. For example, counselor educators heavily relied on simulation exercises to address disability in the classroom (e.g., having students blindfold themselves for an activity to simulate blindness or having them sit in a wheelchair for a short period). Simulation exercises reinforce a deeply medicalized and reductive view of disability, one rooted in fear, pity, and misconception, ultimately erasing disability as both a culture and an identity (Öksüz & Brubaker, 2020; Shakespeare & Kleine, 2013). Beatrice Wright (1980, as cited in Herbert, 2000), cautioned that simulation experiences evoke fear, aversion, and guilt. These exercises rarely foster meaningful or constructive perspectives on disability. Instead of deepening understanding, these exercises risk reinforcing harmful stereotypes, further marginalizing disabled individuals rather than empowering them. Instead of disability simulations, honor the voices and experiences of disabled individuals through their narratives, such as Being Heumann by Judy Heumann, as well as documentaries and movies like Crip Camp, Patrice, or CODA. Contact with disabled individuals has been shown to reduce stigma against disabled people (Feldner et al., 2022; Smith et al., 2011). Additionally, incorporate analyzing ableism through case studies, readings, or media, followed by a structured discussion.
Topics of multiculturalism and diversity have increased over the years; the same cannot be said for disability (Rivas, 2020). Davis (2011) poignantly asked, “Is this simply neglect, or is there something inherent in the way diversity is considered that makes it impossible to recognize disability as a valid human identity?” (p. 4). More than a decade later, this question remains painfully relevant. Atkins et al. (2023) explored this issue through a study using the Counseling Clients with Disabilities Scale to evaluate professionals’ attitudes, competencies, and preparedness when working with disabled clients. The findings underscore the critical need for education and exposure to disability-related topics in counselor training, demonstrating that such efforts improve competency, reduce biases, and foster more inclusive, equitable, and empowering support. However, disability continues to receive significantly less attention than other cultural and identity groups in professional training and discourse (Deroche et al., 2020).
Furthermore, ableist microaggressions continue to be a concern for disabled individuals. Cook and colleagues (2024) conducted a study looking at microaggressions experienced by disabled individuals and found four categories of microaggressions: minimization, denial of personhood, otherization, and helplessness. They also found that experiencing ableist microaggressions affected participants’ mental health and wellness. Additionally, they found that those with visible disabilities were more likely to experience ableist microaggressions than those with invisible disabilities. Given these findings, counselor educators need to be aware that ableist microaggressions exist, what those microaggressions may sound like, and how they impact disabled clients.
Concerns exist about the extent to which counselor education programs cover disability content; there is also a need to examine instructors’ preparedness for covering such content. In a survey of counselor educators in programs accredited by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP), 36% of the faculty surveyed believed their program was ineffective at addressing disability topics and that programs did not address disability and ableism to the extent necessary to produce competent professionals. Only 10.6% felt their program to be “very effective” in this content area, with the belief that their students were only somewhat prepared to work with disabled people (Feather & Carlson, 2019). Notably, these oversights in education translate into inadequacy in practice. A sample of mental health professionals who all reported working with disabled clients indicated the least amount of perceived disability competence in skills, the second least competence in knowledge, and the most competence in awareness (Strike et al., 2004). Faculty self-assessment of their ability to teach disability-related content was strongly linked to their prior work or personal experience with disability. This highlights the importance of integrating exposure to and training on disability-related concepts throughout core areas (Pierce, 2024). Although separated by a decade, these studies can be tied to a unifying, persistent issue: the lack of disability competence in counseling and counselor education spaces.
The 2024 CACREP standards call for an infusion of disability competencies into counseling curricula (CACREP, 2023), meaning that counselor educators and counselors-in-training must reimagine the available literature to provide adequate professional development and growth. Pierce (2024) advised that disability competence areas be focused on the following topics: accessibility, able privilege, disability culture, and disability justice. We must seek to dismantle ableism by infusing disability into curricula in an authentic manner that highlights the societal values and attitudes in which multiple forms of oppression work in tandem to create unique, intersectional experiences for disabled people.
Training Recommendations for Counselor Education Programs
The authors aim to ensure counselor educators have tangible strategies to dismantle ableism and teach their students to do the same. Counselor educators and counselors-in-training must look inward and rid themselves of negative attitudes and biases to eradicate ableism. Part of this process includes the critical skill of self-reflection and examining and understanding biased and ableist beliefs held by individuals and perpetuated by society. Until that happens, counselors will continue to do a disservice to disabled people (Friedman, 2023). For students who have never interacted with disabled people or thought about ableism, these conversations and strategies have the very real possibility of making them uncomfortable. Discomfort is okay. Disabled people often feel awkward or out of place every day because of ableism. It is not our job as counselor educators to make students comfortable; it is our job to make them competent, informed, and ethical professionals.
The following are five tangible strategies to thoughtfully and intentionally dismantle ableism. These strategies are purposefully broad and aim to expose counseling professionals and those in training to an intersectional perspective of disability that acknowledges disability as a valid aspect of diversity, identity, and culture. Rather than siloing these discussions to disability-related training, these strategies belong in all settings within counseling. Counseling professionals must include ableism in the conversations happening in places where they learn and work to shift the way they think, view, respond to, and construct disability. To begin, counselor education programs should consider hosting a workshop or seminar focused on ableism by disabled people to ensure that all students and faculty are on the same page and are using the same terminology. Once this has been established, ableism and disability content and knowledge should be incorporated into lectures, assignments, discussions, and exams across the counselor education curriculum. Further information on this integration is described in the first strategy below.
Define Ableism
One of the factors that further perpetuates ableism is the lack of clarity on what ableism is and how it intersects with other forms of oppression. Counselor educators must share definitions of ableism that center on the perspective of the disabled community. Talia Lewis (2022) provided a working definition of ableism that disabled Black/negatively racialized communities developed:
A system of assigning value to people’s bodies and minds based on societally constructed ideas of normalcy, productivity, desirability, intelligence, excellence, and fitness. These constructed ideas are deeply rooted in eugenics, anti-Blackness, misogyny, colonialism, imperialism, and capitalism. This systemic oppression leads to people and society determining people’s value based on their culture, age, language, appearance, religion, birth or living place, “health/wellness,” and/or their ability to satisfactorily re/produce, “excel,” and “behave.” You do not have to be disabled to experience ableism. (para. 4–6)
This definition expands on the definition provided earlier of ableism as the systemic discrimination and exclusion of disabled people. It rejects the notion that ableism can be dismantled or separated from other forms of oppression (e.g., racism, sexism, and other systems of oppression). Within counseling curricula, we often use the term intersectionality, but it is impossible to address intersectionality with our students if we do not thoughtfully include ableism. We should challenge the idea that disability is a monolithic experience as we seek to build a more complex, interconnected, and whole understanding of disability (Mingus, 2011).
It is also essential to acknowledge internalized ableism, which is ableism directed inward when a disabled person consciously or unconsciously believes in the harmful messages they hear about disability. They project negative feelings onto themselves. They start to believe and internalize the message that society labels disability as inferior. They begin to accept the stereotypes. Internalized ableism occurs when individuals are so heavily influenced by stereotypes, misconceptions, and discrimination against disabled people that they start to think that their disabilities make them inferior (Presutti, 2021). For example, a disabled student may not participate in class because they believe their contributions are inferior compared to their nondisabled peers, or a disabled client may experience feeling undeserving, undesirable, and burdensome.
To effectively implement this awareness, ask students to define ableism in their own words. Coming up with their definition of ableism encourages critical thinking and allows the counselor educator to gauge students’ existing understanding. Then, introduce the Lewis (2022) definitions above to provide a more comprehensive framework. To reinforce these concepts, incorporate case studies illustrating real-world examples of ableism. Analyzing these cases in class discussions or group activities will help students identify ableist structures, challenge assumptions, and explore solutions for creating more welcoming environments. Counselors can examine ableism in societal contexts by viewing movies or television shows that feature disabled characters and analyzing how ableism is portrayed in media. Because of societal barriers to access and the taboos surrounding discussions of disability, the entertainment and news media serve as a key source for many people to form opinions about disability and disabled individuals. Unfortunately, these portrayals are limited and often spread misinformation and harmful stereotypes (Pierce, 2024). One way to help combat this could be by watching a movie or show together as a class and then having a discussion or having students watch on their own and write a short reflection followed by a class discussion. Some suggested movies include Crip Camp, Murderball, The Temple Grandin Story, Patrice, and Out of My Mind. Some suggested television shows include Speechless, Love on the Spectrum, Special, Raising Dion, Atypical, and The Healing Powers of Dude.
Include Disability Representation in Course Content
The phrase “representation matters” also applies to disability. Counselor educators should include disability and discussions of the impact of systemic ableism throughout course content, not only in a single lecture or reading on the course syllabus. Decisions about course content send powerful messages about what the counselor educator, the program, and the broader counseling profession prioritize and value. Including or excluding specific topics reflects the educator’s perspective and shapes future counselors’ professional identity and competencies. When disability is overlooked or inadequately addressed, it signals to students that it is not a central concern in counseling practice, which reinforces systemic gaps in knowledge, awareness, and advocacy. To counter this erasure and to ensure meaningful representation, intentionally incorporate guest speakers, videos, readings, memoirs, and research that center on the perspectives of disabled people. This gives students an authentic and multifaceted understanding of disability beyond theoretical discussions. Consider integrating a book or memoir that centers a disabled perspective alongside the course textbook to bridge the gap between academic content and real-life experiences. This approach not only deepens students’ engagement but also challenges ableist assumptions by highlighting the lived realities, resilience, and contributions of disabled people.
Engage in Conversation About Disability With Students
Disability is not a bad word. Counselor educators must instill this simple yet profound truth in students. Euphemisms like differently abled, handicapable, or special needs perpetuate ableism when used in place of the term disability, implying that disability is something shameful or in need of softening; they do more harm than good. Counselor educators must allow students the opportunity to engage in discussion about disability to challenge the idea that disability is taboo and move into a space where students can appreciate that disability is a natural part of life. Counselor educators must foster a safe and supportive learning community that allows students to engage in dialogue and discussion about their beliefs and experiences that have shaped their beliefs, and examine how those beliefs led to the development or perpetuation of ableist ideas and microaggressions. This allows students to learn, grow, and reshape their beliefs and understanding together. This quote sums it up best: “Disabled people are reclaiming our identities, our community, and our pride. We will no longer accept euphemisms that fracture our sense of unity as a culture: #SaytheWord” (Andrews et al., 2019, p. 6). To empower students to #SayTheWord in both classroom discussions and professional practice, dedicate time, especially during the first weeks of class, to explicitly affirm that disability is not a bad word. Normalize its use by providing historical context, sharing first-person perspectives, and emphasizing the importance of language in shaping attitudes. By reinforcing disability as an act of recognition rather than avoidance, you help students develop confidence in using identity-affirming language and challenging the stigma often associated with the term.
Collaborate, Respond, and Support Disabled People
Counselor educators, counselors, and counselors-in-training should seek opportunities to listen to, respond to, support, and collaborate with disabled counselors and other disabled scholars. Thoughtful collaborations allow for authentic exposure and conversation that support the unlearning of ableist beliefs. This approach is consistent with the disability rights mantra “nothing about us without us” (Charlton, 1998, p. 3), which implies that no change can occur without the direct input of disabled individuals. One opportunity for collaboration includes professional conferences and attending presentations by disabled academics and professionals. Other opportunities for collaboration include working with and supporting local disabled business owners and seeking out organizations such as independent living centers to bring in disabled speakers to share their lived experience and interactions with ableism and microaggressions. Be sure to compensate these individuals for their time so that the work of collaboration is mutually beneficial to all parties.
Disabled people are the experts of their experiences, not professionals. This statement is not synonymous with implementing a client-centered or person-centered approach. Instead, the focus of this statement is to make sure counselors have the tools to trust, support, uplift, and dismantle ableism with disabled clients. If it starts in the classroom, counselors-in-training will be better prepared in practice and life outside of work. As professionals know, trust in the counselor-client relationship is essential for the disabled community. It often develops when individuals feel heard, trusted, and validated, rather than being second-guessed or minimized, especially as they share about the external and internal ableism they face daily. Lund (2022) recommended consulting with both disabled psychologists and trainees to bring a “critical insider-professional perspective” (p. 582) to the profession. By consulting and bringing these disabled professionals in for training or speaking about personal experiences, we can ensure that disabled voices are heard and recognized.
Another way to amplify disabled voices is through the teaching of disability justice. The Disability Justice framework affirms that every person’s body holds inherent value, power, and uniqueness. It recognizes that identity is shaped by the interconnected influences of ability, race, gender, sexuality, class, nationality, religion, and other factors. It stresses the importance of viewing these influences together rather than separately. From this perspective, the fight for a just society must be grounded in these intertwined identities while also acknowledging Berne et al.’s (2018) critical insight that the current global system is “incompatible with life” (para. 13). Central principles of disability justice, such as centering leadership by those most impacted, fostering interdependence, ensuring collective access, building cross-disability solidarity, and pursuing collective liberation, prioritize intersectionality and cross-movement collaboration to guarantee that no one is excluded or left behind. (Pierce, 2024).
Helping students understand and internalize these ideas and principles should lead to the development of more aware and anti-ableist counselors in several ways. Rather than viewing client struggles as isolated or purely personal issues, understand that many forms of suffering, especially those faced by disabled people and people with intersecting marginalized identities, are rooted in larger social, economic, and political systems that devalue certain lives. For example, ableism, racism, and capitalism often create conditions that threaten people’s survival, whether through limited access to health care, environmental injustice, or social exclusion.
Counselors-in-training should be attuned to how multiple aspects of identity (such as disability, race, gender, and class) interact to shape each client’s lived experience. This approach moves counseling away from a one-size-fits-all perspective and helps address the unique, layered barriers that clients face. Traditional counseling and counselor preparation often focus on assisting clients to adapt to oppressive systems. The Disability Justice perspective instead calls for counselors-in-training to see their role as also advocating for systemic change, working toward environments and policies that are actually supportive of all people’s well-being. Rather than idealizing independence, disability justice values interdependence and community care. Counselors and counselors-in-training can foster this by helping clients build supportive networks and by modeling collaborative, relational approaches in practice.
Regularly Reflect on Personal Biases and Be Open to Feedback
Counselor educators often ask counselors-in-training to reflect on their own biases in terms of race, gender, and sexual orientation. However, ableism and disability are often forgotten or left out of those conversations. It is essential for these conversations about bias to include disability so that everyone has opportunities to explore and discuss their own potential biases. Embedding disability representation in the classroom allows everyone to see how they respond to disabled people, especially when that representation is in the form of case studies and client role-play. Then, everyone, including supervisors, can constructively receive feedback from a trusted figure and can change or improve their reactions and responses if necessary. Furthermore, counselor educators and counselors-in-training can keep reflective journals, seek supervision or peer discussions, and review case notes with an anti-ableist lens, which can help identify areas for growth. Additionally, counselor educators should actively solicit feedback from the disability community, welcoming their perspectives without defensiveness. When possible, attend training led by disabled professionals and the disabled community to reinforce a commitment to continuous learning and accountability.
Implications for Counselor Educators
Counselor educators are responsible for training counselors to work with all types of clients, including disabled clients. Counselors will encounter disabled clients, no matter the setting that they are working in. Disability can impact anyone and does not discriminate across gender, race, socioeconomic status, sexual orientation, or geographic location. Disability is the one minority group that anyone can become a part of at any time in their life. Most people will age into disability as they get older (Shapiro, 1994). Counselor educators need to be sure that counselors are confronting and dismantling their own ableism and ableist beliefs and that they understand that they may need to assist clients in processing their own experiences with ableism in society and interactions with others. One self-assessment for self-reflection and insight is the Systematic Ableism Scale (SAS; Friedman, 2023). The SAS has four underlying themes: individualism, recognition of continuing discrimination, empathy for disabled people, and excessive demands. The SAS is a tool that can be used to help understand how contradicting disability ideologies manifest in modern society to determine how best to counteract them. By using this assessment as a self-evaluation tool, both students and counselor educators can identify where their beliefs may be problematic or ableist and then set goals to address and improve in those areas.
We recommend that counselors intentionally occupy spaces where discussions on disability advocacy are occurring. Universities are often regarded as a primary source of knowledge production, but a common misconception is that the people themselves produce the knowledge. The reality is that not all disability content is produced by disabled individuals or organizations. Thus, we encourage counselor educators to expand access to knowledge about disability by seeking spaces outside the institution that share insider perspectives on the disability experience and organizations dedicated to empowering disabled communities. This may involve engaging with informal educational organizations such as Sins Invalid, AXIS Dance Company, and Krip Hop Nation or getting involved with formal professional organizations such as APA Division 22, the American Rehabilitation Counseling Association, or the National Rehabilitation Counseling Association. Some strategies that can be used to advocate for and in support of disabled clients include client-centered advocacy, understanding disability as a cultural identity, and building knowledge of the disability rights movement, ableism, and intersectionality, as well as integrating disability-inclusive language, avoiding ableist assumptions, and incorporating clients’ lived experiences into treatment (Chapin et al., 2018; Smart, 2015; Smith et al., 2011).
The foundation for a competent and qualified counselor begins with their training. This training can be formal education or ongoing professional development. For those responsible for educating counselors-in-training, laying the foundation for anti-ableism practices begins in the classroom. A universal design for learning (UDL) framework, developed by the Center for Applied Special Technology (CAST, 2018), aims to create accessible material and inclusive environments that are usable for all people by intentionally incorporating multiple representations of content to enhance student expression of learning and increase a variety of opportunities for engagement with the learning environment (Black et al., 2015; Dolmage, 2017; Fornauf & Erickson, 2020). UDL principles support anti-ableist practice by encouraging an ongoing partnership between students and instructors that facilitates consistent and practical feedback to promote student belongingness (Hennessey & Koch, 2007; Oswald et al., 2018). Promoting belonging and acceptance in counselor education programs requires intentional strategies that foster inclusivity, respect for diversity, and a strong sense of community. Effective techniques include: 1) Use inclusive curriculum design. Integrate diverse perspectives throughout the curriculum, with special attention paid to marginalized voices, such as disabled voices. 2) Use culturally responsive pedagogy. This includes employing a range of instructional methods to cater to diverse learning styles. Use trauma-informed practices by creating a learning environment that is sensitive to trauma, both past and present. 3) Implement community-building activities such as structuring programs around cohorts and encouraging the formation of affinity groups and peer support groups. 4) Encourage active dialogue and reflection around tough conversations such as diversity, ableism, inequality, and marginalization. This can be done both in person and online via discussion boards. Faculty can also encourage students to explore their thoughts, reflections, and experiences around issues of identity, belonging, and ableism in a reflective journal. 5) Collect feedback to guide continuous improvement. Faculty can assess students’ experiences with inclusion and ableism through climate surveys.
Additionally, the adoption of multiple methods for delivering information in alternate formats and continuous assessment of student progress reduces barriers to student engagement and expression in the learning environment, which in turn systematically challenges normative ableist practice that values a one-size-fits-all perspective that often neglects disabled thought and existence in pedagogical practices (Oswald et al., 2018). UDL strategies to disrupt ableist thought and practices may include using closed captioning on visual multimedia content (e.g., videos, PowerPoint presentations), incorporating movement breaks, creating interactive activities (e.g., role-play activities, gamification, debates on critical topics), and receiving feedback on instruction.
Hill and Delgado (2023) discussed the importance of including disability coursework and content across multiple domains to effectively address ableism in counselor education programs. Building upon their work, we suggest that the following key types of coursework and content be included. At a minimum, disability content should be integrated into the core CACREP curriculum areas: professional counseling orientation and ethical practice, social and cultural foundations, lifespan development, career development, counseling practice, group counseling, assessment and diagnosis, and research and program evaluation (CACREP, 2023).
Foundational Disability Studies
Students should explore and understand how ableism developed and its systemic nature, especially in the current political climate (Campbell, 2009; Dolmage, 2017). Additionally, students can learn about models of disability: medical, sociopolitical, functional, religious, moral, and biopsychosocial (Engel, 1977; Shakespeare, 2006; Smart, 2015). Students must also understand the concept of intersectionality, which examines how disability interacts with race, gender, sexuality, and socioeconomic status (Erevelles & Minear, 2010; Garland-Thompson, 2005).
Ethics and Multicultural Competence
Students should understand the intersection of disability and ethics by being able to apply the ACA Code of Ethics to disability issues (Chapin et al., 2018; Feather & Carlson, 2019). In either an ethics class or a multicultural class, students must learn about crucial disability-related legislation, such as the Rehabilitation Act of 1973, the Americans with Disabilities Act, the Individuals with Disabilities Education Act, and the Workforce Innovation and Opportunity Act. In the multicultural class, students need to understand disability cultural competence and receive training on disability as a cultural identity and recognizing ableism as a form of oppression (Feldner et al., 2022; Smith et al., 2011). Additionally, in the multicultural class, students should be taught about biases and microaggressions, as well as how to identify and address ableist language and behavior.
Counseling Skills and Practice
In a counseling skills class, students must learn accessible counseling techniques, such as modifying approaches for different abilities (e.g., sensory, cognitive, mobility). Students should also be presented with case studies involving disabled clients, with an emphasis on strengths-based and person-centered approaches. Additionally, students ought to receive supervision and advocacy training on how to support and advocate for clients with disabilities in clinical settings. Counselor educators can use the strategies listed here in the classroom and in practice.
Directions for Future Research
Two of the three authors of this article are disabled and bring lived experience to their teaching, writing, research, and engagement with the nondisabled world. This real-world experience informs the strategies presented and has been applied in both classroom and professional settings. However, these approaches have not yet been empirically tested through formal research. Future research could focus on empirically validating these strategies through qualitative or quantitative studies, particularly in evaluating confidence when working with disabled clients before and after implementing these strategies. Strategies include incorporating disability knowledge into the counselor education curriculum coursework (Hill & Delgado, 2023), using critical pedagogy and disability justice frameworks when teaching (Dolmage, 2017; Erevelles & Minear, 2010), providing experiential learning and opportunities for contact with disabled individuals (Smith et al., 2011), giving disability-related education and training for faculty and supervisors (Feldner et al., 2022), and encouraging the development of allyship and advocacy skills (Feldner et al., 2022; Goodman et al., 2004). Additional studies are also needed to examine ableism and confidence in teaching anti-ableist concepts and disability-related competencies by counselor educators. Finally, scales or measures to assess ableism, specifically in counselor education, could be created and validated.
Conclusion
These strategies do not aim to be an all-encompassing, definitive, or exhaustive checklist, as there are many ways to dismantle ableism. These strategies are a starting point, a reminder, a point of reflection, or an opportunity to affirm current strategies. Significantly, these strategies extend beyond counseling and are relevant across various educational and professional settings, from K–12 classrooms to higher education, social work, health care, and beyond. Wherever you land, we invite you to continue learning, growing, and committing to change with us. Alice Wong (2020) proclaimed, “There is so much that able-bodied people could learn from the wisdom that often comes with disability. However, space needs to be made. Hands need to reach out. People need to be lifted up” (p. 17). Together, we can extend our hands, challenge systemic barriers, and work to dismantle ableism in counseling settings and across all aspects of society.
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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Julie C. Hill, PhD, NCC, BC-TMH, LPC, CRC, is an assistant professor at the University of Arkansas. Toni Saia, PhD, CRC, is an associate professor at San Diego State University. Marcus Weathers, Jr., PhD, CRC, LPC-IT, is an assistant professor at Mississippi State University. Correspondence may be addressed to Julie C. Hill, 751 W. Maple St., Fayetteville, AR 72701, jch029@uark.edu.
Aug 26, 2025 | Volume 15 - Issue 3
Mykka L. Gabriel, Laura G. Dunson Caputo, Jenny L. Cureton
Despite rising suicide rates and disparities in minoritized communities as well as calls from experts and community leaders to address cultural factors, most suicide risk assessment (SRA) approaches remain acultural. Counselors who use acultural SRA can cause harm by neglecting to address crucial factors that may heighten or protect clients from suicide risk. This article provides guidance for proactive and responsive broaching in SRA using the four dimensions of the Multidimensional Model of Broaching Behavior (Day-Vines et al., 2020). The model provides an overview of key concepts, explicit recommendations for counselors in diverse settings, and an illustrative case example. Concerns, limitations, and implications for counselors, supervisors, educators, and researchers are addressed.
Keywords: suicide, risk assessment, broaching, cultural factors, acultural
Recent suicide data demonstrate ongoing demographic disparities. Centers for Disease Control and Prevention (CDC; 2025) data showed an increase in suicide between 2018 and 2023 for some non-White racial groups, including a 25.2% increase among Black Americans and 10% increase among Hispanic persons. With a suicide rate of 23.8%, American Indian or Alaska Native persons continue to have the highest rate. Suicide ideation is more than twice as prevalent for adults with disabilities than those without disabilities (Czeisler et al., 2021). Kidd et al. (2023) found that significantly more transgender adults had attempted suicide than cisgender adults: 42% versus 10.6%. In a meta-analysis, Cogo et al. (2022) found that immigrants and refugees are at high risk for suicidal ideation, with rates as high as 70% in some groups. Risks also increase for immigrants and refugees if they experience trauma, socioeconomic disadvantage, or a lack of accessible care.
Recent surveys have highlighted the elevated suicide risk among LGBTQ+ youth with intersecting marginalized identities. Compared to White LGBTQ+ youth, non-White groups reported higher rates of suicidal ideation and attempts. For example, 43% of White, 46% of Latinx, and 55% of Native/Indigenous LGBTQ+ youth attempted suicide in 2022 (The Trevor Project, 2023). Findings from the 2024 survey continued to show higher rates of suicidal ideation among LGBTQ+ youth of color (The Trevor Project, 2024). Sallee et al. (2022) found similar results in their study on interpersonal predictors of suicide among “not straight” adolescents. The authors also highlighted the need for further research on the “unique stressors” of non-White “not straight” students. Collectively, these studies emphasize the necessity of integrating connections between suicide risk and minoritized identity.
Critical suicidology is an emerging qualitative approach increasingly recognized in the mental health field wherein suicidal experiences are contextualized through a cultural and social lens (Marsh, 2020; White, 2017). Community and government leaders have urged professionals to address cultural factors of suicide (Miller & Castle Work, 2024; Rhodes, 2023; U.S. Department of Health and Human Services [DHHS], 2024), which are both individual as well as socioecological (Compton et al., 2005; Day-Vines, 2007; Molock et al., 2023). For instance, systematic oppression is associated with increased suicide risk (Alvarez et al., 2022; Fulginiti et al., 2021). Other contextual factors, such as cultural sanctions and family or social conflict, are better predictors of suicide attempts than acultural factors (Chu et al., 2019; Compton et al., 2005). Acultural understandings of suicide do not include cultural considerations; instead, they only cover “classic risk and protective factors” (Chu et al., 2019, p. 56) such as depression (Chu et al., 2019; Khan, 2005), substance abuse (Lawson-Te Aho & Liu, 2010), and reasons for living (Chu et al., 2019), which are typically conceptualized without acknowledging systemic contributors (Hazan & Romberg, 2022; Lawson-Te Aho & Liu, 2010).
Counseling research has shown that mental health symptoms of Black, Indigenous, and people of color can present differently than those of White clients (Litam, 2020; Wright et al., 2023). However, most suicide risk assessment (SRA) approaches are acultural, which means that they lack consideration of sociocultural factors in suicide risk (Chu et al., 2019; Mendoza-Rivera et al., 2022). Neglecting to address culture in SRA can cause serious misunderstandings of the client’s experience and underestimate their risk of suicide (Rogers & Russell, 2014; Van Zyl et al., 2022). Counselors must consider suicide risk in the context of culture in order to meet clients’ needs as well as to maintain ethical and practice standards (American Association of Suicidology [AAS], 2023; American Counseling Association [ACA], 2014; Ratts et al., 2016). Yet, scant counseling literature (Chu et al., 2013; Molock et al., 2023) provides concrete guidance on how to address culture while assessing suicide risk.
Integrating the Multidimensional Model of Broaching Behavior (Day-Vines et al., 2020) into SRA procedures is a plausible solution for these challenges. Broaching explores racial, ethnic, and cultural (REC) contexts throughout the counseling process (Day-Vines et al., 2007). Broaching applications have been well-documented in the counseling literature (Bayne & Branco, 2018; Day-Vines et al., 2007, 2020; Jones et al., 2019; Jones & Welfare, 2017; King, 2021). In a recent Counseling Today article, counselors noted cultural norms that may exacerbate suicide risk and the use of broaching to build trust (Rhodes, 2023). Our article describes an application of the broaching model (Day-Vines et al., 2020) used in tandem with evidence-based SRA tools when assessing suicide risk with minoritized clients. We briefly review the intersection of culture and suicide, review broaching, compare acultural with culturally responsive SRA, and present the potential of broaching to address the barriers mentioned above. The proposed broaching application contains suggestions for when, what, and how to broach culture for SRA, along with brief illustrative examples. We include implications for counseling, supervising, and teaching, then conclude with critical considerations for counselors and directions to research broaching for culturally responsive counseling related to suicide.
Culture and Suicide
Recommended practice for SRA includes the combination of a formal instrument, or lethality measurement scale, and a clinical interview about the client’s protective factors, ideation, intent, plans, access to lethal means, behavior, and warning signs (AAS, 2023; Jackson-Cherry et al., 2017). Clinical judgment should consider “developmental, cultural, and gender-related issues related to suicidality” (AAS, p. 2). Cultural factors, such as oppression, stigma, misconceptions, and community disconnection, can influence suicide risk. A primary factor driving suicide risk is cultural oppression, including historical trauma, structural racism, and other discrimination (Fulginiti et al., 2021). Suicide risk is higher for individuals with multiple oppressed identities (Vargas et al., 2020), such as Latinx LGBTQ youth (Abreu et al., 2023). People from marginalized communities, such as sexual, gender, and racial minorities (Ayhan et al., 2019; Sim et al., 2021) and people with disabilities (Krahn et al., 2015) face harmful oppression from the health care system itself because of bias and preconceived judgments on presenting behaviors (Johnson, 2024).
Members of these communities also experience stigma and misconceptions. Several instruments measure suicide stigma or negative judgments toward people experiencing suicidal thoughts (Nicholas et al., 2023). Internalizing suicide stigma or stigmatizing messages about one’s minoritized identities increases suicide risk (Carpiniello & Pinna, 2017). Some suicide misconceptions are related to culture. For example, James et al. (2023) found misunderstandings among Black Americans that suicidal thoughts are temporary or not real and that only people from other races or those too weak to deal with life stressors have such thoughts.
These cultural factors can influence whether and how individuals seek support for suicide. Members of marginalized groups report avoiding seeking professional help because of health care oppression (Dautovich et al., 2021). They may not disclose suicidal thoughts to professionals, family, or friends based on messages in their cultural community that doing so would make loved ones disappointed in them, bring shame to their family, and/or prompt their isolation from the community (Knapp & Logan, 2023; Molock et al., 2023).
Suicide protective factors (SPFs) are internal and external factors that create protective barriers that reduce death by suicide (Crosby et al., 2011). Other cultural factors may protect against suicide. Most ethnoracial groups experience social support, community connectedness, and ethnic identity as SPFs (Odafe et al., 2016; Wang et al., 2020). Support from family and friends also acts as an SPF for LGBTQ+ individuals, including queer youth of color (Lardier et al., 2020) and transgender/gender-diverse adults (Rabasco & Andover, 2021). It is important to note that religious, moral, or cultural objections to suicide may be an SPF for some but a risk factor for others in their cultural group and can change from protecting to exacerbating an individual’s suicide risk because of isolation or distress from stigmatizing messages (Odafe et al., 2016; Sharma & Pumariega, 2018).
Competent counseling for suicide involves assessing for suicide risk factors and SPFs and then using that information to inform interventions and continuity of care (AAS, 2023). Standard suicide assessment practices are largely acultural, omitting essential factors like race, ethnicity, and culture in a client’s suicide risk (Chu et al., 2013; Day-Vines, 2007; Molock et al., 2023; Van Zyl et al., 2022). Common SRA tools include the Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008), the Collaborative Assessment and Management of Suicidality (Jobes & Drozd, 2004), and the Ask Suicide-Screening Questions (Horowitz et al., 2012). For example, nearly two decades of C-SSRS validation provides evidence across 10 psychometric properties (The Columbia Lighthouse Project, n.d.). This research has examined samples diverse in setting, diagnoses, age, and cultural demographics, and it has been translated into over 150 languages. The C-SSRS contains questions related to suicide ideation, intensity, and behavior to determine the level of risk (Posner et al., 2008). It has shown high specificity in multiple studies (Kumar et al., 2025) and is one of the few suicide scales that demonstrates sensitivity to change in suicide risk across time (Riblet et al., 2023). However, researchers have noted a persistent lack of meta-analyses investigating the C-SSRS and similar acultural measures with culturally diverse samples (Nam et al., 2024; Pollak et al., 2024).
A few recent SRA tools explicitly address culture, including the Cultural Assessment of Risk for Suicide (CARS; Chu et al., 2013); its screener version, CAR-S (Chu et al., 2018); and SHORES (Cureton & Fink, 2019). CARS is a formal instrument tested with samples including racial, ethnic, and sexual minority adults (Chu et al., 2013, 2019). These validation studies showed acceptable internal consistency for its subscales and high internal consistency overall compared to acultural SRA measures. A recent investigation of CARS with Black American adolescents (Francois et al., 2025) revealed acceptable internal consistency overall but divergent factor structure, indicating that the modified version of CARS-S may not adequately represent minority stress, family conflict, or cultural objections in Black youth suicide risk. SHORES (Cureton & Fink, 2019) is an SPF mnemonic to support recall during SRA, safety planning, and other suicide prevention, intervention, and postvention. To date, no research on its use has been published. Counselors can also utilize the Cultural Formulation Interview (CFI; American Psychiatric Association, 2022) to assess the cultural context of diagnostic symptoms. Whether an SRA tool is acultural or culture-focused, empirically supported or still emerging, two recommendations are consistent in the literature: 1) use it only as an initial or adjunct tool toward comprehensive suicide assessment (e.g., Cureton & Fink, 2019; Kumar et al., 2025) and 2) make adaptations to better address culture (e.g., Chu et al., 2019; Francois et al., 2025; Pollak et al., 2024).
Suicide Risk Assessment and Clinical Interview
As previously stated, recommended SRA practice consists of an evidence-based tool and a clinical interview (AAS, 2023; Jackson-Cherry et al., 2017). Counselors can integrate broaching into the clinical interview to explore cultural factors that shape the client’s level of risk and their subjective experience. We used the C-SSRS (Posner et al., 2008) for illustration and built on previous guidance for broaching practices in counseling (Day-Vines et al., 2020; Erby & White, 2022; Jones & Welfare, 2017) to recommend ways counselors can incorporate cultural considerations effectively into the SRA interview. Although broaching may benefit culturally responsive suicide intervention and ongoing management, we focused on its use in counselor–client collaborative risk assessment as a first step for improved practice.
Broaching
Day-Vines et al. (2007) coined the term broaching to define the counselor’s “ability to consider the relationship of racial and cultural factors to the client’s presenting problem, especially because these issues might otherwise remain unexamined during the counseling process” (p. 401). Broaching facilitates dialogues regarding power and privilege (Erby & White, 2022), strengthens the therapeutic relationship (Knox et al., 2003), and deepens alignment with the Multicultural and Social Justice Counseling Competencies (Day-Vines et al., 2007; Ratts et al., 2016). Broaching has four dimensions of counselor acknowledgment (Day-Vines et al., 2020): (a) intracounseling: REC similarities, differences, and interpersonal processes in the counselor–client relationship; (b) intraindividual: confluence of the client’s identities; (c) intra-REC: within-group concerns between the client and one or more of their cultural communities; and (d) inter-REC: the client’s experiences of oppression. As shown in Table 1 and described below, counselors can integrate each dimension to elicit discussion about culture alongside an evidence-based SRA tool.
Table 1
Multidimensional Model of Broaching Behavior in SRA
| Dimension |
Purpose |
Focus in SRA |
| Intracounseling |
Acknowledges similarities, differences, and interpersonal processes that may impact the
client–counselor relationship |
Invites the client to take the lead role as the expert of their experience and formulate a genuine trust between the client and counselor |
| Intraindividual |
Acknowledges intersecting
identities that shape the client’s experience and view of their presenting concern |
Invites the client and counselor to explore connection(s) between intersecting REC-specific experiences and suicidal ideation |
| Intra-REC |
Identifies within-group concerns between the client and one or
more of their cultural communities |
Creates an opportunity to explore the context of the client’s belongingness, possible isolation, coping, and contribution to follow-up care |
| Inter-REC |
Acknowledges the client’s experiences specific to racism, oppression, and social justice |
Creates an opportunity for the client and counselor to specifically address barriers and disparities that directly contribute to the client’s suicidal ideation |
Note. Table 1 includes the purpose of each MMBB dimension (Day-Vines et al., 2020) and its corresponding focus applied in SRA. Specific examples appear throughout the case study. REC = racial, ethnic, and cultural.
Application of the Multidimensional Model of Broaching Behavior in Suicide Risk Assessments
Broaching race, ethnicity, and culture is crucial in culturally responsive SRA. We propose this approach as an additive component with evidence-based tools (e.g., the C-SSRS). Broaching during the interview provides essential context for results to inform a comprehensive assessment of the client’s suicide risk. Using a case example, we explain how counselors can practically incorporate each dimension of broaching within the SRA clinical interview process.
Case Study
Elliana (she/her) presents to the university counseling center for a walk-in appointment. She is a 19-year-old first-generation college student from another state and identifies as a Black cisgender lesbian. She remembered that her professor mentioned the counseling center at the start of the semester and noticed its promotion as LGBTQ+ inclusive with culturally responsive counselors. Elliana finds it difficult to concentrate, which has resulted in lower grades. Her counselor, a Black heterosexual woman, notices that Elliana has indicated headaches, lack of sleep, feelings of hopelessness, sadness, and suicidal ideation on her intake paperwork. Elliana has not verbally disclosed her suicidal ideation to her counselor. Elliana tells her counselor she has a strong relationship with her family and a strong LGBTQ+-affirming community in her hometown. Elliana is the eldest of three from an intact family. Elliana reports feeling disconnected and isolated at school. Despite participating in various student organizations, Elliana feels like an “outsider” with little sense of belonging and conflicts with her roommate. Elliana shares that she has not disclosed her sexual orientation to her roommate because her roommate made negative comments about the LGBTQ+ community and listens to podcasts with anti-LGBTQ+ rhetoric. The counselor’s primary goal in her first interaction with Elliana is to build a therapeutic relationship and assess for safety. She administers the C-SSRS, which indicates a low level of risk (e.g., Elliana denies having any intent or plan). Therefore, the counselor can assist Elliana with a safety plan and follow-up care. To ensure a more comprehensive understanding of her risk, the counselor incorporates broaching questions to explore how Elliana’s cultural background and lived experiences influence her thoughts and coping.
Opportunities for Broaching
An element of integrating broaching in SRA is determining when to do so. SRA (AAS, 2023) and broaching (Day-Vines et al., 2020) should involve an ongoing and collaborative process. Two forms of broaching are proactive and responsive (Day-Vines et al., 2013; King, 2021). We describe each form as an opportunity to broach SRA with Elliana.
Proactive Broaching
Proactive broaching involves a counselor-led orientation to discussing cultural experiences (King, 2021). Proactive broaching initiates opportunities for clients to discuss cultural concerns (Day-Vines et al., 2020), encourages client openness (Drinane et al., 2018), and ensures more accurate information during diagnosis and assessment (King & Borders, 2019). Proactive broaching ranges from a question on a structured intake to the counselor first introducing cultural considerations into the risk assessment. For Elliana, her counselor may say, “As I’m getting to know you, can you tell me a bit about your culture?” Counselors can strengthen their proactive broaching by providing a rationale for the topic change; addressing verbal and nonverbal reactions to broaching; and utilizing skills of active listening, paraphrasing, and reflections (King & Jones, 2019).
Responsive Broaching
Responsive broaching involves a counselor’s response to a client’s disclosure (Day-Vines et al., 2020; King, 2021). This helps counselors avoid broaching at the wrong time and can particularly benefit counselors who use an organic, conversational counseling style rather than a structured style (Jones & Welfare, 2017). Responsive broaching manifests uniquely based on the situation. Counselors can respond to the client’s spoken cultural content using clinical skills. For example, in response to Elliana telling her counselor that she has a strong relationship with her family and a strong LGBTQ+-affirming community in her hometown, her counselor may paraphrase Elliana’s cultural protective factor by stating, “It sounds like you feel closely connected to your family and the LGBTQ+ community back at home. How do your connections affect your thoughts of suicide?” Responsive broaching could also invite the counselor to be more specific by asking, “How does being a part of a Black family and the LGBTQ+ community influence your thoughts of suicide?” This may invite Elliana to expand on these connections as protective factors contributing to her sense of belonging (Cureton & Fink, 2019).
Because Elliana shares common adjustment experiences with out-of-state first-year students (e.g., anxiety, time management), her counselor may utilize open questions to clarify cultural idioms of distress (APA, 2022). Counselors can also respond to a client’s unspoken cultural content. For example, clients may discuss cultural experiences, such as marginalization or belonging, without explicitly referencing specific cultural identities or terms. Counselors can broach these moments responsively by asking for clarity or gently positing the possibility of culture. For example, Elliana’s counselor may notice her isolation as a potential suicide risk and state, “I heard you say you are feeling like an outsider. Does being a young first-generation college student or having other cultural experiences play a role in your thoughts to kill yourself?” Counselors can strengthen responsive broaching by attending to client responses and utilizing immediacy to process the experience of discussing culture.
Content of Broaching
Another element of integrating broaching in SRA is determining what to broach. Both broaching (Day-Vines et al., 2020) and suicide assessments (AAS, 2023) encompass clients’ holistic experiences, suggesting that broaching can include any part of the client’s lived experience. King (2021) indicated that broaching typically serves one of two purposes: broaching cultural similarities and differences within the counseling relationship or broaching cultural content within the client’s experience. Similarly, Day-Vines et al. (2020) illustrated four dimensions of broaching: intracounseling, intraindividual, intra-REC, and inter-REC. We propose that the Multidimensional Model of Broaching Behavior can be used as a guide for counselors to utilize during the interview process of the suicide risk assessment. This section includes an interactive review of each dimension of broaching regarding an SRA with Elliana.
Intracounseling
Broaching the intracounseling dimension includes broaching similarities, differences, and interpersonal processes between client and counselor (Day-Vines et al., 2020), which communicates to the client that talking about race, ethnicity, and culture is permissible and explores how to navigate these topics within the counseling relationship (Day-Vines et al., 2020). Broaching cultural experiences within the counseling relationship strengthens the relationship (King, 2021). Counselors can broach intracounseling factors proactively or responsively. In the case of Elliana, her counselor may proactively broach by saying:
I often ask clients about their cultural identities during a suicide assessment because I want to understand how culture may play a role in their experience of suicide and mental health. We are both Black women, but I try not to assume our experiences are the same. For example, I am older than you, and we may have different generational experiences. We may also have other identities and cultural experiences that are different. I encourage you to share your experiences with me as we go through this assessment.
Here, the counselor comments on observable shared identities and invites Elliana to share her cultural experiences. The counselor also tells Elliana that she is the expert in her experience.
Counselors can also broach intracounseling factors responsively. Broaching for the relationship responsively involves identifying cultural concerns in the client’s disclosure and inviting discussion contextualized within the counseling relationship (Day-Vines et al., 2020). For example, a counselor may say, “You mentioned that you decided to come to the counseling center because your professor mentioned we are culturally responsive and LGBTQ+ affirming. I am here to support you, and together, we will make a plan of action.” With each approach, her counselor is direct and invites therapeutic support by intentionally keeping the client’s identities at the center of their relationship.
Intraindividual Factors
Counselors can assess intraindividual factors (Day-Vines et al., 2020) related to suicide, such as how cultural experiences may influence suicidality. The counselor explores Elliana’s experiences related to her intersecting identities and possible connections to her suicidal ideation. For example, the counselor may initially assess intraindividual factors by introducing the exploration: “Thank you for sharing your identities with me. You told me you do not feel like you belong, despite being involved in various activities. Could you tell me more about not belonging?” The counselor would use clinical skills to explore Elliana’s sense of belonging, reflecting on her experiences and possible distress connected to her intersecting identities.
Intra-REC Dimension
Counselors can assess the intra-REC dimension, which includes within-group concerns between the client and one or more of their cultural communities (Day-Vines et al., 2020) related to suicide. The counselor could continue to explore the differences between Elliana’s strong connections with her family and the LGBTQ+ community in her hometown and her lack of school belonging as a first-generation college student. For example, a counselor may ask Elliana, “I’m hearing you’re involved in various campus organizations, yet you feel like an outsider. From your perspective, what, if any, cultural factors contribute to this feeling?” This conversation could introduce a conversation about existing coping skills and her interpretation of her experiences. The counselor could use this information to assist with identifying Elliana’s needs, along with a focused follow-up care plan for appropriate mental health services.
Inter-REC Dimension
Counselors can assess the inter-REC dimension, which is the client’s experiences of oppression (Day-Vines et al., 2020) related to suicide. Elliana talked about her roommate making negative comments and listening to podcasts with anti-LGBTQ rhetoric. The counselor could assess the level of impact of this concern relating to her suicidality by asking “When you hear your roommate make negative comments and listen to podcasts with anti-LGBTQ rhetoric, what thoughts come to your mind?” Questions like this can help Elliana connect her own experiences and allow her to clarify if and how her roommate contributes to her suicidal ideation.
Discussion
This case study provides several factors to consider alongside an evidence-based SRA. Counselors must follow the guidelines of an SRA to ensure client safety and protective factors and make informed decisions for continuity of care. The intentional use of the Multidimensional Model of Broaching Behavior can serve as a guide to assist counselors in applying an integrative approach to the SRA interview process. Establishing trust between client and counselor can encourage insight into the client’s unique needs. The Multidimensional Model of Broaching Behavior provides the framework for intentional relationship building and conceptualizing the client—in this case, Elliana—through her overlapping identities (young adult, first-generation college student, Black, cisgender, and lesbian).
Broaching race, ethnicity, and culture applies to all clients and is not exclusive to cross-cultural experiences (Bayne & Branco, 2018). In alignment with current research (Bayne & Branco, 2018; Erby & White, 2022), broaching can be a valuable tool for assessing risk while recognizing and validating the client’s unique experiences, regardless of whether they share identities with the counselor. This idea aligns with other scholars who suggest that “all counseling is multicultural counseling” (Ivey & Ivey, 2001). Culturally competent counselors are encouraged to self-explore their broaching attitude (i.e., avoidant; Day-Vines et al., 2007, 2020) for an insightful self-assessment of the multiple dynamics within the crisis therapeutic relationship.
Broaching is a promising approach to exploring culture during SRA. However, there are some considerations. First, the nature of acute crisis often requires that responders abbreviate their assessment and hasten action to best prevent risk (Collins & Collins, 2005). In these circumstances, counselors may need to prioritize acultural SRA prompts and/or vary broaching statements based on the goal at hand (King, 2021). For instance, counselors might broach content to conceptualize risk for an immediate plan, or they might broach the relationship to promptly reduce the power differential. Indirect and/or closed-ended broaching (e.g., “Even though we are different, I want to understand what is happening for you right now so we can be together on this.”) may be sufficient in time-limited crisis response.
Second, counselors will ineffectively apply broaching if they expect universal client reactions. Day-Vines et al. (2007) suggested that client reactions to broaching vary based on internal and external factors. For example, a client may prefer to focus on a specific pressing concern instead of discussing culture. Counselors should follow the client’s lead in how culture informs the remaining SRA. If Elliana had declined to discuss her intra-REC experiences when her counselor asked about cultural factors when she feels like an outsider in various campus organizations, the counselor should refrain from asking further questions or details to respect her decision.
Implications for Counselors
There are implications for counselors when using broaching during SRA. Rather than replacing existing practice, a counselor can incorporate broaching into their typical SRA procedures. A broaching conversation with an instrument that explicitly addresses culture, such as CARS or CARS-S (Chu et al., 2013, 2018), may provide a smooth orientation to the survey and/or support nuanced exploration of its results. Counselors can prepare to use broaching in SRA by understanding which cultural factors typically increase suicide risk and which operate as protective factors. Attuning to these factors during SRA may help counselors explore social determinants of mental health (Lenz & Lemberger-Truelove, 2023; Lenz & Litam, 2023). The scope of this article was necessarily limited to SRA because of its conceptual and logistical complexity in counselor practice; however, broaching factors and determinants can inform case conceptualization, safety planning, ongoing counseling intervention, and case management.
Implications for Educators and Supervisors
Implications of broaching in SRA also exist for educators and supervisors. Their professional roles include preparing trainees to address crises and provide culturally responsive care (ACA, 2014; Council for the Accreditation of Counseling and Related Educational Programs [CACREP], 2023). Preparing trainees and licensed counselors to broach in SRA aligns with current counseling literature that advocates for improvements to suicide training (Binkley & Elliot, 2021) and a social justice framework for supervision (Dollarhide et al., 2021). Educators and supervisors would benefit from ongoing professional development, reflexive practices, and consultation to prepare them to address broaching in SRA.
Educators can introduce broaching strategies during suicide counseling instruction. This integration could help programs address CACREP (2023) standards on suicide (G.16) and multicultural counseling (Section B). Students who received suicide counseling instruction before practicum reported lower anxiety (Binkley & Leibert, 2015) and higher levels of preparedness, knowledge, and comfort in suicide response (Shannonhouse et al., 2018). Introducing broaching strategies during suicide counseling instruction has the potential to produce similar results.
Supervisors can integrate broaching SRA into supervision practice. Supervisors can broach culture within the supervisory relationship (King & Jones, 2019) to strengthen the supervisor’s understanding of the supervisee’s culture, help the supervisee comprehend their own positionality in counseling and supervision, and increase the supervisee’s understanding of broaching itself. Supervisors use discussion and case conceptualization to support supervisees’ preparedness for SRA, broaching, and their synthesis. Modeling or roleplaying broaching (Erby & White, 2022; Jones et al., 2019) in SRA may help supervisees practice skills.
Future Directions
Future scholarship can explore broaching race, ethnicity, and culture in SRA even when the client is not affiliated with a minoritized status. For instance, a White, Christian, heterosexual, cisgender male may hold multiple privileged identities, yet White males continue to show high suicide death rates (CDC, 2025). Counselors may consider using a similar approach to proactive and responsive broaching to inquire about religious and family values, social ideals, and beliefs about suicide, which shape both risk and protective factors.
Research on broaching in SRA is needed to determine the impact on client conceptualization, clinical decision-making, and postvention. Qualitative research with counselors and minoritized clients could provide insight into the experiences of broaching in SRA, informing clinical perspectives on topics such as relativity, therapeutic rapport, and training needs. Quantitative research might reveal the differential effectiveness of SRA with and without broaching. A future investigation of the Broaching Attitudes and Behavior Survey (Day-Vines et al., 2013, 2024) may determine the effectiveness of broaching in SRA. Educational research may assess the impact of incorporating broaching into SRA instruction (e.g., on confidence and skill development) and supervision in practicum and internship. Another direction is to advance the applications for broaching for intervention and ongoing management of suicide in counseling.
Conclusion
People from minoritized groups experience increased suicide risk (CDC, 2025; Czeisler et al., 2021; Kidd et al., 2023; The Trevor Project, 2023) and specific suicide risk and protective factors, such as systemic oppression (Alvarez et al., 2022; Fulginiti et al., 2021), cultural sanctions against suicide, and the impact of family/social relationships (Chu et al., 2019; Compton et al., 2005). Despite ethical and practice standards (AAS, 2023; ACA, 2014; Ratts et al., 2016) and calls from professional and community leaders (DHHS, 2024; Miller & Castle Work, 2024), most SRA practice neglects these factors (Mendoza-Rivera et al., 2022), which can increase harm (Rogers & Russell, 2014; Van Zyl et al., 2022). Counselors can improve their SRA practice by utilizing the Multidimensional Model of Broaching Behavior (Day-Vines et al., 2020) to explore REC contexts (Day-Vines et al., 2007) during initial and repeat assessments to inform intervention. Supervisors and educators can inform and guide counselors in broaching in SRA to ensure ethical and effective practice. Existing research demonstrating the positive impacts of broaching can expand to examine its use for assessing suicide risk for clients across identities.
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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Mykka L. Gabriel, LPCC-S, is a doctoral candidate at Kent State University. Laura G. Dunson Caputo, PhD, LPCC-S, is an assistant professor of practice at John Carroll University. Jenny L. Cureton, PhD, LPCC (OH), LPC (CO, TX), is an associate professor at Kent State University. Correspondence may be addressed to Mykka L. Gabriel, Kent State University, White Hall 310, PO Box 5190, Kent, OH
44240-0001, mgabri12@kent.edu.
Jul 25, 2025 | Volume 15 - Issue 2
Sara E. Ellison, Jill M. Meyer, Julia Whisenhunt, Jessica Meléndez Tyler
Nonsuicidal self-injury (NSSI) has historically been associated with deficits in impulse control; however, evidence suggests that individuals high in self-control also self-injure. This constructivist grounded theory study aimed to explore the nature of undercontrolled and overcontrolled self-injury to fill gaps in the literature and to improve clinical understanding and treatment. The resulting Theory of Overcontrolled and Undercontrolled Self-Injury provides a preliminary understanding of the mechanisms that guide overcontrolled and undercontrolled NSSI, the processes that can facilitate individuals switching profiles, and the processes that lead to cessation of self-injurious behavior, thereby contributing to the development of more comprehensive theories of self-harm. Additionally, clinical implications for developing assessments and interventions aimed at preventing and treating NSSI are discussed.
Keywords: nonsuicidal self-injury, self-control, undercontrolled, overcontrolled, self-harm
Nonsuicidal self-injury (NSSI) is the act of intentional, self-inflicted damage of body tissue without the intent to end one’s life and for purposes not socially or culturally sanctioned (Klonsky et al., 2014). NSSI takes many forms including cutting, scratching, piercing, or burning the skin; preventing wounds from healing; and head banging (Favazza, 2011). The functions of NSSI vary considerably between individuals; however, commonly endorsed reasons are emotion regulation, self-punishment, relief from dissociation, and the communication of psychological pain (Doyle et al., 2017; Edmondson et al., 2016).
NSSI affects individuals across the lifespan, but onset frequently begins in adolescence (Brager-Larsen et al., 2022). Prevalence rates in community samples suggest that approximately one in five individuals report a history of self-injury (Andover, 2014; Giordano et al., 2023). Clinically, NSSI is a frequent presenting concern; 97.9% of licensed clinicians reported working with NSSI at some point during their careers (Giordano et al., 2020). Despite this, counselors often experience anxiety and self-doubt when working with clients who self-injure (Whisenhunt et al., 2014), perhaps in part because of the limited scholarly resources available to guide intervention.
NSSI has historically been linked with impulse control problems, largely because of its association with borderline personality disorder (BPD; Hamza et al., 2015). However, recent meta-analyses examining NSSI and impulsivity have produced mixed findings (Hamza et al., 2015; Liu et al., 2017). One study examined the degree of impulsivity and found that 77% of participants waited an average of 15 minutes or less between NSSI thought and action (Glenn & Klonsky, 2010). A positive relationship was also found between the frequency of NSSI and lack of premeditation and perseverance. However, no differences in inhibitory control function were found between individuals who self-injured and those who did not. Before its recent classification as a condition for further study in the DSM-5 (American Psychiatric Association [APA], 2013), NSSI appeared only once in the manual, as a symptom of BPD.
Undercontrol and Overcontrol
Self-control is a multidimensional construct that encompasses the ability to regulate behavior following social norms, moral standards, and long-term goals (Baumeister & Heatherton, 1996). Self-control has been linked to numerous positive outcomes, including superior academic performance, well-being, and relationships (Hofmann et al., 2014; Tangney et al., 2004). However, although many theorists (e.g., Metcalfe & Mischel, 1999; Tangney et al., 2004) posit that high levels of self-control are invariably advantageous, some have argued that the relationship between self-control and well-being is curvilinear, with both the highest and lowest levels of self-control capacity being maladaptive (Block & Block, 1980; Lynch et al., 2015).
Although research on overcontrol (OC; i.e., the excessive presence of self-control) is limited, maladaptive overcontrol is not new. Block and Block developed a theory that focused on individual differences in impulse control, which varies from undercontrol to overcontrol (Block, 2002; Block & Block, 1980). Undercontrolled (UC) individuals struggle with impulse and emotion regulation, exhibiting spontaneity, impulsivity, emotional variability, disregard for social norms, and indifference to ambiguity. In contrast, overcontrolled individuals excessively inhibit their impulses and expressions, which is characterized by emotional restraint, dependability, high organization, and an unnecessary delay of gratification or denial of pleasure. More recently, Lynch (2018) proposed a transdiagnostic model of disorders of overcontrol in conjunction with the development of Radically Open Dialectical Behavioral Therapy (RO DBT). This model suggests that although overcontrolled individuals often achieve measurable success, they frequently experience pervasive loneliness and psychological distress.
Undercontrolled and Overcontrolled NSSI
NSSI has historically been associated with deficits in impulse control (Glenn & Klonsky, 2010); however, evidence suggests that individuals high in self-control also self-injure (Claes et al., 2012; Hempel et al., 2018). Hempel et al. (2018) found that self-injurious behavior in undercontrolled individuals is typically impulsive, emotionally driven, and may involve others. In contrast, overcontrolled individuals tend to engage in planned, rule-governed, and secretive self-injury. Although this study offers compelling evidence of differing self-injurious behaviors based on undercontrol and overcontrol, further research is needed to fully understand these differences.
Purpose of the Study
Despite extensive research on NSSI, much remains to be understood about this behavior. The inclusion of NSSI as a condition for further study in the latest DSM revision (APA, 2022) underscores the need for more research to refine diagnostic criteria and clinical interventions. Significant research has yet to focus on NSSI within the frameworks of undercontrol and overcontrol. Thus, our study aimed to develop a theory about undercontrolled and overcontrolled self-injury in order to fill existing gaps in the literature and to enhance clinical understanding and treatment. Our research question was: What are the experiences, attitudes, and behaviors related to undercontrolled and overcontrolled self-injury?
Method
We selected a constructivist grounded theory approach, which seeks to offer explanations about a phenomenon from the perspective of those who experience it (Charmaz, 2014). This inductive approach facilitates the construction of a theoretical model that systematically describes processes associated with the phenomenon of interest (Charmaz, 2014) and, therefore, is well-suited to helping counselors understand their clients’ experiences and behaviors (Hays & Singh, 2023). Constructivist methodology holds the ontological position that our world is socially constructed through interactions over time; therefore, the researchers and participants are co-creators of knowledge (Charmaz, 2014).
Researcher Reflexivity
Reflexivity is essential if researchers’ experiences and interpretations influence the grounded theories they construct (Charmaz, 2014). Sara E. Ellison is a White cisgender woman, a doctoral student, and a licensed professional counselor (LPC). She has experience working with clients who self-injure in residential and outpatient settings, which sparked her interest in the differences in undercontrolled and overcontrolled NSSI. This clinical experience and her training in dialectical behavior therapy (DBT) and RO DBT influenced the expectation that UC NSSI would align with characteristics such as impulsivity, emotionality, and openness, and that OC NSSI would align with planning, inhibited emotion, and secretiveness. Jill M. Meyer is a White cisgender woman, a professor and Director of Counselor Education at a CACREP-accredited R1 university, and an LCPC. Her education, training, and clinical experiences are outside of this topic area, positioning her to be objective in the study of NSSI. She approached this research with curiosity about whether OC and UC NSSI would reflect characteristics previously described in the literature on OC and UC.
Julia Whisenhunt is a White, cisgender woman and a professor at a regional comprehensive university with a CACREP-accredited program. She is an LPC and a certified professional counselor supervisor who specializes in crisis intervention and has studied NSSI for approximately 15 years. Based on her work with clients who self-injure and her prior research and scholarship on the topic, she entered with core assumptions about NSSI that may have contributed to her conceptualization of the data. Whisenhunt believes that NSSI most often serves as a coping skill for intense intrapersonal experiences (e.g., self-loathing, despair, anger, fear, shame, anxiety, dissociation) and is best treated through a person-centered approach. Jessica Meléndez Tyler is a Latina cisgender woman and a faculty member at a CACREP-accredited R1 institution. She is a licensed counseling supervisor with 15 years of experience working with at-risk adults in outpatient settings. Tyler’s clinical experiences have deepened her understanding of the complexities of NSSI, driving her commitment to advancing knowledge and interventions in this area. She approached this research with the assumption that UC and OC play a significant role in NSSI and that effective and humanistic therapeutic interventions can improve the quality of life for affected individuals. Our values of empathy, compassion, and a nonjudgmental approach to behaviors that have often been misunderstood by the public guided our interpretation of the data, aiming to view NSSI through a lens of human complexity rather than pathology.
This research was completed as a dissertation study with Ellison receiving support and guidance from the other authors throughout the research process. Ellison conducted intensive interviews and coding, with Meyer and Whisenhunt advising and supporting the consideration of multiple perspectives. We met eight times during data collection and analysis, during which we reviewed emerging codes, participant narratives, and developing theory. We also engaged in reflexivity exercises and triangulated the findings with existing NSSI scholarship. Tyler assisted with study conceptualization and manuscript development.
Participants and Procedures
After obtaining institutional review board approval, we used purposeful criterion sampling and theoretical sampling to recruit participants (Timonen et al., 2018). Selection criteria included adults who had self-injured five or more times in their lifetime and self-identified as undercontrolled or overcontrolled. Although qualitative research on NSSI often includes individuals with any NSSI experience (e.g., Hambleton et al., 2022), we chose to recruit those with significant NSSI histories to better understand their behavioral, emotional, and cognitive patterns. This is consistent with previous qualitative research including those who have self-injured five to six times in their lifetime (da Cunha Lewin et al., 2024; Kruzan & Whitlock, 2019).
It is recommended that researchers screen participants for vulnerabilities and balance the need for rich data with potential harm when asking sensitive questions (Hays & Singh, 2023); therefore, we conducted a literature review to assess the potential iatrogenic effects and benefits related to participating in interviews broaching NSSI. Researchers have viewed self-injury in the context of the transtheoretical stages of change model and suggested that individuals enter the termination stage after 3 years of abstinence from NSSI behavior (Kruzan et al., 2020). Previous studies (Muehlenkamp et al., 2015; Whitlock et al., 2013) have indicated that participating in detailed NSSI research did not have significant adverse effects; however, to minimize risk, participant eligibility for the study was based on the absence of any current suicidal ideation and no self-injury in the past 3 years.
In order to reach individuals with meaningful self-injury experience, we posted a recruitment flyer in four Facebook and Reddit support groups related to self-injury. We also emailed calls for participation to experts in the field and shared them on listservs, including Counselor Education and Supervision Network, Georgia Therapist Network, and Radically Open DBT Listserv. Participants received a $25 e-gift card as compensation for their time and contributions.
The 20 study participants all self-identified as undercontrolled (UC; n = 10, 50%) or overcontrolled (OC; n = 10; 50%) as described by Block and Block (1980). Most participants identified as White or Caucasian (n = 14, 70%), with three identifying as Multi-Racial (15%), two identifying as African American and/or Black (10%), and one identifying as Hispanic or Latino/a/x (5%). Likewise, most participants identified as women (n = 18, 90%), with one identifying as a nonbinary woman (5%) and one identifying as a man (5%). Participants ranged in age from 18 to 43, with the mean age being 29.4. The participants lived in various geographic regions, with the most common region being the South (n = 12, 60%), followed by the Midwest (n = 4, 20%), Northeast (n = 2, 10%), and West (n = 2, 10%). We ceased recruiting participants once we achieved comprehensive coverage of emerging categories and new data no longer provided theoretical insights (Charmaz, 2014).
Data Collection
After identifying eligible participants via a screening and demographic questionnaire, Ellison conducted intensive, semi-structured Zoom interviews, each lasting about 60 minutes. The researchers developed the interview protocol after reviewing current qualitative literature and assessment measures on NSSI and consulting with two NSSI subject matter experts with significant qualitative research experience (see Appendix for complete interview protocol). Intensive interviewing relies on the practice of following up on unanticipated areas of inquiry prompted by emerging data (Timonen et al., 2018); therefore, after several participants mentioned their reactions to NSSI in peers or media representations, a question related to perception of others’ NSSI was integrated into subsequent interviews. Participants chose pseudonyms in order to protect their identities; all interviews were audio-recorded and transcribed. Participants were then invited to review their transcripts and make any revisions, redactions, or additions to ensure the accuracy of their voices and experiences.
Data Analysis
Ellison conducted initial coding by labeling data segments to summarize and categorize them. Transcripts were repeatedly read and analyzed as new data were collected to identify similarities and differences in participant narratives. Focused coding then aimed to refine the most salient codes into categories and themes in order to develop a larger theory (Charmaz, 2014). During this phase, Ellison condensed the 38 initial codes into concise descriptions encapsulating participants’ narratives, resulting in 15 themes that explained the relationships between findings. This process moved the analysis from descriptive to conceptual, guiding theory development (Charmaz, 2014). Ellison, Meyer, and Whisenhunt met multiple times to review the developing codebook, connect data, and clarify theory development.
Constant comparative methods (Glaser & Strauss, 1967) were used throughout coding to identify patterns and to ground the theory in participant narratives. Memo writing recorded analytic ideas for later follow-up. Data and codes were organized using Dedoose, a HIPAA-compliant, password-protected online qualitative software. After reaching theoretical saturation we conducted member checks by emailing participants a summary of themes and categories to solicit feedback. All 20 participants confirmed that the emerging theory aligned with their experiences.
Trustworthiness Strategies
Several strategies were employed to enhance rigor and mitigate methodological limitations in this qualitative study. Participant perspectives and the investigated phenomenon’s authenticity are crucial for the study’s validity (Denzin et al., 2023). Member checking was consistently used during data collection and analysis, enabling participants to confirm the relevance of findings to their experiences. Follow-up questions were integrated into interviews to clarify participant responses (Hays & Singh, 2023) and participants reviewed their interview transcripts and initial findings to provide feedback (Charmaz, 2014). Five participants contributed additional insights, enriching the theoretical framework with their unique perspectives. Researcher reflexivity was employed to acknowledge personal beliefs, values, and biases that might influence data interpretation (Hays & Singh, 2023), addressing reactions to participants, insights into potential findings, and adjustments made to the research process.
Findings
The findings of this grounded theory analysis describe the experiences, attitudes, and behaviors related to OC and UC NSSI, including the processes that can facilitate individuals switching profiles and the processes that lead to the cessation of self-injurious behavior.
OC NSSI
Restrained
OC NSSI was associated with high levels of restraint, which allowed participants to mask negative emotions, delay self-injury, and moderate how deeply they cut. Motivated by the highly private nature of OC NSSI, participants often postponed their self-injury for several hours or more to keep it hidden. This time was frequently used to plan when, where, and how self-injury might occur. Emma described this:
There were definitely times where maybe something would happen like at school. Or somewhere out in public or something like that. Where I knew that . . . because I was extremely secretive about what I was doing, that I maybe thought, “well, later I might go home and do that.” I can’t remember ever thinking to myself, “well, I need to go home right now and cut,” you know? That was never crossing my mind.
Participants also used restraint during the behavior, cutting deeply enough to feel relief but not so severely that it resulted in medical attention or attention from others. Jenny shared:
When I was cutting . . . I had to really pay attention. Really focus, laser focus, to not do something wrong or not cause more grievous harm or also to sort of maintain some pain, but maybe not too much pain, not go too deep.
Participants expressed a sense of pride in their ability to utilize restraint related to OC NSSI, which contributed to their sense of identity and differentiated their behavior from impulsive conceptualizations of self-injury.
Highly Private
Participants were highly private about their OC NSSI, prompting them to avoid disclosure experiences, take great care to hide injuries and scars, and avoid medical attention. This desire to conceal their self-injury was often motivated by maintaining a specific image or not burdening others. Emma shared, “I didn’t want to be a burden to anyone or my pain to be a burden to anyone. And so that was my worst nightmare, for someone to know what was going on.” OC NSSI was seen as deeply personal and carried out solely for the benefit of participants. The highly private nature of OC NSSI influenced the location of participants’ self-injury as well as rules that would support keeping it hidden, as Madeline described:
I never . . . very rarely cut on my arms or like even my legs because I [was] training for triathlons and was swimming. And so a lot of it was like on my breasts, on like my pelvic area where it would never be seen.
The avoidance of medical care meant that some participants took responsibility for caring for severe wounds independently. Phoenix described learning to suture her wounds on YouTube. Rex instituted a disinfecting process after a cut on her leg became severely infected: “I didn’t want to end up in the hospital having to have somebody ask a question about [self-injury].” Even after the cessation of NSSI, participants were often reluctant to discuss the behavior. Jenny disclosed that her participation in this study represented more discussion about her self-injury than all her other disclosures combined. The private nature of participants’ OC NSSI made them less likely to seek help, including mental health care.
Guided by Rules and Ritual
Participants describing OC NSSI spoke of rules that dictated their use of specific tools, number of cuts, and locations on the body. Often, these rules were based on a compensatory approach to self-injury in which participants responded to specific wrongdoings or perceived failures with distinct approaches to self-punishment. These rules provided the scaffolding for behavior that became ritualistic. Participants described a structured, disciplined approach to self-injury that was often motivated by upholding established routines rather than emotional dysregulation or NSSI urges. Katie shared that her self-injury occurred nightly around the same time and in the same location: “There were nights where I didn’t really feel like I had like a lot of emotions. And it was more of that secret part of it, where I was keeping a routine. Like, ‘Well, time to go do this.’” Madeline adhered rigidly to the rules and ritual she had established for herself: “I’m not gonna stop. If I’ve decided this is gonna happen 113 times, I’m doing 113. Like, regardless of if I decide halfway through, I don’t wanna keep doing this.”
Participants also described ritualized aftercare, often involving an organized medical supply kit, which became a meaningful part of the self-injury process. In some cases this also involved photographing, writing about, or otherwise documenting their wounds. Phoenix shared that she “always stitched it up, or whatever. In the moment, it was something that was very destructive. But afterwards, it was always taken care of . . . maybe in a way, that was a way of kind of taking care of myself.” The rules and rituals associated with participants’ OC NSSI created order and structure in their lives. They imbued the behavior with meaning that elevated it beyond a simple emotion regulation tool.
Perception of Others’ NSSI as Inferior
Participants describing OC NSSI often expressed feeling as though their self-injury was superior to others’ and were highly judgmental of NSSI that they viewed as impulsive or not intentionally hidden. They eschewed the idea of their own NSSI as attention-seeking and felt a sense of pride in their ability to control their impulses and affect and meticulously hide their behavior. Katie shared, “I think I felt very judgmental of [others who self-injured], like, ‘How come you’re doing this to yourself and then sharing it to everybody?’ Like, ‘I can’t believe you’re using this to get attention and stuff like that.’”
These participants used words such as “correct,” “pious,” “better,” and “right” to describe the way they self-injured, positioning themselves as morally superior and intrinsically dissimilar from others who approached the behavior differently. Emma described this:
Pride is a strange word to describe it, but it was almost sort of like being more pious. It was like . . . I’m holding this big secret. I’m doing this thing, and that’s the way it should be. So I felt like I was doing it correctly.
Participants viewed their OC NSSI as different from what they saw around them, which contributed to both a sense of isolation and a feeling of pride.
Cessation—Loss of Utility and Defined Decision to Stop
Cessation of OC NSSI often occurred when the behavior lost its utility and followed a defined decision to stop. This pragmatic approach meant that once the benefits of self-injury waned, participants saw no reason to continue to engage with it, as Katie described:
I feel like I achieved what I wanted to achieve and now I don’t feel like doing it anymore . . . I remember going into therapy afterwards and thinking, “I don’t know why I’m here because like I don’t even feel these urges anymore. So . . . there’s no point.”
Although cessation experiences sometimes included counseling or other interventions, they often occurred independently, consistent with the highly private nature of OC NSSI.
Scaffolded by their ability to exercise restraint, participants rarely went back on their decision or experienced a lengthy cessation process. Katie stated, “I think that was another part of the control. Like I get to decide when I do this and how I do this and when I stop and stuff like that.” Lauri also identified a defined ending of her self-injurious behavior:
I actually got to a point where I was like, “Okay, I’m in my 30s now. This has like, you know, got to stop. Like, this is not okay.” But I actually went and got a tattoo as a marker that I’m not doing this anymore, and I haven’t.
The resoluteness with which they committed to their decision to stop often felt more salient than any distress they experienced because of cessation.
UC NSSI
Impulsive
UC NSSI was described as occurring in an impulsive and unplanned manner. Participants described an urgency to their self-injurious thoughts that motivated them to seek immediate relief, often within minutes of the decision to self-injure. Lauri stated that when she had an urge to self-injure, “It was kind of like a panic, like trying to get to it as soon as possible to get relief.” To facilitate this, some participants always carried self-injury tools with them. Others used whatever they could find nearby, even it was not their preferred instrument. If these participants delayed their self-injury, it was due to seeking favorable circumstances rather than planning or premeditation. Amy shared: “There wasn’t a premeditated like separate razor blade or anything. It was just, I knew where and when I could do it. And so if I got overwhelmed, I might go take a shower or something.” This impulsiveness sometimes contributed to disclosure experiences because participants could not inhibit their self-injury urges until they reached a private space, or their hastiness contributed to others’ suspicions.
Disclosed Despite Secrecy
UC NSSI was often disclosed despite participants’ desire for secrecy. Participants’ inability to delay their NSSI behavior or mask their emotions sometimes contributed to self-injuring with others present or in manners that were more likely to be discovered. Additionally, participants described conflicting feelings related to disclosure in which they often desired for others to know about their NSSI while simultaneously experiencing shame or embarrassment about the behavior. Rose described wanting to cut in places that could be covered, but also shared that she didn’t hide her self-injury from her friends:
I had a couple of really close friends at college, and I told one of them pretty early on, and that was voluntary . . . I don’t remember how I told the others or if I just said, “it’s okay if you tell the others.” But eventually, my friend group knew.
Lola described hiding her self-injury, but not so deliberately that it didn’t raise people’s suspicions: “I always wore long sleeves, which definitely I guess I could say my parents felt a little bit suspicious of when it was summertime and stuff.” Eventually, Lola’s mom became so suspicious that “she asked to look, and so I showed her, and she found out, and we had a conversation about it and everything.” Jane also shared conflicting thoughts related to disclosure. On one hand, she shared, “I would cut my arms mostly. And that was like a, ‘hey, I’m doing this,’ kind of thing.” At the same time, she remembered thinking:
This is embarrassing. I don’t really want people to know or ask me about it. But it was also like, in a place where like, sometimes I’d be in a t-shirt. So sometimes you would see it. Or sometimes people would notice.
Participants’ ambivalence about disclosure often resulted in inconsistent or disorganized concealment behaviors, making the discovery of their NSSI by others more likely.
Guided by Emotion
Emotion influenced when, where, and how UC NSSI occurred. Participants reported being highly responsive to their mood states and experiencing self-injury as a potent strategy to cope with dysregulation. Because they were typically unable or unwilling to inhibit their impulses, self-injurious behavior often occurred at the peak of emotional distress. Rose reported that “any negative feeling, but especially like guilt or regret [or] shame” might trigger an episode of self-injury, “so it was very much an emotional regulator.”
Pacey described the emotional intensity when he would self-injure: “Definitely [self-injury would occur] at the top. Sometimes I remember crying really hard when it was happening, or feeling so anxious that I was lightheaded. And the cutting would help bring that emotion down.” This connection between emotionality and UC NSSI meant that participants more frequently conceptualized their triggers as interpersonal, resulting from interactions that precipitated emotional distress.
Perception of Others’ NSSI as Superior or Relatable
If participants encountered peers that self-injured or media representations of NSSI, their view was often that others’ NSSI was superior or relatable. Participants sometimes described feeling that others’ self-injury was “cooler,” “better,” “brave,” or more “impactful” than their own and endorsed a desire to emulate this. Jane shared:
There was definitely a period of time where I would see people who maybe were self-injuring in a way that was more aggressive than I was doing it and definitely had some inferiority complex going on like, oh . . . mine’s not impactful . . . I felt like an imposter.
When Pacey joined online support groups, he “felt a lot of similarities to their stories . . . And it was nice to know that I wasn’t alone.” Even when participants identified a misalignment between others’ self-injurious behaviors and their own, they typically remained nonjudgmental and assumed that others were doing the best they could. Rose shared:
In the books I read, it was portrayed really sympathetically. Like, they’re struggling, and so are the friends [I knew that self-injured]. But somehow still, I got that idea of people do it for attention. But my personal experience from books and friends was just like, they’re having a hard time, and that’s the only way they can figure it out.
Participants’ view of others’ NSSI as superior or relatable influenced their willingness to engage in conversations with others who self-injured, further supporting their capacity to seek and receive help.
Cessation—Interpersonal Influence and Protracted Process of Stopping
Interpersonal influence (e.g., therapy or pressure from peers or family) contributed to the cessation of UC NSSI. Jasmine described the support from her inner circle as essential to her self-injury cessation. “They would encourage me to call one of them and just have them come over or have me go to the restroom or outside near a tree and just talk through what my emotions were telling me.” Amy also leaned on support from friends:
Having that friend that knew about it from freshman year that I lived with was also a help in not doing it again because I could go literally right next door to her room and kind of talk about how I was feeling for a second and sit on her floor and just let that feeling pass.
Rose shared that seeing a counselor twice weekly supported her in decreasing and ultimately stopping NSSI. Because participants frequently had already disclosed their UC NSSI, interpersonal support was more likely to be available and, therefore, influential to cessation.
Participants also highlighted the lengthy process of stopping their self-injury. Tricia recalled gradually working on controlling her emotions in other ways:
It wasn’t something that I stopped immediately because, like I said, I tried to work on my emotions. I tried to control my anger. I went back to it and almost went back to it a lot of times. I tried to distract myself from the cause of the pain. . . . It wasn’t a fast process. It was a gradual process.
Participants experiencing a protracted cessation process did not typically memorialize it or assign specific meaning to the final experience.
Processes Supporting Participants Switching Profiles
UC to OC NSSI: Aging and Feedback
Participants reported that getting older and receiving negative feedback influenced their transition from UC NSSI to OC NSSI. Jane shared her feeling that “when you’re in your teens, a lot of people are doing weird self-harm shit. . . . by the time you’re in your 20s, if people see something on your arm, they’re like, ‘what the fuck is wrong with you?’” Shane echoed this: “It was easier to hide when I got older because I understood—cognitively, I was like, ‘well, this isn’t really healthy or appropriate.’ But I still did it.” As participants encountered criticism or judgment related to self-injury, they often became more secretive, restrained, or ritualistic in their behaviors. Roxanne shared how feedback influenced the way she engaged with self-injury:
I had a friend notice, and she told the teacher and I was really embarrassed. And then my grandmother found out and she was really mad. And so I realized that I needed to do a better job hiding it. And so that’s why I moved locations, because I really didn’t want anybody to know. I was embarrassed by it. But it did make me feel a lot better. And so I wanted to keep doing it.
When participants transitioned from a UC NSSI profile to an OC NSSI profile, they typically continued to self-injure in this manner until cessation.
OC to UC NSSI: Intense Interpersonal Distress, Fear, and Shame
Participants described experiences of intense interpersonal distress as a salient factor in their transition from OC NSSI to UC NSSI. During relational conflict that resulted in extreme dysregulation, participants reported losing the ability to moderate their emotions or how severely or impulsively they self-injured. Rex shared an experience of UC NSSI that occurred in the context of an abusive relationship, describing it as a departure from her previous self-injury, which was private, superficial, and very controlled:
and she kept on yelling and yelling and then I did it in front of her and the fat started bleeding out of my arm. . . . It was like scarier and felt way more out of control than anything like I had ever experienced as far as self-harm.
Participants’ impulsivity and emotionality in these moments meant that they might self-injure in the presence of others or reach for tools they didn’t normally use, resulting in wounds that were more severe than they normally experienced.
When participants who typically self-injured in a restrained, private manner experienced UC NSSI, the result was acute feelings of fear and shame. Perhaps because they had previously held judgment of self-injury that occurred impulsively and publicly, self-judgment often occurred in the wake of a transition to UC NSSI. Olive described the fear they felt after the last time they self-injured, which resulted in 17 stitches:
I was having nightmares and flashbacks for three months afterwards. So it was traumatic for me to experience, and I scared myself. I didn’t know that I could do that to myself. I didn’t know that I was capable of causing that kind of harm, and I guess it made me realize how dangerous it was for me to be doing what I was doing because when I actually did it I had a total loss of control in that moment.
These feelings of fear and shame felt by participants, coupled with the loss of equilibrium related to their NSSI identity, prompted them to reconsider the role of NSSI in their lives. Often, this episode of UC NSSI represented the last time they self-injured.
The Theory of Overcontrolled and Undercontrolled Self-Injury, illustrated in Figure 1, was developed based on participant narratives and feedback to represent the experiences, attitudes, and behaviors associated with OC and UC NSSI. Participants were asked to self-identify as UC or OC; however, this classification did not consistently align with their profile of self-injury. For example, three participants identified that their NSSI behavior was markedly different than their behavior in the rest of their lives. Additionally, several participants described transitioning from one profile to another at some point during their self-injury. As a result of this unexpected finding, we categorized participant NSSI based on their descriptions of their self-injurious experiences, attitudes, and behaviors rather than their self-identified personality typology.
Figure 1
Theory of Overcontrolled and Undercontrolled Self-Injury
Discussion
This study provides insight into how self-control influences individuals’ experiences of NSSI. The data identified two distinct profiles, which is consistent with prior research indicating the ability to differentiate NSSI behavior based on its occurrence in OC or UC contexts (Hempel et al., 2018). OC NSSI was characterized as restrained, private, and rule-guided, aligning with previous conceptualizations of OC linked to impulse inhibition, high distress tolerance, and rigid behavioral patterns (Block, 2022; Block & Block, 1980; Lynch et al., 2015). Similarly, UC NSSI was described as impulsive, disclosed despite secrecy, and emotion-driven, consistent with literature highlighting heightened emotional fluctuations, low distress tolerance (Block, 2002), and higher levels of openness and expressiveness (Gilmartin, 2024).
Although a desire for secrecy was reported in both OC and UC NSSI, the commitment and dedication to maintaining this privacy varied between groups. This study’s findings differ slightly from those of Hempel et al. (2018), who described UC NSSI as public, lacking nuance regarding participants’ internal conflicts. Participants’ dissonance regarding disclosure may be viewed through a lens of dialectics. Linehan (1993) described BPD, a disorder of UC, as a “dialectical failure” in which individuals vacillate between contradictory viewpoints, rendering their behavior inconsistent and confusing. OC, on the other hand, has been associated with maladaptive perfectionism (Lynch et al., 2015), in which individuals avoid vulnerability to maintain an image of flawless performance (Dunkley et al., 2003). Those striving to appear problem-free may perceive their self-injury as a sign that they are flawed or weak and thus go to great lengths to conceal it. Because both groups describe their NSSI as secretive, further exploration of disclosure patterns is essential to facilitate deeper understanding.
An unexpected finding was that participants’ perceptions of others’ NSSI differed based on whether they engaged in UC or OC NSSI. One explanation for the association between OC NSSI and a perception of others as inferior may lie in a phenomenon described by Lynch (2018) as “the enigma predicament.” The enigma predicament is a self-protective stance in which OC individuals believe they are fundamentally different or more complex than others. This attitude maintains social isolation, aloofness, and a feeling of being misunderstood. Cultural emphasis on self-control may bolster beliefs of superiority among these individuals, fostering a secret sense of pride.
No existing literature was found that explored the judgments of individuals who self-injure related to others’ NSSI; however, viewing these findings through the lens of social norms offers context. OC individuals are sensitive to social pressures and conformity, whereas UC individuals are less concerned with societal norms (Block, 2002). Individuals experiencing UC NSSI may be more likely to disregard prescriptive norms for self-presentation, facilitating empathy or admiration for those openly displaying their NSSI. Those experiencing OC NSSI, which is typically a well-kept secret, may be unlikely to encounter others engaging in NSSI in a like manner.
Another novel finding lies in the shifts participants described in their self-injury profile as a direct result of specific experiences, such as aging and feedback. Although no existing literature was found that examined this phenomenon, UC typically peaks in early to middle adolescence (Hasking & Claes, 2020), suggesting that aging may influence a transition from impulsive to more restrained NSSI for some individuals. It is also plausible that individuals whose self-injury was disclosed (i.e., UC NSSI) would receive more negative feedback than those whose self-injury remained concealed (i.e., OC NSSI). Participants who reported switching from OC to UC NSSI attributed this change to experiences of intense interpersonal distress that appeared to eclipse their high capacity for restraint and control. Lynch (2018) described this phenomenon as “emotional leakage,” in which OC individuals temporarily lose the ability to inhibit their impulses, leading to intense emotional outbursts followed by feelings of shame and self-criticism.
Implications for Counselors
The emergent theory in this study creates a new theoretical model that may provide valuable implications for clinical practice. The identification of two distinct profiles of NSSI supports previous research indicating that individuals with both low and high levels of self-control may engage in self-injurious behavior (Hempel et al., 2018). The current proposed criteria for NSSI disorder, listed in Section III of the DSM-5-TR (APA, 2022) as a condition for further study, would identify both OC and UC NSSI as conceptualized in this study. For instance, criterion C specifies that self-injury may involve “a period of preoccupation with the intended behavior that is difficult to control” or “frequent thoughts about self-injury, even if not acted upon” (p. 923). This expands previous views of NSSI by recognizing behaviors that involve greater restraint alongside those driven by impulse inhibition failures.
Knowing this, counselors may benefit from conducting thorough assessments to accurately diagnose and differentiate between OC and UC NSSI. This can involve using clinical interviews, standardized assessments, and behavioral observations to evaluate clients’ impulse control and emotional regulation abilities. Recommended measures include the Assessing Styles of Coping: Word-Pair Checklist (Lynch, 2018) for adults and the Youth Over- and Under-Control Screening Measure (Lenz et al., 2021) for children and adolescents. To assess OC and UC self-injury specifically, including questions in clinical interviews that evaluate the dimensions explored in this study may be helpful. Clinicians can also inquire specifically about clients’ NSSI impulsivity and emotionality levels, disclosure and aftercare behaviors, and whether any rules or rituals inform the behavior. Questions such as, “When you self-injure, do you tell anyone about it before or afterward?” and “Do you have any rules about when, where, or how you self-injure?” may assist clinicians in developing a deeper understanding of the processes driving the behavior, thereby informing the use of congruent therapeutic interventions.
Participants in this study highlighted distinct processes influencing their NSSI behaviors and cessation, emphasizing the need for tailored treatment approaches based on whether NSSI occurs in an OC or UC context. Traditional therapeutic approaches to treating self-injury, such as DBT (Linehan, 1993) and emotional regulation group therapy (Andover & Morris, 2014), which focus on improving emotional regulation and distress tolerance, may need to be adapted or supplemented to address specific vulnerabilities and underlying mechanisms related to OC NSSI. Interventions targeting UC NSSI should emphasize enhancing inhibitory control and distress tolerance while reducing emotional reactivity. Conversely, interventions treating OC NSSI should aim to relax excessive inhibitory control and rigidity while increasing emotional expressiveness and openness. RO DBT, which was developed specifically to treat disorders of OC by targeting deficits related to excessive inhibitory control (Lynch et al., 2015), represents a promising approach for these clients.
Understanding participants’ perceptions of others’ NSSI behaviors also holds implications for social contagion (Conigliaro & Ward-Ciesielski, 2023). Previous research has implicated identifying or relating with others who self-injure (Whitlock et al., 2009) and a higher need to belong (Conigliaro & Ward-Ciesielski, 2023) as factors increasing vulnerability to social contagion. Because UC NSSI was associated with a perception of others’ NSSI as superior or relatable, individuals exhibiting this self-injury profile may be more vulnerable to the effects of social contagion. Counselors should be aware of these dynamics when formulating interventions.
Lastly, counselors can benefit from considering how the enigma predicament may negatively impact the therapeutic relationship with OC clients who may believe that they are so complex or unique that they will invariably be misunderstood (Lynch, 2018). This may explain why study participants experiencing OC NSSI sometimes found therapy unrewarding or unhelpful, particularly if counselors generalized about self-injury in a way that felt incongruous with their experiences. Knowing this, counselors should aim to set aside their assumptions about self-injury and allow the client to educate them on their experience.
Care should also be taken when asserting that OC NSSI behavior is normal, common, or understandable. Although this might typically be viewed as a positive intervention (i.e., normalizing the behavior), such expressions may cause alliance ruptures in this population (Lynch, 2018). Acknowledging these unique perspectives and avoiding assumptions about the normalcy or commonality of NSSI behaviors can help maintain therapeutic rapport and prevent alliance ruptures. By integrating these implications into clinical practice, counselors can enhance their ability to effectively assess, conceptualize, and intervene with UC and OC NSSI, ultimately promoting resilience and improved psychological well-being.
Limitations and Suggestions for Future Research
Several limitations must be acknowledged in order to interpret this study’s findings. First, because of the absence of validated measures of UC and OC, participants self-identified based on Block and Block’s (1980) conceptualization of these terms. Knowing the challenges associated with the clinical assessment of OC (Hempel et al., 2018) and the subjective nature of self-assessment, it is reasonable to assume that some participants may have self-identified in ways that are incongruent with established criteria for UC and OC. Future studies aimed at the development of instruments capable of effectively measuring and differentiating between OC and UC NSSI would aid mental health and medical professionals in congruent conceptualization and intervention for NSSI. They would also pave the way for quantitative exploration of UC and OC NSSI, potentially fostering greater knowledge, understanding, and generalizability.
The sample in this study was composed predominantly of White women, limiting its ability to encompass a diversity of experiences. It is possible that a more diverse sample would have generated different results. Future studies should intentionally strive to incorporate more diverse samples, specifically focusing on amplifying the voices and experiences of gender-diverse individuals, people of color, and men. Care should be taken in generalizing the results of this analysis, especially in groups underrepresented in sampling. Additionally, participants in this study had not self-injured in the last 3 years, which may have allowed for a greater degree of cognitive processing related to their experiences. Future studies focusing on current self-injurious experiences are needed to support the development of effective interventions in this population.
Finally, this study’s qualitative design has inherent limitations despite efforts to ensure credibility and trustworthiness. The semi-structured interview method used may influence participant responses through question framing, wording, and presentation. Additionally, the research team’s perspective inevitably influences the interpretation of findings, allowing for alternative interpretations by different research teams.
Conclusion
The constructivist grounded theory findings enrich our initial grasp of how self-control influences NSSI experiences, attitudes, and behaviors, offering significant implications for mental health research and clinical practice. Future efforts should focus on translating these insights into evidence-based assessments and interventions that acknowledge individuals’ attitudes, motivations, and vulnerabilities associated with NSSI, aiming to effectively enhance resilience and well-being.
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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Appendix
Interview Protocol
- Please give me a brief timeline of your experiences with self-injury over the course of your lifetime.
Alternate wording:
I’d like to ask you to think back to the first time you self-injured. Could I ask you to describe what led to that moment?
- Where on your body did you typically self-injure?
- Have you ever hurt yourself during self-injury to the extent that you needed medical assistance, even if you did not receive it?
Follow-up questions:
a. What was the experience of seeking medical help like for you?
b. How did you manage treating the injury without medical professionals?
- What has your experience been with disclosing your self-injury to others?
Follow-up questions:
a. Who are the people in your life that are aware that you have self-injured?
b. Did you choose to tell those people about your self-injury or did they find out in some other way?
c. What were people’s responses when they found out that you had self-injured?
d. What influenced your decision to disclose or not disclose your self-injury?
- Please describe the purpose of your self-injury?
Alternate wording:
How did your self-injury influence your mental health? Relationships?
What did self-injury offer you?
- When you self-injured, to what extent did you plan how, when, or where you were going to do it in advance?
Follow-up questions:
a. How would you describe the period of time between thinking about how or when you were going to self-injure and the self-injurious behavior itself?
b. How long was the period of time, generally, between the thought and the behavior?
- Did you have any rules about when, where, or how you self-injured? If so, could I ask you to describe them to me?
- If you think about your level of distress or emotionality as a wave with a peak where the emotion is most intense, when did your self-injury typically occur along that continuum?
- If a close friend or family member had seen you in the moments before you self-injured, to what extent would they have suspected that you were in distress?
Follow-up question:
What factors would have influenced their idea that you were/were not in distress?
- How would you describe the experiences that led you to stop self-injuring?
Is there anything else you would like to add about your experiences that we haven’t touched on?
Sara E. Ellison, PhD, NCC, ACS, LPC, is adjunct faculty at Auburn University and the University of West Georgia. Jill M. Meyer, PhD, LPCP, CRC, is a professor and Director of Counselor Education at Auburn University. Julia Whisenhunt, PhD, NCC, LPC, CPCS, is a professor, assistant chair, and program director at the University of West Georgia. Jessica Meléndez Tyler, PhD, NCC, BC-TMH, LPC-S, is an associate professor at Vanderbilt University. Correspondence may be addressed to Sara E. Ellison, 3084 Haley Center, Auburn, AL 36849, szm0194@auburn.edu.
Jul 25, 2025 | Volume 15 - Issue 2
Michael T. Kalkbrenner, Shannon Esparza
Physicians in the United States are a client population facing increased risks for mental distress coupled with a reticence to seek professional counseling. Screening tools with valid scores have utility for helping counselors understand why prospective client populations who might benefit from counseling avoid seeking services. The Revised Fit, Stigma, and Value (RFSV) Scale is a screener for measuring barriers to counseling. The primary aims of the present study were to validate RFSV scores with physicians in the United States and to investigate demographic differences in physicians’ RFSV scores. Results revealed that the RFSV Scale and its dimensionality were estimated sufficiently with a national sample of physicians (N = 437). Physicians’ RFSV scores were a significant predictor (p = .002, Nagelkerke R2 = .05) of peer-to-peer referrals to counseling. We also found that male physicians and physicians with help-seeking histories were more sensitive to barriers to counseling than female physicians and physicians without help-seeking histories, respectively. Recommendations for how counselors can use the RFSV Scale when working with physician clients are provided.
Keywords: Revised Fit, Stigma, and Value Scale; counseling; barriers to counseling; help-seeking; physicians
Because of the particularly stressful nature of their work, coupled with the pressure in medical culture to not display psychological vulnerability (Linzer et al., 2016), physicians in the United States must be vigilant about their self-care. Physicians are responsible for treating over 300 million patients in the United States, which can lead to elevated psychological distress that may undermine the quality of patient services and physicians’ personal well-being (Walker & Pine, 2018). Attending personal counseling is associated with a number of personal and professional benefits for physicians (Melnyk et al., 2020). However, a stigma toward seeking counseling and other mental health support services exists in the U.S. medical culture (Dyrbye et al., 2015). Lobelo and de Quevedo (2016) found that physicians are attending counseling at lower rates since 2000, with approximately 40%–70% attending counseling before the year 2000 and only 12%–40% after 2000. One of the next steps in this line of research is gaining a better understanding of barriers to counseling, including reasons why physicians are reluctant to attend.
Screening tools with valid scores are one way to understand why individuals are reticent to attend counseling (Goldman et al., 2018). For example, the Revised Fit, Stigma, and Value (RFSV) Scale is a screening tool with rigorously validated scores for measuring barriers to counseling (Kalkbrenner et al., 2019). Scores on the RFSV Scale have been validated with seven different normative samples since 2018, including adults in the United States (Kalkbrenner & Neukrug, 2018), mental health counselors (Kalkbrenner et al. 2019), counselors-in-training (Kalkbrenner & Neukrug, 2019), college students attending a Hispanic Serving Institution (HSI; Kalkbrenner et al., 2022), and STEM students (Kalkbrenner & Miceli 2022).
At the time of this writing, RFSV scores have not been validated with a normative sample of physicians. Validity evidence of test scores can fluctuate between normative samples (American Educational Research Association [AERA] et al., 2014; Lenz et al., 2022). Accordingly, counseling practitioners, researchers, and students have a responsibility to validate scores with untested populations before using the test in clinical practice or research (Lenz et al., 2022). Validating RFSV scores with a national sample of U.S. physicians may provide professional counselors with a clinically appropriate screening tool for ascertaining what barriers contribute to physicians’ reluctance to attend counseling services. Identifying barriers to counseling within this population may also promote efforts to increase physicians’ support-seeking behaviors (Mortali & Moutier, 2018).
Barriers to Counseling
Counseling interventions provide physicians with protective factors such as promoting overall health and wellness (Major et al., 2021) and decreasing emotional exhaustion associated with burnout (Wiederhold et al., 2018). Despite these correlations, Kase et al. (2020) found that although 43% of a sample of U.S. pediatric physicians had access to professional counseling and support groups, only 17% utilized these services. Participants cited barriers to attending counseling, including inconvenience, time constraints, preference for handling mental health issues on their own, and perceiving mental health services as unhelpful.
A significant barrier contributing to U.S. physicians’ reticence to attend counseling is the influence of medical culture which reinforces physician self-neglect and pressure to maintain an image of invincibility (Shanafelt et al., 2019). This pressure can begin as early as medical school and may lead to a decreased likelihood of seeking counseling, as medical students who endorsed higher perceptions of public stigma within their workplace culture perceived counseling as less efficacious and considered depression a personal weakness (Wimsatt et al., 2015). An association of frailty with mental health diagnoses and treatment may be driven by incongruences in medical culture between espoused values and actual behaviors, such as teaching that self-care is important, yet practicing excessive hours, delaying in seeking preventive health care, and tolerating expectations of perfectionism (Shanafelt et al., 2019). Such hidden curricula may perpetuate the stigma of seeking mental health treatment, which is considered a primary driver of suicide in the health care workforce (American Hospital Association [AHA], 2022).
In addition to the barrier presented by medical culture, the stigmatization and negative impact on licensure of receiving a diagnosis also discourages physicians from seeking care (Mehta & Edwards, 2018). Almost 50% of a sample of female U.S. physicians believed that they met the criteria for a mental health diagnosis but had not sought treatment, citing reasons such as a belief that a diagnosis is embarrassing or shameful and fear of being reported to a medical licensing board (Gold et al., 2016). It is recommended best practice for state medical licensing boards to phrase initial and renewal licensure questions to only inquire about current mental health conditions, to ask only if the physician is impaired by these conditions, to allow for safe havens, and to use supportive language; yet in a review of all 50 states, the District of Columbia, and four U.S. territories, only three states’ or territories’ applications met all four conditions (Douglas et al., 2023). Thus, it is unsurprising that out of a sample of 5,829 U.S. physicians, nearly 40% indicated reluctance to seek formal care for a mental health condition because of licensure concerns (Dyrbye et al., 2017). The barriers of medical culture and its expectations, stigma, and diagnosis are consequential; further research is needed given the pressure physicians may experience to remain silent on these issues (Mehta & Edwards, 2018).
Demographic Differences
A number of demographic variables are related to differences in physicians’ mental health and their attitudes about seeking counseling (Creager et al., 2019; Duarte et al., 2020). For example, demographic differences such as gender and ethnoracial identity can add complexity to physicians’ risk of negative mental health outcomes (Duarte et al., 2020). Sudol et al. (2021) found that female physicians were at higher risk of depersonalization and emotional exhaustion than male physicians, while physicians from racial/ethnic minority backgrounds were more likely to report burnout than White physicians. Gender identity can also affect help-seeking behavior, as female physicians are more likely than male physicians to utilize social and emotional supports and less likely to prefer handling mental health symptoms alone (Kase et al., 2020). Work setting is another demographic variable that is associated with physicians’ mental health wellness, as Creager et al. (2019) identified lower burnout and stress rates among physicians working in private practice than those working in non–private practice settings.
Help-seeking history has become a more frequently examined variable in counseling research, often categorized into two groups: (a) individuals who have attended at least one session of personal counseling or (b) those who have never sought counseling (Cheng et al., 2018). This demographic variable is especially important when evaluating the psychometric properties of screening tools for physicians, who encounter numerous obstacles to accessing counseling services. Help-seeking history is related to more positive attitudes about seeking counseling, as Kevern et al. (2023) found that 80% of a sample of U.S. resident physicians who attended mental health counseling reported their sessions increased their willingness to attend counseling. These collective findings suggest demographic variables such as gender, ethnoracial identity, work setting, and help-seeking history may impact physicians’ mental health and their sensitivity to barriers to attending counseling and thus warrant further investigation.
The Revised Fit, Stigma, and Value Scale
Neukrug et al. (2017) developed and validated scores on the original 32-item Fit, Stigma, and Value (FSV) Scale with a sample of human service professionals in order to appraise barriers to attending personal counseling. The FSV subscales assess sensitivity to three potential barriers to counseling attendance, including fit, the extent to which a respondent trusts the counseling process; stigma, the feelings of shame or embarrassment associated with attending counseling; and value, the perceived benefit of being in counseling. Kalkbrenner et al. (2019) also developed and validated scores on a briefer 14-item version of the FSV Scale (the RFSV Scale), that contains the original three subscales. Additionally, Kalkbrenner and Neukrug (2019) identified a higher-order factor, the Global Barriers to Counseling Scale, which is the composite score of the RFSV’s Fit, Stigma, and Value single-order subscales.
Integrative Behavioral Health Care
Mental health challenges and attitudes toward seeking support are shaped by both individual (microsystemic) and broader societal (macrosystemic) factors, making it impossible for a single discipline to address these issues (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023). As a result, the counseling profession is increasingly adopting interdisciplinary collaboration models, in which mental health professionals work together to deliver holistic care to clients or patients. Emerging research highlights interventions aimed at reducing barriers to accessing counseling services (e.g., Lannin et al., 2019). However, the complex interplay of ecological factors influencing mental health distress and service utilization makes evaluating these interventions challenging. Accordingly, counselors and other members of interdisciplinary teams need screening tools with valid scores to help determine the effectiveness of such interventions.
The primary aims of the present study were to validate RFSV scores with a national sample of physicians in the United States and to investigate demographic differences in physicians’ RFSV scores. The validity and meaning of latent traits (i.e., RFSV scores) can differ between different normative samples (AERA, 2014; Lenz et al., 2022). RFSV scores have not been normed with physicians. Accordingly, testing for factorial invariance of RFSV scores is a pivotal next step in this line of research. In other words, the internal structure validity of RFSV scores must be confirmed with physicians before the scale can be used to measure the intended construct. Although a number of different forms of validity evidence of scores exists, internal structure validity is a crucial consideration when testing the psychometric properties of an inventory with a new normative sample (AERA, 2014; Lenz et al., 2022). If RFSV scores are validated with a national sample of U.S. physicians, counselors can use the scale to better understand why physicians, as a population, are reticent to seek counseling.
Pending at least acceptable validity evidence, we sought to investigate the capacity of physicians’ RFSV scores for predicting referrals to counseling and to examine demographic differences in RFSV scores. Results have the potential to offer professional counselors a screening tool for understanding why physicians might be reticent to seek counseling. Findings also have the potential to reveal subgroups of physicians who might be especially unlikely to access counseling services. To these ends, the following research questions (RQs) were posed:
RQ1. What is the factorial invariance of scores on the RFSV Scale among a national sample of U.S. physicians?
RQ2. Are U.S. physicians’ RFSV scores statistically significant predictors of making at least one referral to counseling?
RQ3. Are there demographic differences to the RFSV barriers among U.S. physicians’ RFSV scores?
Method
Participants and Procedures
A quantitative cross-sectional psychometric research design was utilized to answer the research questions. The current study is part of a larger grant-funded project with an aim to promote health-based screening efforts and wellness among physicians. The aim of the previous study (Kalkbrenner et al., 2025) was to test the psychometric properties of three wellness-based screening tools with physicians. In the present study, we further analyzed the data in Kalkbrenner et al. (2025) to answer different research questions about a different scale (the RFSV Scale) on barriers to counseling. This data set was collected following approval from our IRB. Crowdsourcing is an increasingly common data collection strategy in counseling research with utility for accessing prospective participants on national and global levels (Mullen et al., 2021). Qualtrics Sample Services is a crowdsource solutions service with access to over 90 million prospective participants who voluntarily participate in survey research for monetary compensation. Grant funding was utilized to engage the services of a data collection agency to enlist a nationwide cohort of U.S. physicians. Qualtrics Sample Services was selected because they were the only crowdsource service we came across that could provide a sample of more than 400 licensed U.S. physicians. A sample greater than 400 was necessary for answering the first research question because 200 participants per group is the lower end of acceptable for multiple-group confirmatory factor analysis (MG-CFA; Meade & Kroustalis, 2006). Qualtrics Sample Services provided us with a program manager and a team of analysts who undertook a meticulous quality assessment of the data. This quality assessment involved filtering out respondents exhibiting excessive speed in responding, random response patterns, failed attention checks, and instances of implausible responses (e.g., individuals claiming to be 18 years old with an MD).
A total of N = 437 valid responses that met quality standards were obtained. An analysis of missing values indicated an absence of missing data. Examination of standardized z-scores and Mahalanobis (D) distances identified no univariate outliers (z > ± 3.29) and no multivariate outliers, respectively. Skewness and kurtosis values for physicians’ scores on the RFSV Scale were within the range indicative of a normal distribution of test scores (skewness < ± 2 and kurtosis < ± 7). Participants in the sample (N = 437) ranged in age from 25 to 85 (M = 47.80, SD = 11.74); see Table 1 for the demographic profile of the sample.
Table 1
Demographic Profile of the Sample (N = 437)
| Sample Characteristics |
n |
% |
| Gender |
|
|
| Male |
217 |
49.7 |
| Female |
215 |
49.2 |
| Transgender |
1 |
0.2 |
| Nonbinary |
1 |
0.2 |
| Preferred not to answer |
3 |
0.7 |
| Ethnoracial Identity |
|
|
| American Indian or Alaska Native |
1 |
0.2 |
| Asian or Asian American |
28 |
6.4 |
| Black or African American |
76 |
17.4 |
| Hispanic, Latinx, or Spanish origin |
97 |
22.2 |
| Middle Eastern or North African |
6 |
1.4 |
| Multiethnic |
6 |
1.4 |
| White or European American |
216 |
49.4 |
| Identified as another race, ethnicity, or origin |
1 |
0.2 |
| Preferred not to answer |
4 |
0.9 |
| Help-Seeking History |
|
|
| No help-seeking history |
228 |
52.2 |
| Help-seeking history |
208 |
47.6 |
| Work Setting |
|
|
| Private practice |
202 |
46.2 |
| Non–private practice |
233 |
53.3 |
| Did not report work setting |
2 |
0.5 |
Measures
Prospective participants voluntarily indicated their informed consent and confirmed that they met the eligibility criteria for participation, including being a physician licensed as an MD, treating patients in the United States, and being over 18 years old at the time of data collection. Participants then responded to a demographic questionnaire and completed the RFSV Scale.
The RFSV Scale
The RFSV Scale is a screening tool designed to measure respondents’ sensitivity to barriers to attending counseling (Kalkbrenner et al., 2019) and is comprised of three subscales. Participants respond to a stem (“I am less likely to attend counseling because . . . ”) on the following Likert scale: 1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree nor Disagree, 4 = Agree, or 5 = Strongly Agree. Higher scores indicate greater reluctance to seek counseling. The Fit subscale measures the degree to which a respondent believes that the counseling process is congruent with their personality, values, or beliefs (e.g. “I couldn’t find a counselor who would understand me”). The Stigma subscale measures one’s reluctance to attend counseling because of shame or embarrassment (e.g. “It would damage my reputation”). The Value subscale appraises the degree to which a respondent perceives the effort required to attend counseling as beneficial (e.g. “It is not an effective use of my time”).
Kalkbrenner et al. (2019) found moderate to strong reliability evidence of scores on the RFSV subscales (Fit α = .82, Stigma α = .91, Value α = .78) and support for the internal structure validity of the RFSV through factor analysis. Additionally, Kalkbrenner and Neukrug (2018) demonstrated evidence of internal structure validity of RFSV scores through confirmatory factor analysis (CFA). Moreover, Kalkbrenner et al. (2022) found internal structure validity and criterion validity evidence of RFSV scores. More specifically, Kalkbrenner et al. (2022) found internal structure validity evidence of RFSV scores via CFA with a normative sample of STEM students. In addition, Kalkbrenner et al. (2022) found that STEM students’ scores on the Value barrier were a statistically significant predictor of a non-test criterion (referrals to the counseling center), which supported criterion validity of RFSV scores.
Cronbach’s alpha (α) and McDonald’s omega (ω) were calculated to estimate the reliability of physicians’ scores on the RFSV Scale. Consistent with the Responsibilities of Users of Standardized Tests (RUST-4E) standards, we computed confidence intervals (CIs) for each point reliability estimate (Lenz et al., 2022). All CIs were estimated at the 95% level. The following interpretive guidelines for internal consistency reliability evidence of test scores were used: α > .70 (Tavakol & Dennick, 2011) and ω > .65 (Nájera Catalán, 2019). Among the sample of physicians in the present study, scores on the Fit subscale showed acceptable internal consistency reliability of scores (α = .819, 95% CI [.789, .846]; ω = .827, 95% CI [.799, .851]). Scores on the Stigma subscale displayed acceptable-to-strong internal consistency reliability evidence of scores (α = .896, 95% CI [.877, .912]; ω =. 902, 95% CI [.885, .918]). Physicians’ scores on the Value subscale displayed acceptable internal consistency reliability of scores (α = .817, 95% CI [.781, .848]; ω =.820, 95% CI [.783, .850]). Finally, we found strong internal consistency reliability estimates of scores on the Global Barriers scale (α = .902, 95% CI [.885, .915]; ω = .897, 95% CI [.887, .911]).
Data Analytic Plan
MG-CFA is an advanced psychometric analysis for determining the extent to which the meaning of latent constructs remain stable across subgroups of a sample (Dimitrov, 2012). MG-CFA is particularly sensitive to sample size (Meade & Kroustalis, 2006). A number of guidelines for MG-CFA sample size exist; however, at least 200 participants per each level of every invariance variable tends to be the minimum. To ensure that the present sample included 200+ participants in each group (see Table 2), the gender identity and ethnoracial identity variables were coded as female or male and White or non-White, respectively, for sample size considerations. This method of dummy coding highlights a frequent sample size–based challenge encountered in survey research, particularly in the context of assessing gender or ethnoracial identity (Ross et al., 2020). However, this coding method can be appropriate for survey research provided that the authors openly acknowledge the limitations inherent in such procedures, and that there is at least some degree of consistency between the dummy-coded groups and both the existing literature and the research questions (Ross et al., 2020). The coded groups are consistent with the literature and RQs, as findings in the extant literature (e.g., Duarte et al., 2022) demonstrated mental health care disparities between White and non-White and between male and female physicians. There are macro- and microlevel inequalities in the U.S. health care system between White and non-White populations (Matthew, 2015). Using the comparative method between participants with White and non-White ethnoracial identifies can have utility for highlighting the discrepancies in the U.S. health care system (Matthew, 2015; Ross et al., 2020). The limitations of this statistical aggregation procedure in terms of external validity will be articulated in the Discussion section.
Table 2
Multiple-Group Confirmatory Factor Analysis: RFSV Scale With U.S. Physicians
| Invariance Forms |
CFI |
∆CFI |
RMSEA |
∆RMSEA |
RMSEA CIs |
SRMR |
∆SRMR |
Model Comparison |
| Ethnoracial Identity: White (n = 216) vs. Non-White (n = 215) |
| Configural |
.934 |
|
.057 |
|
.049; .064 |
.070 |
|
|
| Metric |
.933 |
.001 |
.055 |
.002 |
.048; .063 |
.070 |
< .001 |
Configural |
| Scalar |
.928 |
.005 |
.055 |
< .001 |
.048; .062 |
.071 |
.001 |
Metric |
| Gender Identity: Female (n = 215) vs. Male (n = 217) |
|
| Configural |
.936 |
|
.056 |
|
.048; .063 |
.060 |
|
|
| Metric |
.935 |
.001 |
.055 |
.001 |
.047; .062 |
.066 |
.006 |
Configural |
| Scalar |
.921 |
.014 |
.057 |
.002 |
.051; .064 |
.067 |
.001 |
Metric |
| Help-Seeking History: Yes (n = 208) vs. No (n = 228) |
|
| Configural |
.921 |
|
.062 |
|
.055; .070 |
.080 |
|
|
| Metric |
.921 |
< .001 |
.061 |
.001 |
.053; .068 |
.080 |
< .001 |
Configural |
| Scalar |
.906 |
.015 |
.063 |
.001 |
.057; .070 |
.079 |
.001 |
Metric |
| Work Setting: Private Practice (n = 202) vs. Non-Private Practice (n = 233) |
|
| Configural |
.942 |
|
.053 |
|
.045; .061 |
.062 |
|
|
| Metric |
.937 |
.005 |
.054 |
.001 |
.046; .061 |
.075 |
.013 |
Configural |
| Scalar |
.936 |
.001 |
.052 |
.002 |
.044; .059 |
.075 |
< .001 |
Metric |
|
|
|
|
|
|
|
|
|
|
We computed an MG-CFA to test the factorial invariance of U.S. physicians’ RFSV scores (RQ1). All statistical analyses were computed in IBM SPSS AMOS version 29 with a maximum likelihood estimation method. The fit of the baseline configural models was compared to the following cutoff scores: root mean square error of approximation (RMSEA < .08 = acceptable fit and < .06 = strong fit), standardized root mean square residual (SRMR < .08 = acceptable fit and < .06 = strong fit), and the comparative fit index (CFI, .90 to .95 = acceptable fit and > .95 = strong fit (Dimitrov, 2012; Schreiber et al., 2006). Pending at least acceptable fit of the baseline models, we used the following guidelines for factorial invariance testing: < ∆ 0.010 in the CFI, < ∆ 0.015 in the RMSEA, and < ∆ 0.030 in the SRMR for metric invariance or < ∆ 0.015 in SRMR for scalar invariance (Chen, 2007; Cheung & Rensvold, 2002).
A binary logistic regression analysis was computed to investigate the predictive capacity of physicians’ RFSV scores (RQ2). The predictor variables included physicians’ interval level scores on the RFSV Scale. The criterion variable was whether or not physicians have made at least one referral to counseling (0 = no or 1 = yes). Interscale corrections between the RFSV scales ranged from r = .44 to r = .55, indicating that multicollinearity was not present in the data.
A 2 (gender) X 2 (ethnicity) X 2 (work setting) X 2 (help-seeking history) factorial multivariate analysis of variance (MANOVA) was computed to investigate differences in physicians’ RFSV scores (RQ3). The categorical level independent variables (IVs) included gender (female or male), ethnoracial identity (White or non-White), help-seeking history (yes or no), and work setting (private practice or non–private practice). The dependent variables (DVs) were physicians’ interval level scores on the RFSV Scale. Box’s M test demonstrated that the assumption of equity of covariance matrices was met, F = (90, 73455.60) = 86.28, p = .719.
Results
Factorial Invariance Testing
An MG-CFA was computed to answer the first research question regarding the factorial invariance of U.S. physicians’ scores on the RFSV Scale. First, the baseline configural models were investigated for fit. We then tested for invariance, as the baseline models showed acceptable fit based on the previously cited guidelines provided by Dimitrov (2012) and Schreiber et al. (2006), including gender identity (CFI = .936, RMSEA = .056, 90% CI [.048, .063], and SRMR = .060), ethnoracial identity (CFI = .934, RMSEA = .057, 90% CI [.049, .064], and SRMR = .070), help-seeking history (CFI = .921, RMSEA = .062, 90% CI [.055, .070], and SRMR = .080), and work setting (CFI = .942, RMSEA = .053, 90% CI [.045, .061], and SRMR = .062).
In terms of invariance, all of the fit indices (∆CFI, ∆RMSEA, and ∆SRMR) supported both metric and scalar invariance of scores for ethnoracial identity and work setting (see Table 2). For the gender identity and help-seeking history variables, the ∆RMSEA and ∆SRMR supported both metric and scalar invariance of scores. The ∆CFI supported metric but not scalar invariance of scores for the help-seeking history and gender identity variables. Demonstrating invariance can be deemed acceptable solely based on metric invariance (Dimitrov, 2010). This is particularly true when only a single fit index, such as the CFI, confirms metric invariance but not scalar invariance of scores.
Logistic Regression
A logistic regression analysis was computed to answer the second research question regarding the predictive capacity of physicians’ RFSV scores. The logistic regression model was statistically significant, X2 (3) = 15.36, p = .002, Nagelkerke R2 = .05. The odds ratios, Exp(B), demonstrated that an increase of one unit in physicians’ scores on the Stigma subscale (higher scores = higher barriers to counseling) was associated with a decrease in the odds of having made at least one referral to counseling by a factor of .711, Exp(B) 95% CI [.517, .947], p = .036. In addition, an increase of one unit in physicians’ scores on the Value subscale was associated with a decrease in the odds of having made at least one referral to counseling by a factor of .707, Exp(B) 95% CI [.508, .984], p = .040.
Factorial MANOVA
A 2 (gender) X 2 (ethnicity) X 2 (work setting) X 2 (help-seeking history) factorial MANOVA was computed to investigate differences in physicians’ RFSV scores (RQ3). A significant main effect emerged for gender on the combined DVs, F = (3, 409) = 6.50, p < .001, Λ = 0.95, n2p = .05. The statistically significant findings in the MANOVA were followed up with post-hoc discriminant analyses. The discriminant function significantly discriminated between groups, λ = 0.94, X2 = 25.07, df = 3, Canonical correlation = .29, p < .001. The correlations between the latent factors and discriminant functions showed that Fit (−1.17) loaded more strongly on the function than Stigma (0.68) and Value (0.62), suggesting that Fit contributed the most to group separation in gender identity. The mean discriminant score on the function for male physicians was 0.24 and the mean score for female physicians was −0.25 (higher scores = greater barriers to counseling).
A significant main effect emerged for help-seeking history on the combined DVs, F = (3, 409) = 4.57, p = .004, Λ = 0.95, n2p = .03. The post-hoc discriminant function significantly discriminated between groups, Wilks λ = 0.96, X2 = 19.61, df = 3, Canonical correlation = .21, p < .001. The correlations between the latent factors and discriminant functions showed that Value (1.03) loaded more strongly on the function than Stigma (0.28) and Fit (0.26), suggesting Value contributed the most to group separation in help-seeking history. The mean discriminant score on the function for physicians with a help-seeking history was −0.23 and the mean score was 0.21 for physicians without a help-seeking history.
Discussion
The aims of the present study were to: validate RFSV scores with a national sample of physicians in the United States, investigate the capacity of RFSV scores for predicting physician referrals to counseling, and investigate demographic differences in physicians’ RFSV scores. The findings will be discussed in accordance with the RQs. The model fit estimates for each of the baseline configural models were all in the acceptable range based on the recommendations of Dimitrov (2012) and Schreiber et al. (2006; see Table 2). The acceptable fit of the configural models supported that the RFSV Scale and its dimensionality were estimated adequately with a normative sample of physicians. RFSV scores have been normed with seven different normative samples since 2018, including adults in the United States (Kalkbrenner & Neukrug, 2018), mental health counselors (Kalkbrenner et al., 2019), counselors-in-training (Kalkbrenner & Neukrug, 2019), college students at an HSI (Kalkbrenner et al., 2022), and STEM students (Kalkbrenner & Miceli, 2022). The baseline CFA results in the present study extend the generalizability of RFSV scores to a normative sample of physicians in the United States. Because we found support for the baseline configural models, we proceeded to test for invariance of scores.
Invariance testing via MG-CFA takes internal structure validity testing to a higher level by revealing if the meaning of a latent trait stays consistent (i.e., invariant) between specific groups of a normative sample (Dimitrov, 2012). The results of factorial invariance testing were particularly strong and evidenced both metric and scalar invariance of RFSV scores for the ethnoracial identity and work setting variables. The ∆ in RMSEA and SRMR also supported both metric and scalar invariance for the help-seeking history and gender identity variables. The ∆ in CFI revealed metric, but not scalar invariance of scores for the help-seeking history and gender identity variables. Metric invariance alone can be sufficient for demonstrating invariance of scores across a latent trait (Dimitrov, 2010). This is particularly true when only a single fit index, such as the CFI, supports metric invariance but not scalar invariance of scores. In totality, the MG-CFA results supported invariance of physicians’ RFSV scores by ethnoracial identity, work setting, and, to a lesser but acceptable degree, help-seeking history and gender identity.
The MG-CFA results demonstrated that RFSV scores were valid among a national sample of U.S. physicians (RQ1). This finding adds rigor to the results of RQs 2 and 3 on predictive and demographic differences in physicians’ RFSV scores, as the scale was appropriately calibrated with a new normative sample. A test of the predictive capacity of RFSV scores revealed that physicians’ scores on the Stigma and Value subscales were statistically significant predictors of having made one or more referrals to counseling (RQ2). In other words, lower levels of stigma and higher attributions to the value of counseling were associated with higher odds of physicians making one or more referrals to counseling at a statistically significant level. This finding is consistent with Kalkbrenner and Miceli (2022), who found that scores on the Value subscale were predictors of referrals to counseling among STEM students. Similarly, Kalkbrenner et al. (2022) found that scores on the Value subscale predicted supportive responses to encountering a peer in mental distress among college students attending an HSI. Collectively, the findings of the present study are consistent with past investigators (e.g., Kalkbrenner et al., 2022) who found that more positive attitudes about counseling tend to predict increases in the odds of having made one or more peer referrals to counseling.
The final aim of the present study was to test for demographic differences in physicians’ sensitivity to the RFSV barriers (RQ3). We found statistically significant main effects for the gender identity and help-seeking history variables. Results revealed that male physicians were more sensitive to the Fit barrier than female physicians. This finding suggests that physicians who identify as male might be more skeptical about the counseling process in general and may doubt their chances of finding a counselor they feel comfortable with. This finding adds to the extant literature on physicians’ mental health and attitudes about seeking counseling. Past investigators (e.g., Sudol et al., 2021) documented female physicians’ increased risk for mental health stress when compared to male physicians. The findings of the present study showed that male physicians were more sensitive to the Fit barrier than female physicians. Accordingly, it is possible that female physicians are more likely to report symptoms of and seek support services for mental health issues than male physicians. This might be due, in part, to differences between male and female physicians’ beliefs about the fit of counseling. Future research is needed to test this possible explanation for this finding.
We found that physicians with a help-seeking history (i.e., attended one or more counseling sessions in the past) were less sensitive to the Value barrier when compared to physicians without a help-seeking history. Similarly, past investigators found associations between help-seeking history and more positive attitudes about the value and benefits of seeking counseling, including among STEM students (Kalkbrenner & Miceli 2022), college students at an HSI (Kalkbrenner et al., 2022), and adults living in the United States (Kalkbrenner & Neukrug, 2018). Collectively, the results of the present study are consistent with these existing findings, which suggest that physicians and members of other populations with help-seeking histories tend to attribute more value toward the anticipated benefits of counseling.
Limitations and Future Research
We recommend that readers consider the limitations of the present study before the implications for practice. Causal attributions cannot be drawn from a cross-sectional survey research design. Future researchers can build upon this line of research by testing the RFSV barriers using an experimental approach. Such research could involve administering the scale to physician clients before and after their counseling sessions. Such an approach might yield evidence on how counseling reduces sensitivity to certain barriers. However, it is important to note that pretest/posttest approaches can come with a number of limitations, including attrition, regression to the mean, history, and maturation.
Dummy coding the sociodemographic variables into broader categories to ensure adequate sample sizes for MG-CFA was a particularly challenging decision, especially for the ethnoracial identity variable. Although this statistical aggregation procedure can be useful for making broad and tentative generalizations about ethnicity and other variables (Ross et al., 2020), it limited our ability to explore potential differences in the meaning of the RFSV barriers among physicians with identities beyond White or non-White, and male or female. Future research with a more diverse sample by gender and ethnoracial identity is recommended.
Implications for Practice
The findings from this study provide robust psychometric evidence that supports the dimensionality of U.S. physicians’ scores on the RFSV Scale and carries important implications for counseling professionals. The National Board for Certified Counselors (NBCC; 2023) emphasizes the use of screening tools with valid scores as a means of improving clinical practice. Additionally, ethical guidelines for counselors stress the importance of ensuring that the screening tools that they utilize offer valid and reliable scores, derived from representative client samples, to uphold their effectiveness and proper application (AERA, 2014; Lenz et al., 2022; NBCC, 2023). Mental health issues and attitudes about utilizing mental health support services are influenced by microsystemic and macrosystemic factors (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023). To this end, implications for practice will be discussed on both microsystemic and macrosystemic levels.
The practicality of the RFSV Scale adds to its utility, as it is free to use, simple to score, and typically takes between 5 and 8 minutes to complete. Identifying barriers or doubts that physician clients have about counseling during the intake process might help increase physician client retention. To these ends, counselors can include the RFSV Scale with intake paperwork for physician clients. Counselors can use the results as one way to gather information about doubts that their physician clients might have about attending counseling. Suppose, for example, that a physician client scores higher on the Fit subscale (higher scores = higher barriers to counseling) than the Stigma or Value subscales. It might be helpful for the counselor and client to discuss how they can make the counseling process a good fit (i.e., how and in what ways the counseling process can be congruent with their personality, values, or beliefs). Increasing physician clients’ buy-in regarding the counseling process may increase retention.
Counselors could also administer the RFSV Scale at the beginning, middle, and end of the counseling process when working with clients who are physicians or medical students. Results might reveal the utility of counseling for reducing barriers to counseling among clients who are physicians or medical students. Our results revealed that physicians with help-seeking histories perceived greater value about the benefits of counseling than physicians without help-seeking histories. Mental health support services provided by counselor education students can be a helpful resource for medical students and residents (Gerwe et al., 2017). Accordingly, there may be utility in counselor education programs collaborating with medical colleges and schools to address stigma around seeking counseling that can exist in the medical field. This broader perspective is consistent with the ecological systems direction that the counseling profession spearheaded (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023) and could help address stigma toward seeking counseling before medical students become physicians. More specifically, directors and clinical coordinators of counseling programs can reach out to directors of medical schools to establish collaborative relationships in which counseling interns provide supervised counseling services to medical students and residents. This might have dual benefits because medical schools would be able to offer their students free mental health support services and counseling programs would provide additional internship sites for their students. Early intervention before students become physicians could reduce stigma toward counseling throughout their careers.
Time constraints can be a barrier to counseling among physicians, residents, and medical students (Gerwe et al., 2017; Kase et al., 2020). Accordingly, it could be beneficial for counseling students who are interested in working with medical students or residents to complete their internship placements in the same settings where medical students and residents work. In all likelihood, providing supervised group and individual counseling for medical students at their work sites would increase the accessibility of counseling.
The counseling profession is moving toward interdisciplinary collaboration models that involve teams of mental health professionals working together to provide comprehensive client/patient care (Lenz & Lemberger-Truelove, 2023; Pester et al., 2023). Interventions designed to reduce barriers to counseling are only beginning to appear in the extant literature (e.g., Lannin et al., 2019). The ecological systemic nature of mental health distress and influences on attitudes about accessing mental health support services makes evaluating the utility of reducing barriers to counseling interventions complex. To address this, counselors and interdisciplinary teams need screening tools with reliable and valid scores in order to effectively assess the impact of these interventions.
The results of CFA and MG-CFA in the present study confirmed that the RFSV Scale measured the intended construct of measurement with a national sample of U.S. physicians (RQ1). Thus, the RFSV Scale may have utility as a pretest/posttest for measuring the effectiveness of interventions geared toward reducing barriers to counseling. The extant literature on interventions for reducing barriers to counseling is in its infancy. Lannin et al. (2019) started to fill this gap in the knowledge base by conducting an intervention study with random assignment. Lannin et al. (2019) tested the extent to which contemplation about seeking counseling and self-affirmation were related to seeking mental health screening and general information about mental health support services. Results revealed that participants who used both self-affirming personal values and contemplation were significantly more likely to seek mental health screening and general information about mental health than participants in the contemplation-only group. In addition, participants in the contemplation about seeking counseling group only reported higher self-stigma. Findings indicated that interventions including both contemplation and self-affirmation of participants’ personal values were more likely to increase receptivity to outreach efforts.
Lannin et al. (2019) sampled undergraduate students attending a historically Black college/university. Lannin et al.’s (2019) intervention might have utility with physicians. However, to the best of our knowledge, the screening tools used by Lannin et al. have not been validated with U.S. physicians. Accordingly, professional counselors can use the RFSV Scale as one way to measure potential reductions in barriers to seeking counseling before and after participating in interventions geared toward promoting help-seeking among physicians. Fully developing an intervention that reduces barriers to counseling is beyond the scope of this study. Although future research is needed in this area, the results of this study confirmed that the RFSV Scale measured the intended construct of measurement with a national sample of U.S. physicians. Accordingly, professional counselors can use the RFSV Scale to better understand why prospective or current physician clients are reluctant to seek counseling. For example, professional counselors can work with medical supervisors and the directors of physician residency programs to administer the RFSV Scale at orientations for new physician employees and medical residents. The results could reveal specific barriers that are particularly salient in a given medical setting. Professional counselors can use the results to structure psychoeducation sessions about the utility of counseling for physicians. Suppose, for example, that physicians in a particular setting score higher on the Stigma subscale. A counselor can structure the content of the psychoeducation session on reducing stigma toward counseling. Specifically, the session could involve reframing seeking counseling in the context of the courage it takes for one to reach out to a counselor and the benefits associated with participating in counseling. These sessions may also help strengthen interpersonal bonds among physicians and begin to normalize mental health support within the medical community.
Consistent with the findings of Kalkbrenner and Miceli (2022), we found that lower scores on the Value subscale (lower scores = greater perceived benefits of counseling) was a statistically significant predictor of higher odds of participants having made one or more peer referrals to counseling. This finding, combined with the extant literature on physicians’ vulnerability to mental health distress and reticence to seek counseling (Lobelo & de Quevedo, 2016; Walker & Pine, 2018), suggested that peer-to-peer support may be a valuable resource for counselors who work in medical settings. In other words, we found that greater perceived value of the benefits of counseling was a statistically significant predictor of an increase in the odds of physicians recommending counseling to another physician. Accordingly, professional counselors who work in medical settings are encouraged to organize peer-to-peer support networks among physicians within their work setting. For example, professional counselors can work to promote physicians’ awareness of the value of attending professional counseling, particularly for reducing burnout, grieving the loss of a patient, coping with the demanding work life of physicians, and increasing general health (Major et al., 2021; Trivate et al., 2019; Wiederhold et al., 2018). Our results revealed that when compared to female physicians, male physicians scored higher on the Fit subscale (higher RFSV scores = poorer attitudes about counseling) and physicians with a help-seeking history scored higher on the Value subscale than those without help-seeking histories. To this end, there may be utility in focusing outreach sessions about the benefits of counseling to male physicians. For example, professional counselors could produce short videos, flyers, or other types of media on the benefits that attending counseling can have for physicians. These media sources can be shared with physicians. Such awareness advocacy about the benefits of counseling may result in an increase of peer-to-peer referrals to counseling among physicians.
Summary and Conclusion
Physicians in the United States face increased risks for mental distress and often hesitate to seek professional counseling (Lobelo & de Quevedo, 2016; Walker & Pine, 2018). Screening tools with validated scores are essential resources for helping professional counselors to understand why potential clients avoid seeking counseling services. The RFSV Scale measures barriers to counseling. This study aimed to validate RFSV scores among U.S. physicians and investigated demographic differences in their scores. Results indicated that the RFSV Scale and its dimensions were adequately estimated with a national sample of physicians in the United States. Physicians’ RFSV scores significantly predicted peer-to-peer counseling referrals. We identified demographic differences in sensitivity to barriers to counseling based on gender identity and help-seeking history. Physicians who self-identified as male and those without help-seeking histories were more sensitive to barriers to counseling than female physicians or physicians with help-seeking histories, respectively. At this phase of development, professional counselors can use the RFSV Scale as a tool for understanding barriers to seeking counseling among physicians.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Michael T. Kalkbrenner, PhD, NCC, is a full professor at New Mexico State University. Shannon Esparza, BA, is a graduate student at New Mexico State University. Correspondence may be addressed to Michael T. Kalkbrenner, Department of Counseling and Educational Psychology, New Mexico State University, Las Cruces, NM 88003, mkalk001@nmsu.edu.
