Jan 17, 2024 | Volume 13 - Issue 4
Julie Smith-Yliniemi, Krista M. Malott, JoAnne Riegert, Susan F. Branco
Faith and Indigenous healing ceremonies offer spiritually oriented interventions that maintain client wellness or mitigate client existential, biopsychosocial, or spiritual distress. Mental health practitioners of all identities may ethically apply ceremony-assisted treatments with Native and non-Native populations. Three such interventions are described in this article, drawn from Indigenous traditions as practiced personally and professionally by the first and third authors. Directives for use, including populations appropriate for application, adaptations, ethical considerations, and culturally responsive competency considerations, are included.
Keywords: Indigenous, healing ceremonies, ceremony-assisted treatments, Native, culturally responsive
Across time and cultures, humans have engaged in rituals as a means for fostering healing, resilience, grounding, and connection to something larger than oneself, to ultimately create and sustain meaning and health in life (Dallas et al., 2020; Ingerman, 2018). A ritual or ceremony entails enacting a sequence of behaviors or ideas relating to symbols and meanings (La Fontaine, 1985). Healing ceremonies are spiritually oriented rituals that seek to return a person to wellness or to maintain one’s physical, spiritual, or emotional health, particularly in the face of perceived threats or losses (Crouch, 2016; Kumar et al., 2023). Such traditions often stem from religious, cultural, or ethnic roots and are commonly performed to signify celebrations or other important events (Kumar et al., 2023). These acts also offer spiritual coping as a means to address difficult existential, biopsychosocial, or spiritual situations (Crouch, 2016; Mathew, 2021); to elicit healing narratives or conversations regarding trauma; and to honor feelings of frustration, fear, anxiety, and guilt (Crouch, 2016).
Indigenous healing and ceremonial practices are part of community wellness and healing traditions for Native tribes across the North American continent (Causadias et al., 2022; Saiz et al., 2021). Such practices are passed down by the generations, despite having been forced underground for a period when the U.S. government outlawed Native American cultural practices (Irwin, 1997). Indeed, colonizers have sought to suppress and erase the Indigenous knowledge and practices of colonized communities around the world throughout history.
Scholars have recently recognized the efforts of Indigenous communities across North America to reclaim the many traditional practices to which they had been denied access because of the violence of colonization (McCormick, 2021). This healing movement is embodied in the United Nations Declaration on the Rights of Indigenous Peoples (United Nations, 2008), emphasizing the rights of Indigenous people to maintain their cultural, spiritual, and health traditions and practices (Kumar et al., 2023; McCormick, 2021). In turn, ceremony-assisted treatments can be used by and with persons of all Indigenous roots to enact healing and sustain wellness and survivance (e.g., resistance and thriving in the face of oppression; Vizenor, 1993).
Because of the efficacious nature of healing rituals, mental health practitioners of all identities have sought to apply traditional practices with Indigenous clientele and in addressing a variety of symptoms of client distress (McCormick, 2021). Non-Native American mental health practitioners have drawn upon Indigenous rituals such as smudging and drumming to address myriad forms of presenting distress across tribal groups (Blackett & Payne, 2005). Examples of issues addressed through such rituals include chronic pain (Greensky et al., 2014), distress from discrimination and colonization (Lu & Yuen, 2012; West-Olatunji et al., 2008), and substance use (Spillane et al., 2021).
In light of the universal practice around making meaning through ritual, certain Indigenous interventions may also be considered for adaptation with non-Native clientele, albeit with caution and an ethical mindset (Rathod et al., 2019). Currently, however, there are limited guidelines around the ethical implementation of ceremony-assisted interventions for non-Native practitioners, particularly for work with non-Native clientele. Such guidelines are essential to mitigate harmful acts of appropriation born from colonization and the continued exploitation of Indigenous communities and their practices on the North American continent (Meade et al., 2022).
Consequently, considering the importance and power of ritual and ceremony as a healing and wellness practice, we offer recommendations for non-Native and Native practitioners to ethically explore and incorporate ceremony-assisted interventions into practice with Native and non-Native clientele. We provide an overview of relevant provisions of the American Counseling Association’s ACA Code of Ethics (ACA; 2014) and, through examples, outline how practitioners can implement ceremony-assisted treatments while avoiding cultural appropriation.
Next, we present three ceremony-assisted treatments, including smudging, drumming, and a letting-go ceremony. Such traditions stem from Indigenous origins and are applied by authors Smith-Yliniemi and Riegert in both professional and personal settings. Suggestions for use, including appropriate populations and areas of distress, are included. We address ethical considerations in promoting respectful and culturally sensitive use of each practice, to share traditions with broader populations while seeking to maintain the cultural integrity of said practices.
Regarding language use in this article, we will interchangeably apply the terms Native, Native American, Indian, and Indigenous to refer to persons who are indigenous to Turtle Island (i.e., the lands recognized by the dominant normative population as North America). Reference will be made to Creator, to indicate a universal reference by Indigenous communities of a spiritual presence greater than oneself. In addition, drawing from the preferred naming conventions of tribal communities, the terms Ojibwe and Anishinaabe will be used interchangeably in referring to Smith-Yliniemi’s and Riegert’s origins. However, we recognize that Indigenous people on Turtle Island are a diverse group of tribes or nations with their own languages, traditions, cultures, and naming conventions (National Museum of the American Indian, n.d.). Consequently, different tribes or Indigenous communities may choose different terminologies and for unique reasons, and many will likely take differing stances from those put forth in this article.
Practitioner Positionality
As the authors, we collectively identify as counselor educators. We each approach the directives in this article with multiple intersecting identities and critical lenses with which we seek to understand and make meaning of the world and our work. We attempt to embody cultural humility, responsiveness, and antiracist and decolonizing frameworks. We recognize that counseling as a practice has historically applied a pathologizing and therefore harmful lens toward clientele and, in particular, toward communities whose identities have been minoritized by dominant normative systems (Malott et al., 2023). Hence, to counter this deficit-based narrative, we ascribe to a strengths-based perspective and recommend practitioners do likewise (White et al., 2020). We encourage Native American practitioners seeking to “remember what they already know” about Indigenous practices as they return to their ancestral roots. In light of these points, we will transparently and authentically share the identities and frameworks we bring to this work.
Julie Smith-Yliniemi identifies as an Anishinaabe ikwe, an Indigenous woman, who grew up on a Native American reservation in the Midwest. Additional heritage includes Scandinavian descent. Intersectionalities include being a mother, wife, daughter, cisgender, temporarily able-bodied, and a person who engages in her traditional Native American ceremonial practices. Her personal and professional lens is grounded in humanistic and relational–cultural theories.
Krista M. Malott identifies with multiple intersecting identities that profoundly shape her lens, some of which include being White, U.S.–born, cisgender, female, temporarily able-bodied, spiritually agnostic, and a member of a transracially adoptive family. She principally assumes humanist, systemic, antiracist, and intersectional lenses, which shape her worldviews and her approach to her work.
JoAnne Riegert identifies as an Anishinaabe ikwe who lives and works on a Native American Indian reservation in a rural community. Her ancestral heritage also includes French Canadian and German descent. Her familial roles include being a grandmother, mother, sister, daughter, niece, and aunt. She is steeped in the Native American community and her worldview originates from this perspective. Her theoretical foundation incorporates restorative justice practices and relational-cultural theory.
Susan F. Branco identifies as a Latina, South American–born, transracial adoptee, cisgender female, able-bodied, descendent of the Guahibo tribe, and connected to the Anishinaabe culture through marriage. She is an active member of the adoptee community and is working to reculturate and reclaim her lost cultural and Indigenous heritage. Her clinical and scholarly work revolve around relational-cultural and liberation theories.
Ethical Application and Considerations
For the purpose of this article, we approach the concept of adaptation with a collectivist perspective, whereby we eschew an ownership concept of healing practices by any one cultural group. Consequently, as counselor educators and mental health practitioners, we collectively suggest that some Indigenous ritual or ceremonial healing practices may also be adapted for clients of non-Native identities, and by practitioners of all cultural identities, albeit while keeping certain points in mind—for example, if undertaken with respect and sensitivity, awareness, and guidance, and with the understanding that every person has origins to some tract of land and a spiritual connection to earth and self. This perspective is not true, of course, for all Native interventions, and not all Indigenous people will adhere to this stance. Attending to ethical guidelines can reduce the risk of appropriation, whereby cultural knowledge is used without proper and respectful acknowledgement to the cultural creators (Lalonde, 2021). Ethical guidelines may also increase cultural appreciation, adaptation, and acknowledgement, along with respectful attribution to the creators of certain interventions without stereotyping (Han, 2019; Hiratsuka et al., 2018; Meade et al., 2022).
To further attend to issues of ethics and harm in drawing on Indigenous healing ceremonies, non-Native counselors may refer to Meade et al.’s Checklist for Counselor Practitioners (2022). Meade and colleagues (2022) cited the need for practitioners to acquire cultural knowledge to more ethically implement ceremony-assisted practices, beginning with researching the “origins of the clinical intervention” (p. 103). We encourage practitioners to consider relevant ethical standards (ACA, 2014) as a starting point in the journey to Indigenous practice implementation and adaptation. We will denote suggested ethical standards after each ceremony-assisted treatment description.
Ceremony-Assisted Treatments
In the following sections we describe three specific healing rituals premised on Indigenous ceremonial treatments as means for supporting clients in healing or in sustaining wellness in a private (i.e., individual client) setting: smudging, drumming, and a letting-go ceremony. We detail when and how (and with whom) such practices could optimally be applied. A case example is used to illustrate application of each ritual with clients, with directives for the cultural adaptation of each. Considering the right and essential need for Indigenous peoples to protect their lands, traditions, and ceremonies (Drissi, 2023; United Nations, 2008), each ritual includes directives according to ethical use of its application, including consideration around appropriation and reverence for land and material use, when applicable.
Smudging
Smudging is an act of burning a traditional medicinal plant with the purpose of cleansing the body, mind, or spirit; renewing energy within and around individuals in a particular space or with a certain object; or calling for help in opening oneself to a new experience (Borden & Coyote, 1991). Some people incorporate smudging into their daily lives, while others apply it as needed. For instance, if a person is in the presence of someone who is giving off negativity or energy that is not welcoming, they may leave and smudge themselves to cleanse themselves of the negativity. At other times, if a person receives a gift or buys something new, they smudge that object in order to cleanse it. Cleansing a space to bring positive energy is also a common use of smudging. Hence, if someone moves into a new or different home, or is using a specific space for a ceremony, they might walk around the space, smudging it.
Smudging may invoke positive energy for a specific event. For instance, both in-person or virtual meetings can be started with a smudge. Smith-Yliniemi smudges each morning as a way to start her day positively. A counselor could begin sessions with a smudge, if the client desires to do so, along with personalizing or adapting the ceremony according to the client’s expressed needs or wants.
Smudging is a ceremonial process with a purpose, a beginning, and an end, with different teachings according to different tribal or community norms. Examples of smudging materials include cedar, sage, and sweetgrass. Those materials can be purchased or found in nature. In Smith-Yliniemi’s Anishinaabe community, sage is used, and it is gathered within a natural setting, with the act of gathering as part of the ceremonial process. Grown in the wild, sage differs according to the ecosystem in which it resides. Smith-Yliniemi’s community typically picks sage annually during the summer months when it is grown and ready, typically found in ditches and usually in patches. The person picking the sage will offer tobacco to Mother Earth and to the sage plant prior to picking it, to give thanks.
Traditional tobacco has been used for spiritual and medicinal purposes within communities for generations. It is central to culture, spirituality, and healing (National Native Network, n.d.). To offer tobacco, a person takes a pinch of loose-leaf tobacco from a bag or jar and places it in the palm of their left hand. The left hand is typically used because it is closest to our hearts. One then closes their hand with the tobacco secured in the fist and prays to Mother Earth and gives gratitude for the healing medicine offered by sage; they also ask the sage to help all who smudge with it. After the prayer, the tobacco in the left hand is gently placed next to the sage plants intended for harvest.
One of the Anishinaabe Original Instructions from Creator is to take only what one needs, so that there is enough for others. Individuals typically pick enough sage for those who are unable to do so, such as elders or those affected by an impairment. The sage is cut or picked from the stem of the plant, leaving the root intact; in this way the sage is able to regrow each year. Once picked, the sage is hung upside down to dry, a process that can take several weeks depending on the heat and humidity. It is then bundled and stored in a dry place to be used throughout the year.
Although smudging can be used at any time of the day, it is often done in the morning. To smudge, a small amount of sage is taken off the bundle and rolled into a small ball. It is usually placed in a shell or a special bowl and then lit with matches. The teaching Smith-Yliniemi received is that, when smudging, the smoke from the burning sage is initially taken into the hands and placed over the heart while asking Creator to open one’s heart to the experience they are about to have, as a new beginning. That beginning may entail the opening of the day, a counseling session, an event related to a life transition, or something else. In this way, a person asks for help to open their heart to a new experience.
Next, the smoke from the sage is smudged (fanned or wafted) toward the throat area while asking Creator to help with one’s words—to formulate loving and respectful words and thoughts and to know when to use them thoughtfully. Hence, one smudges the throat to reduce impulsivity and increase thoughtfulness and deliberation in speaking. Next, the ears are smudged while asking Creator to help the person hear what they are meant to hear, as so much of what one hears can cause undue worry. Hence, smudging the ears allows others’ words not meant to be heard to dissipate. In this way, Creator helps people to better hear only that which promotes learning and growth or the calming of our minds.
Next, the eyes are smudged while asking Creator to help one see what they are meant to see, including the best in others—knowing that all persons have flaws and wounds from living in a world full of chaos and worry. Additionally, the person asks to look beyond the physical, to use a lens that Creator intends. Seeing in this way allows one to live in a more peaceful manner. The person then smudges their head while asking Creator to help them with healthy thoughts and the ability to welcome a positive mindset. Consequently, through this ceremony, a person seeks spiritual and physical healing through the cleansing of any negative feelings, thoughts, or energies. They ask Creator to help them to be present and open to a more positive, healthy, and compassionate way of being toward themselves and others.
Counselors or clients of any identity can smudge if it is something they feel called to do and it makes them (or their clients) feel better. As the process is used by Indigenous communities around the world, anyone can have their own smudging routine. Some groups use smudging in association with ceremonies, as a means to feel connected to something they have lost, such as their culture and ways of being, or to address loss from war, genocide, intergenerational trauma, or colonialism. Smudging can be used as a precursor to a “welcome home” ceremony for Native American clients who were adopted and do not know their culture well or urban Indians lacking direct connection to their reservation or tribe. The ritual serves as an opening process that clears the space of any negative energy before enacting that ceremony. Smudging in this way brings in positive energy and allows attendees to be fully present and with open spirits, hearts, and minds. In turn, the welcome home ceremony acts as a coming-together process that helps individuals feel a part of their cultural community, as a symbolic rebirth of their connection to their culture.
Smudging can cleanse one’s mind, body, and spirit, bringing the person to the here and now, and therefore it can help with depression, trauma, anxiety, or substance abuse. In turn, researchers have cited smudging to have significant meaning for individuals in regard to myriad issues, from physical health issues (Greensky et al., 2014) to mental health recovery (Spillane et al., 2021) to connecting employees to one another and to their work setting through the ritual itself (McPhee et al., 2017).
Ethical Considerations
In considering the ethics of applying smudging with clients, there are several points to keep in mind. First, for non-Indigenous practitioners, it is essential that ethical standard C.2.a. Boundaries of Competence (ACA, 2014) is considered. This states that practitioners, at minimum, read about and, ideally, receive training or experience with the practice of smudging. Such services could be advertised as one intervention available to specific populations, similar to the way other modalities are advertised (e.g., via the practitioner’s website, written materials, and verbally). Mentions of smudging should include its traditional origins and meaning, in order to educate potential clients about the nature of the intervention. Potential areas of learning include understanding the historical roots and practices of smudging, recognizing the impact of colonialism and contemporary culture on the practice (McCormick, 2021), and attending to personal bias and values per standard A.4.b. Personal Values (ACA, 2014).
In addressing issues of cultural appropriation, practitioners should avoid use of the intervention solely for profit, aligned with standard A.4.a. Avoiding Harm (ACA, 2014). When using the intervention, they should clearly credit the source and origins of the practice for their clients. Regarding materials, they should also be mindful to avoid taking more sage than necessary, to allow others access to the plant. Ideally, counselors would consult, learn, and draw from local cultural protocol and original persons/elders/tribes of their area. They would also keep in mind that what is acceptable in one community is not the same in others, and that although some Indigenous persons believe that Indigenous medicines are there to help people of any and all identities, others believe such practices should be maintained as sacred and exclusive to their community. Hence, one should seek out protocols and perspectives in their local community, aligned with ethical standard C.2.e. Consultations on Ethical Obligations (ACA, 2014).
Finally, if smudging with clients whose ancestors may have used the practice, such as African Americans, it is important to gauge their cultural awareness regarding their identities. Perhaps encourage research around ancestral African ceremonial practices or research such histories collaboratively. Explore their perspectives and emotions around what is discovered; what has been lost to colonialism, enslavement, genocide, and other historical traumas; and how they wish to proceed with smudging as a practice in collaboration with the counselor. A decolonizing counseling framework could be drawn upon for processing deep-seated trauma and corresponding emotions stemming from colonization impacts (Millner et al., 2021). In so doing, counselors will attend to ethical standard A.2.c. Developmental and Cultural Sensitivity (ACA, 2014).
Adaptation Possibilities
As an intervention, smudging is suitable for adaptation. If not using sage, counselors can still engage in the act of cleansing a space. Some clients may be interested in burning a different herbal medicine that is meaningful to them. Some may be interested in using incense or oils to cleanse themselves or the space they are in. Adaptations, in turn, can be made in collaboration with each client, to honor their own cultural norms and practices.
Smudging: A Case Example
Kiah, a 15-year-old Indigenous youth, sought out her school counselor, who was non-Indigenous. The client had been struggling with identity issues since hearing that there was going to be a school-sponsored powwow at the end of the school year. Some of her friends asked her if she would be dancing, as they knew she was Native American. However, she moved from the reservation to the city over 10 years ago and didn’t know much about her culture or dancing. As a result, she was feeling disconnected and anxious about who she was as a Native American.
In an effort to support Kiah, the school counselor researched and read articles regarding Native American identity and also reached out to the school district’s Native American education director in order to glean ideas on how to effectively work with the student. The director advised the counselor to engage Kiah in an activity that included her memories of living on the reservation while asking her what she may want to reconnect to.
During this activity, Kiah remembered her grandmother having a shell on her kitchen table, a distinct smell, and feelings of calmness in her home. Working collaboratively, the student and counselor recalled that her grandmother would engage in the ceremonial practice of smudging each day, and Kiah realized this was something she would like to do in reconnecting to her culture. The Native American education director shared the smudging teaching with the student and helped procure sage from a local Native American–owned shop. The student relearned this ceremonial practice and planned to regularly practice the new ritual as a way to stay grounded in and connected to her identity.
Drumming
The goals of drumming are to find rhythm in one’s life again; to help people celebrate, grieve, and heal; and to feel connected to Mother Earth as one was once connected to their mother’s womb (Rojiani et al., 2022). Many Indigenous people believe that drumming represents the heartbeat of Mother Earth. The act of drumming connects the drummer with the earth. It is a practice that is both intimate and ceremonial. Drumming has been shown to enact multiple positive outcomes in clients, with examples including positive identity development (Rojiani et al., 2022); stress reduction and empowerment (Maschi et al., 2013); coping with societal oppression (McKinley, 2023); and anxiety reduction, decreased self-stigma, and the improvement of mood (Mungas & Silverman, 2014; Rowe et al., 2023).
Drums can be made from different animal hides; in the Midwest region, they are often made with deer hides. Drums can be made or bought, with kits accessible online. Drumming music can come from any origin. Oftentimes, Indigenous songs originate from someone’s dream and then are gifted to a person or group. One example is that of an elder who once dreamt a specific song for a women’s ceremony, and then gifted the song to Smith-Yliniemi and Riegert. The elder sang the song to them, and it was their responsibility to learn the song and sing it at that certain monthly ceremony from then on, which has been done for the past decade. The drum is considered a sacred living object, as an animal gave their life so that humans could benefit and heal. Consequently, caring for a drum should occur regularly and is considered a ritualistic ceremonial experience, whereby the keeper has the responsibility to acknowledge its life and treat it with great respect and honor.
The act of drumming includes tapping the instrument with a drumstick or hand. One or multiple individuals can drum. Drumming can be used in ceremonies. In some communities, behavioral health departments offer ceremonies to community members as a way to heal and connect with their Indigenous roots. As an example of the use of drumming in counseling, when Smith-Yliniemi engaged in group trauma therapy with adolescents, she would use drumming as a way to connect members. They would begin with a smudge and then one person would choose a song and either drum and sing individually or ask the group to join if they happen to know the song.
Individuals of all identities can drum, as the practice is not exclusively Indigenous (e.g., there are music therapy degrees that incorporate drumming for all). Anyone can drum, as it comes from within; one doesn’t have to be a musician or take lessons. Drumming can be used with myriad client issues, including depression, oppression, anxiety, affect regulation, substance use, and identity strengthening. As noted in the prior paragraph, drumming can connect members of a group to enhance social interest (Sperry et al., 2021) or create a sense of belonging and humanization (Craddock et al., 2022).
Ethical Considerations
In considering the ethics of applying drumming with clients, there are several points to keep in mind. First, like the above directives with smudging, for non-Indigenous practitioners, it is essential that practitioners adhere to standard C.2.a. Boundaries of Competence (ACA, 2014) and read about, research, and study—and ideally receive training or experience with—the practice of drumming. Potential areas of learning include understanding the historical roots and practices of drumming, recognizing the impact of colonialism and contemporary culture on the practice (Quarshie, 2023), and use of drumming in contemporary healing practices (Rojiani et al., 2022; Rowe et al., 2023), all of which support adherence to standard C.2.b. New Specialty Areas of Practice (ACA, 2014). In addition, counselors can describe the practice, meaning, and impacts of drumming both in advertising and verbally with clients.
Adaptation Possibilities
When drumming with clients whose ancestors may have used the practice, such as African Americans, similar to the suggestions for smudging, it is important to explore their awareness of their identities and roots, encourage research around their ancestors’ ceremonial practices, or research such histories collaboratively. Explore their perspectives and emotions around what is discovered; what has been lost to colonialism, enslavement, genocide, and other historical traumas; and how they wish to proceed with drumming as a practice in collaboration with the counselor.
Drumming: A Case Example
Zane, a non-Indigenous, African American client sought counseling because of feeling depressed following several failed romantic relationships. Zane explained to the counselor that he had a recent “aha” moment when he realized he kept breaking up with his partners because he didn’t know who he was. His insight came after watching a movie on African American history and realizing he wasn’t sure of who he was, where he was from, or any cultural practices of his African American ancestors. Zane asked, “How am I supposed to know what I want in others when I don’t even know myself”?
The counselor explored with Zane what parts of the movie called him to his “aha” moment. He explained that it was a part in which African ceremonies were taking place and that the drumming had immediately brought him to tears. Throughout the next few sessions Zane and his counselor explored his African roots, and he ordered a drum kit so that he could make his own drum. Zane also reached out to a local African organization and began attending a bimonthly community event that promotes African culture and song. Over time and across the counseling sessions, Zane’s mood appeared to significantly improve. He began to discuss additional ways of researching his identity and to also consider the implication of these explorations on his dating choices going forward.
Letting-Go Ceremony
A letting-go ceremony is a ritual that allows a person to process and/or release thoughts, emotions, or memories around beliefs or experiences in order to bring about healing and a sense of peace and to make room for new ways of being or engaging in the world (McCormick, 2021). It is often believed that one cannot simply talk their way through a trauma, but that they must spiritually and physically release it as well. Using tobacco ties is one traditional way to release a trauma, as a symbol of letting go, freeing oneself from the human experience, and returning the trauma back into the earth. It is a metaphor for no longer having to carry a certain burden.
Tobacco is considered a sacred medicine that represents the earth and is used for myriad purposes in Indigenous communities (National Native Network, n.d.). A tobacco tie can be created by placing a small amount of tobacco on a cloth and folding or tying the corners to create a small ball or sachet. It can be connected to a chain of ties, as well. The ties are released or given to the earth or sky, through laying them near the roots of a tree or placing them in a fire.
The process itself can be ceremonial, implemented with fasting or praying. The idea is an offering to the spirit world meant to impact the here and now in the physical world and to release some of the pain associated with an event (Wilson & Restoule, 2010). When the client and counselor practice the ceremony together, both are able to let go of part of the pain. The collective connection of healing helps to ease some of the traumatic experience.
In an example of using tobacco ties in group counseling, Smith-Yliniemi would often invite a medicine person to be part of the closure process for trauma groups. The medicine person would instruct group members to make a tobacco tie for each trauma they wanted to release from their bodies and their lives. These ties would then be used in a sweat lodge ceremony in the final session of a 10–12 week group.
The idea of symbolically “giving over/letting go” or releasing something as a means for healing is a universal act and therefore can be drawn upon and applied by counselors and clients of any identity. However, the ceremony would look different according to the client’s identity and wishes. Letting go allows one to release thoughts or beliefs that keep them held to the past—hence, it allows people to stay more focused in the present moment, which could apply to many topics. Common letting-go issues include grief, traumas, and depression, as well as negative and harmful thoughts, feelings, habits, and experiences. Ultimately, we could not think of any issue that necessarily would not benefit from a spiritual and/or physical ceremonial process of “letting go.” The client, of course, must be amenable to the idea of letting go; hence, the counselor should collaboratively determine client readiness for letting go and explore client reluctance, if it does arise, as a natural part of the process.
Ethical Considerations
Individuals of any identity can engage in letting-go ceremonies, and likely the best practice is to initially draw upon clients’ own cultural practices specific to letting go in line with standard E.5.b. Cultural Sensitivity (ACA, 2014). However, if they are unaware of any such practice in their own community, counselors may adapt a letting-go ceremony as described here to meet the client’s need. Because letting-go ceremonies can be particularly emotionally laden for both the client and counselor, we encourage counselors to monitor their own wellness and to be mindful of counselor impairment, as noted in ACA ethical standard C.2.g. Impairment (2014).
Adaptation Possibilities
If a person does not use tobacco as part of the letting-go ceremony, other elements of nature can be used instead. For example, a person can use a stone. A stone/rock is known as a “grandfather” in many Indigenous cultures. They have been on the earth the longest and have helped humans for many generations, carrying wisdom and strength. As a symbol of letting go, a person could find and hold a grandfather (rock) in their hand, releasing their pain from the human experience back into the earth through the rock, symbolizing that we do not have to carry the pain within us, but that we can release it to Mother Nature, who serves as a caregiver to us all.
Letting-Go Ceremony: A Case Example
Lisa, a non-Indigenous client, came to counseling to address the trauma of losing an unborn child. During the sessions, the counselor and Lisa explored the impact of this trauma. Together, they decided to engage in a letting-go ceremony as a means for healing. As a first step, the counselor gave credit to the origins of the letting-go ceremony and explained to the client how and from whom the intervention was learned.
In preparation for the ceremony, the counselor obtained the necessary items, while also tending to their own emotions to ensure that the ceremony was delivered in a healthy and therapeutic way. The counselor prepared the meeting space to ensure that it was free of distractions. A blanket was laid on the floor with a sacred altar or centerpiece, on which both the counselor and Lisa placed items that were meaningful to them. Elements of the natural world were also part of the altar—examples of potential elements include a stone, tree leaves, a small dish of water, and even an electric candle to represent fire.
In addition, objects that represented other important people in the client’s life could be present, such as a small picture or an item that belongs to a significant person. That object signifies that one does not carry the challenges in their lives alone, that there are other humans who helped to guide one along the way. In this case, the centerpiece objects were selected collaboratively by the counselor and Lisa with the intention of providing support during the letting-go ceremony.
Next, the counselor offered a small piece of cloth (4” by 4” square) to Lisa, while keeping a piece of the material for themself. In this cloth, Lisa and the counselor placed dried herbs and natural earth medicines brought specifically for the ceremony. They then tied their individual bundles of herbs with a small string and held them in their left hands, which are closest to the human heart. Importantly, only a small amount of dried medicine (one teaspoon) was used for the cloth tie.
Next, a song was played. (Other options include reading a poem or offering several moments of silence.) The counselor explained to Lisa that the particular moment was spent intentionally in sending any energy from the traumatic experience into the tied cloth. After some time passed and the client signaled that they felt ready, the counselor brought the session to a close. The altar was disassembled while both participants continued to hold their ties.
At the end of the session, the counselor explained that the cloth tie that held the medicine and the energy from the ceremony can be placed on the earth, left at the base of a tree, placed in the woods, or even put near a body of water. The implication and healing properties of the ceremony were that the energy and emotions from the loss are now part of the tie and part of the earth, so that Lisa did not have to carry them all individually. The counselor also explained that a letting-go ceremony was not a one-time practice, and that throughout Lisa’s life, she now had the knowledge to practice letting go as needed.
Competency and Cultural Responsivity Considerations
We have identified methods by which practicing counselors can begin to implement ceremony-assisted treatments. Suggestions for obtaining more information about ceremony-assisted experiences include reaching out to and collaborating with one’s local Indigenous community and seeking out a knowledge expert. It is important to offer a gift to the person who is sharing their knowledge. Gift giving in this way aligns with the spirit of the 2014 ACA Code of Ethics preamble, which asserts the importance of honoring and “embracing a multicultural approach in support of the worth, dignity, potential and uniqueness of people within their social and cultural contexts” (p. 2). ACA ethical standard A.10.f. Receiving Gifts may also be relevant for giving gifts to those from whom one learns. Making a gift to recognize the importance of honoring cultural norms around gifting is certainly in keeping with the reasons and values behind this standard. Gift giving in this instance could entail any tangible item given with thoughtful consideration from one’s heart to the heart of the person from whom they seek wisdom. Examples include plants from the earth (dried or fresh), an object with a meaningful phrase, something useful (such as towels/blankets), or a handmade item. The gift item itself is not as important as the intention behind it—as an expression of love and respect and the sharing of gratitude for the opportunity to be open and learn from wisdom keepers. The experience of earnestly seeking, listening, and developing deeper understanding creates an opportunity for the growth of cultural humility (Tham & Solomon, 2023). Additionally, practitioners are building cultural responsivity as they adopt customs and traditions with awareness of the cultural origins.
Once knowledge of the healing ceremony is learned, practitioners should also offer the earth a gift of natural essence (a stone, small berry, dried herb, or small amount of water), as the counselor now holds this wisdom and has a responsibility to honor the earth and the person who gifted it to them. This connection and reciprocity between the natural and human world are a continual exchange of gratitude. It is essential that practitioners give due credit to the contributors of newly learned practices and traditions (Meade et al., 2022). In service delivery, sincerity is honored while using our own language and understanding.
In considering competency, ethical standard C.2.b. New Specialty Areas of Practice cites the need for counselors to take steps to ensure competence in applying new techniques, and always with the lens of “protecting others from possible harm” (p. 8). Additionally, counselor commitment to ongoing learning is emphasized in ethical standard C.2.f. Continuing Education (ACA, 2014). Hence, learning should not be considered as a singular universal practice; rather, practitioners should seek to learn in the moment from the knowledge keeper and engage in ongoing consultation, learning, and interaction with the wisdom holders. Continual practitioner reflection and the eliciting of client feedback—to determine the meaningfulness and impact of such interventions—is also essential to determining counselor effectiveness. These steps align with ethical standard C.2.d. Monitor Effectiveness (ACA, 2014), stating the importance of counselor action in monitoring the effectiveness of the work they do.
Conclusion
Ceremony-assisted treatments are powerful sources of healing and health for clientele. Ritual is essential for all humans, as a means for healing and for the maintenance of one’s physical, spiritual, and emotional health (Hewson et al., 2014)—albeit in ways that are uniquely shaped by personal culture and experiences (McCormick, 2021). We hope that the interventions included in this article can be used to enhance client mental health and health care needs.
Essential directives noted in this article include the importance of consulting with Indigenous healers within (or in approximation to) readers’ own contexts, to consider the ethical application of Indigenous-origin healing practices. We suggest seeking out and receiving education around such interventions, their histories, and the communities from which they originate to gain further understanding and respect for the practices. Those working in school systems may want to work collaboratively with an Indigenous education director in the ethical provision of ceremony-based interventions in their setting or to advocate for hiring such professionals for settings that lack an expert. Readers can also refer to the Association for Multicultural Counseling and Development’s Native American Concerns Group as a resource for Native counselors as well as for professionals counseling Native populations.
We reiterate that the perspectives around the use of and appropriation of Indigenous practices differ within and across Indigenous communities. Meade et al.’s (2022) Checklist for Counselor Practitioners reminds practitioners to remain vigilant to their own intersecting identities and to adhere to ethical practices in order to avoid harmful cultural appropriation. We attend to several of these recommendations by acknowledging and sharing our intersecting identities and offering guidance on ethically adapting the interventions to all clients.
Finally, going forward, when sharing these healing teachings, we encourage readers to maintain an awareness of the deep roots of these practices—stretching back and beyond seven generations—as a way to honor the ancestors who came before us and who have persisted in the face of great tragedy. We recognize the oral traditions that have allowed these teachings to be passed across the generations and ask readers to mindfully and respectfully pass on such teachings (orally or in writing) for seven generations more. In this way, future communities will know the healing practices that have aided Indigenous people for thousands of years, and they can adapt such practices in ways that heal and bring balance and wholeness to each unique community. Ultimately, we hope that counselor awareness of such factors will ensure that these teachings are shared in a mindful, loving, and honorable way.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
American Counseling Association. (2014). ACA code of ethics. https://www.counseling.org/resources/aca-code-of-ethics.pdf
Blackett, P. S., & Payne, H. L. (2005). Health rhythms: A preliminary inquiry into group-drumming as experienced by participants on a structured day services programme for substance-misusers. Drugs: Education, Prevention and Policy, 12(6), 477–491. https://doi.org/10.1080/09687630500342881
Borden, A., & Coyote, S. (2007, April 25). Smudging ceremony. http://www.snowwowl.com/nainfosmudging.htm
Causadias, J. M., Alcalá, L., Morris, K. S., Yaylaci, F. T., & Zhang, N. (2022). Future directions on BIPOC youth mental health: The importance of cultural rituals in the COVID-19 pandemic. Journal of Clinical Child & Adolescent Psychology, 51(4), 577–592. https://doi.org/10.1080/15374416.2022.2084744
Craddock, L., Kells, M., Morgan, L., & Shah-Beckley, I. (2022). Drumming, singing and ceremony within a psychologically informed planned environment for women on the offender personality disorder pathway. The Journal of Forensic Practice, 24(2), 123–137. https://doi.org/10.1108/JFP-05-2021-0026
Crouch, M. A. (2016). A breath of fresh air: A family ceremony. Families, Systems, & Health, 34(1), 64–66.
https://doi.org/10.1037/fsh0000167
Dallas, T., Baroutsa, N. M., & Dein, S. (2020). The power of the divine: Religion, rituals, and healing in Greece. Mental Health, Religion & Culture, 23(8), 718–732. https://doi.org/10.1080/13674676.2020.1825363
Drissi, S. (2023, September). Indigenous peoples and the nature they protect. UN Environment Programme.
https://www.unep.org/news-and-stories/story/indigenous-peoples-and-nature-they-protect
Greensky, C., Stapleton, M. A., Walsh, K., Gibbs, L., Abrahamson, J., Finnie, D. M., Hathaway, J. C., Vickers-Douglas, K. S., Cronin, J. B., Townsend, C. O., & Hooten, W. M. (2014). A qualitative study of traditional healing practices among American Indians with chronic pain. Pain Medicine, 15(10), 1795–1802. https://doi.org/10.1111/pme.12488
Han, H.-C. (2019). Moving from cultural appropriation to cultural appreciation. Art Education, 72(2), 8–13. https://doi.org/10.1080/00043125.2019.1559575
Hewson, P., Rowold, J., Sichler, C., & Walter, W. (2014). Are healing ceremonies useful for enhancing quality of life? The Journal of Alternative and Complementary Medicine, 20(9), 713–717. https://doi.org/10.1089/acm.2013.0248
Hiratsuka, V. Y., Parker, M. E., Sanchez, J., Riley, R., Heath, D., Chomo, J. C., Beltangady, M., & Sarche, M. (2018). Cultural adaptations of evidence-based home-visitation models in tribal communities. Infant Mental Health Journal, 39(3), 265–275. https://doi.org/10.1002/imhj.21708
Ingerman, S. (2018). The book of ceremony: Shamanic wisdom for invoking the sacred in everyday life. Sounds True.
Irwin, L. (1997). Freedom, law, and prophecy: A brief history of Native American religious resistance. American Indian Quarterly, 21(1), 35–55. https://doi.org/10.2307/1185587
Kumar, M., Guruvayoorappan, S., & Menon, S. (2023). Transgressing narrative boundaries: Exploring how indigenous faith-healing rituals from Kerala move beyond the limitations of narrative therapy. Psychological Studies, 68(2), 1–10. https://doi.org/10.1007/s12646-023-00715-9
La Fontaine, J. S. (1985). Initiation. Penguin.
Lalonde, D. (2021). Does cultural appropriation cause harm? Politics, Groups, and Identities, 9(2), 329–346. https://doi.org/10.1080/21565503.2019.1674160
Lu, L., & Yuen, F. (2012). Journey women: Art therapy in a decolonizing framework of practice. The Arts in Psychotherapy, 39(3), 192–200. https://doi.org/10.1016/j.aip.2011.12.007
Maschi, T., MacMillan, T., & Viola, D. (2013). Group drumming and well-being: A promising self-care strategy for social workers. Arts & Health, 5(2), 142–151. https://doi.org/10.1080/17533015.2012.748081
Mathew, L. E. (2021). Braiding western and eastern cultural rituals in bereavement: An autoethnography of healing the pain of prolonged grief. British Journal of Guidance & Counselling, 49(6), 791–803.
https://doi.org/10.1080/03069885.2021.1983158
McCormick, R. (2021). Indigenous North American healing. In R. Moodley & E. Lee (Eds.), The Routledge international handbook of race, culture and mental health (pp. 485–495). Routledge.
McKinley, C. E. (2023). “Prayer is universal”: How integrative faith practices enable Indigenous peoples’ persistence and resistance to transcend historical oppression. Psychology of Religion and Spirituality, advance online publication. https://doi.org/10.1037/rel0000497
McPhee, D., Julien, M., Miller, D., & Wright, B. (2017). Smudging, connecting, and dual identities: Case study of an aboriginal ERG. Personnel Review, 46(6), 1104–1119. https://doi.org/10.1108/PR-10-2015-0270
Malott, K. M., Barraclough, S., & Yee, T. (2023). Towards decolonizing diagnosis: A critical review and suggested alternatives. International Journal for the Advancement of Counselling, 45, 1–17. https://rdcu.be/c3o3O
Meade, N. A., Branco, S. F., Burt, I., White, R. K., & Hanks, A. (2022). Cultural appropriation, appreciation, and adaption: A rejoinder to “Effects of a Rite of Passage Ceremony on Veterans’ Well-Being.” Journal of Counseling & Development, 100(1), 96–103. https://doi.org/10.1002/jcad.12400
Millner, U. C., Maru, M., Ismail, A., & Chakrabarti, U. (2021). Decolonizing mental health practice: Reconstructing an Asian-centric framework through a social justice lens. Asian American Journal of Psychology, 12(4), 333–345. https://doi.org/10.1037/aap0000268
Mungas, R., & Silverman, M. J. (2014). Immediate effects of group-based wellness drumming on affective states in university students. The Arts in Psychotherapy, 41(3), 287–292. https://doi.org/10.1016/j.aip.2014.04.008
National Museum of the American Indian. (n.d.). The impact of words and tips for using appropriate terminology: Am I using the right word? Native Knowledge 360°. https://americanindian.si.edu/nk360/resources/Impact-of-Words-and-Tips-for-Using-Appropriate-Terminology-Am-I-Using-the-Right-Word
National Native Network. (n.d.). Traditional tobacco. http://keepitsacred.itcmi.org/tobacco-and-tradition/traditional-tobacco-use/
Quarshie, N. O. (2023). Spiritual pawning: “Mad slaves” and mental healing in Atlantic-era West Africa. Comparative Studies in Society and History, 65(3), 475–499. https://doi.org/10.1017/S0010417523000051
Rathod, S., Gega, L., Degnan, A., Pikard, J., Khan, T., Husain, N., Munshi, T., & Naeem, F. (2019). The current status of culturally adapted mental health interventions: A practice-focused review of meta-analyses. Neuropsychiatric Disease and Treatment, 2018(14), 165–178. https://doi.org/10.2147/NDT.S138430
Rojiani, R., Junn, A., Wood, M., Gordon, K. L., & Sells, D. (2022). Group drumming for incarcerated men may improve community reintegration: A mixed methods pilot study. Journal of Experimental Criminology, 18, 825–846. https://doi.org/10.1007/s11292-021-09460-3
Rowe, K., Pozuelo, J. R., Nickless, A., Nkosi, A. D., dos Santos, A., Kahn, K., Tollman, S., Wagner, R. G., Scerif, G., & Stein, A. (2023). The adolescent HIV executive function and drumming (AHEAD) study, a feasibility trial of a group drumming intervention amongst adolescents with HIV. AIDS Care, 35(11), 1796–1814. https://doi.org/10.1080/09540121.2023.2195607
Saiz, J., Galilea, M., Molina, A. J., Salazar, M., Barsotti, T. J., Depak, C., & Paul, J. M. (2021). Spirituality and employment in recovery from severe and persistent mental illness and psychological well-being. Healthcare, 9(1), 57. https://doi.org/10.3390/healthcare9010057
Sperry, J., Casteleiro, G., Rinard, A., & Cooper, P. (2021). Group drumming and the Crucial Cs: Immediate effects of an Adlerian-based group drumming intervention on mood and social interest among college students. The Journal of Individual Psychology, 77(2), 225–237. https://doi.org/10.1353/jip.2021.0017
Spillane, N. S., Schick, M. R., Nalven, T., Goldstein, S. C., Kirk-Provencher, K. T., Hill, D., & Kahler, C. W. (2021). Testing the Competing Life Reinforcers model for substance use in reserve-dwelling First Nation youth. American Journal of Orthopsychiatry, 91(4), 477–486. https://doi.org/10.1037/ort0000543
Tham, S. S., & Solomon, P. (2023). Practicing cultural humility will achieve recovery-oriented mental health practice and service delivery. Administration and Policy in Mental Health and Mental Health Services Research, 1–4. https://doi.org/10.1007/s10488-023-01307-5
United Nations. (2007). United Nations Declaration on the Rights of Indigenous Peoples. https://social.desa.un.org/issues/indigenous-peoples/united-nations-declaration-on-the-rights-of-indigenous-peoples
Vizenor, G. (1993). The ruins of representation: Shadow survivance and the literature of dominance. American Indian Quarterly, 17(1), 7–30. https://www.jstor.org/stable/1184777
West-Olatunji, C., Shure, L., Garrett, M. T., Conwill, W., & Rivera, E. T. (2008). Rite of passage programs as effective tools for fostering resilience among low-income African American male adolescents. The Journal of Humanistic Counseling, Education and Development, 47(2), 131–143.
https://doi.org/10.1002/j.2161-1939.2008.tb00053.x
White, R. K., Hanks, A., Branco, S., Meade, N., & Burt, I. (2020, February 11). A collective voice: Indigenous resilience and a call for advocacy. Counseling Today. https://ct.counseling.org/2020/02/a-collective-voice-indigenous-resilience-and-a-call-for-advocacy
Wilson, D. D., & Restoule, J.-P. (2010). Tobacco ties: The relationship of the sacred to research. The Canadian Journal of Native Education, 33(1), 29–45. https://doi.org/10.14288/cjne.v33i1.196520
Julie Smith-Yliniemi, PhD, NCC, LPCC, is an assistant professor and Director of Community Engaged Research at the University of North Dakota. Krista M. Malott, PhD, LPC, is a full professor at Villanova University. JoAnne Riegert, PhD, LPCC, is a mental health professional from the White Earth Indian Reservation. Susan F. Branco, PhD, NCC, BC-TMH, LPC, LCPC, ACE, is an associate professor at Palo Alto University. Correspondence may be addressed to Julie Smith-Yliniemi, 1301 N Columbia Rd, Suite E-2, Grand Forks, ND 58202, julie.smithyliniemi@und.edu.
Jan 17, 2024 | Volume 13 - Issue 4
Sunanda M. Sharma, Jennifer E. Bianchini, Zeynep L. Cakmak, MaryRose Kaplan, Muninder K. Ahluwalia
According to the American Counseling Association and the Council for Accreditation of Counseling and Related Educational Programs, social justice advocacy is an ethical imperative for counselors and a training standard for counseling students. As a group of socially conscious mental health counseling students and faculty, we developed and facilitated a social justice advocacy group to learn about tangible ways to engage in social justice action. Using the S-Quad model developed by Toporek and Ahluwalia, we formed and facilitated a social justice advocacy group for our peers. This paper will serve as a reflection of our experiences engaging in the process.
Keywords: social justice, advocacy, counseling students, S-Quad model, mental health
When describing the motivation for her political aspirations, Georgia gubernatorial hopeful Stacey Abrams (2019) stated, “We have to have people who understand that social justice belongs to us all.” This quote speaks to this group of authors who feel strongly about the importance of social justice in mental health counseling. This ethos served as the motivation to create a peer-led group to foster the development of our social justice advocacy skills. We used the S-Quad model (Toporek & Ahluwalia, 2020) to form and facilitate a social justice advocacy group for master’s and doctoral counseling students at our institution.
Historically, the counseling profession has been rooted in social justice advocacy (SJA) with Frank Parsons’s efforts to support White European immigrants in the United States to develop their vocational goals (Gummere, 1988; Toporek & Daniels, 2018). However, SJA has not been consistently operationalized across counselor training programs (Counselors for Social Justice [CSJ], 2020). Although ethical standards established by the American Counseling Association’s ACA Code of Ethics (ACA; 2014) encourage counselors to advocate for clients and communities when appropriate (A.7.a, A.7.b.), and training standards established by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) state that SJA should be a part of counseling curriculum (2.F.2.b.), counselors have reported receiving little guidance about how to implement advocacy in practice (Field et al., 2019; Ratts & Greenleaf, 2018). As counseling students, we experienced the same concern. To address this gap in our educational experience, we created and facilitated a group based on the S-Quad model (strengths, solidarity, strategies, and sustainability) of SJA (Toporek & Ahluwalia, 2020). As a group of socially conscious mental health counseling students, our aim was to grow in our roles as professionals by learning about, teaching, and engaging in SJA. In the process, we learned about ourselves as budding counselors and educators.
Literature Review
In their foundational article, Vera and Speight (2003) called on the counseling profession to expand its understanding of multicultural competence; they asserted that without SJA, counselors are perpetuating the systems of oppression from which their clients are attempting to heal. Utilizing intrapsychic approaches which neglect to account for contextual factors not only perpetuates oppressive counseling practices, but it also does a disservice to those with marginalized identities (Ratts, 2009; Vera & Speight, 2003). In order to properly serve clients, counselors must step beyond the classroom, expand the original conceptualization of our roles, and explore beyond the counseling office (Ratts, 2009; Ratts & Greenleaf, 2018; Vera & Speight, 2003). Despite the increase in available resources such as the ACA Advocacy Competencies (Toporek et al., 2009) and the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016), the number of sociocultural forces such as racial demographics of counseling programs and reliance on theories and interventions developed for White European clients prevents social justice from being a central force in the profession (CSJ, 2020).
As mental health professionals, we are positioned to understand the impact that oppression has on health (Nadal et al., 2021), which speaks to the need for operationalizing social justice counseling and SJA so counselors may support client wellness. Counseling students require more knowledge and practice to obtain appropriate resources and tools in order to intervene and resist systemic oppression (Vera & Speight, 2003). Ratts (2009) named social justice as the “fifth force” in counseling in an attempt to concretize the relevance and importance of challenging the status quo in counseling. However, the perceived attitude of the counseling profession toward social justice is reflected in the definition of counseling. The 20/20 initiative was a movement to unify the profession and solidify professional identity by arriving at the definition of counseling. Delegates from 31 counseling-related organizations (e.g., CACREP, Chi Sigma Iota) participated in a Delphi-method study to achieve consensus on a definition; however, only 29 organizations ultimately endorsed the definition (Kaplan et al., 2014). Although the definition for counseling includes the word “empower”; it does not include the words “social justice” or “advocacy.” Thus, CSJ was one organization that did not support the new definition (Kaplan et al., 2014). Despite these challenges, Ratts and Greenleaf (2018) assert that counselors must develop the advocate part of their identity, yet they note that there is more of a focus on traditional counseling skills rather than acknowledging the shifting sociopolitical climate and equipping counselors with the skills to address these concerns. The leadership and advocacy course (or the content in another course; CACREP, 2023) in CACREP-accredited counseling doctoral programs often only focuses on leadership and advocacy within and for the profession. Although CACREP (2023) standards do not dictate the courses a counseling program must offer, there continues to be limited discussion of SJA and social justice, nor are there solid instructional methods for counselor educators to use in the classroom (Chapman-Hilliard & Parker, 2022). This situation hinders students’ understanding of the role systemic issues have on minoritized communities, further deterring people in those communities from seeking help.
As counselors and counseling students, we understand our responsibility to advocate for clients, but we feel unprepared to fulfill our ethical (and for many of us, moral) duty. We did not learn enough about the concrete, tangible skills that a professional counselor can utilize to challenge oppression and inequity. We were unable to locate any studies regarding peer-led SJA groups for counseling students, thus we hope to contribute something novel to the counseling literature and encourage counseling students to better understand and grow into their roles as social justice advocates. Counselors-in-training (CITs) and practicing counselors within the profession sometimes question the relevance of SJA and report feeling confused about how to implement SJA in counseling (Field et al., 2019; Ratts & Greenleaf, 2018). hooks (1994) notes it is imperative that a student accepts responsibility for their education and becomes “an active participant, not a passive consumer” (p. 14). Thus, we engaged in this process to support our colleagues in the counseling student body and take accountability for our education.
Taking Action: Social Justice Advocacy Group
Leading organizations in the profession claim a two-pronged approach to advocacy: one prong advocating for the legitimacy of the counseling profession, and the other advocating on behalf of the clients and students whom counselors serve (Chang et al., 2012). In our educational experience, SJA on behalf of and in partnership with clients was emphasized, but tangible interventions were not discussed. Further, systemic issues and inequities were often left unaddressed. Thus, we developed this group to more concretely address the second “prong” of advocacy in counseling. First and fourth authors Sunanda M. Sharma and MaryRose Kaplan were part of the executive board of Chi Sigma Mu (Chi Sigma Iota chapter at Montclair State University) and co-founded the social justice committee. Second and third authors Jennifer E. Bianchini and Zeynep L. Cakmak were the first members of the committee who proposed ideas and facilitated events and activities related to social justice that they felt passionately about. Bianchini proposed a social justice book club ahead of a presentation that the CSI chapter organized (hosting the authors of the book Taking Action). The book club met three times with up to three students, from whom we received feedback to help us form the SJA group.
The following semester, fifth author Muninder K. Ahluwalia proposed restructuring the book club into an advocacy group by utilizing the Taking Action text as a framework to teach students about systemic SJA. CACREP (2015) standards state that multiculturalism and social justice must be discussed throughout counseling courses (2.F.2.b.); however, in our experiences, we found that social justice is addressed as an ethical and moral imperative, but curricula do not address concrete SJA skills and strategies to combat systemic oppression. The counseling program in which the first four authors are enrolled and the fifth author is a faculty member offers a social justice counseling class as an elective. However, the class is not consistently offered every semester and has only been taught by that one faculty member. Thus, our aim with this group was to provide a space for our colleagues in which we could collaboratively learn about how to enact social justice. This section will describe the S-Quad model, explain the group structure, outline the proposed learning objectives, and provide a table that outlines the curriculum of the group.
The S-Quad Framework
As a profession, mental health counseling is positioned to “buffer” against challenges with oppression and changes to the status quo (Kivel, 2020). There is an emphasis on intrapsychic interventions to combat systemic issues, rather than attempt to uproot the oppression itself (Kivel, 2020; Ratts, 2009; Toporek, 2018). Toporek (2018) noted that upon reflection of the way the profession is positioned and her privileged identities, she developed a framework through which to take social justice action despite the challenges she continues to encounter. The S-Quad model includes four Ss for social justice advocates to formulate a way to address systemic injustices: strengths, solidarity, strategy, and sustainability (Toporek & Ahluwalia, 2020).
Strengths are described as a combination of one’s existing “skills, knowledge, and expertise” (Toporek & Ahluwalia, 2020, p. 27). Although strengths can be qualities one already has, both personal and professional, the authors also encourage budding advocates to reflect upon strengths that they would like to develop. Solidarity has multiple facets to its definition, as advocates are asked to support, honor, and respect communities they intend to engage with and to also seek support from their personal networks to remain grounded (Toporek & Ahluwalia, 2020). Solidarity is enacted through collaborative efforts and through the lens of cultural humility (Toporek & Ahluwalia, 2020). Strategy is the implementation of strengths and solidarity to construct a plan of action (Toporek & Ahluwalia, 2020). It is important to evaluate the efficacy, efficiency, and impact of different strategic plans to ensure they work toward the stated goal and—most importantly—benefit the community that the action is intended for (Toporek & Ahluwalia, 2020). Finally, a unique facet of the S-Quad model is the fourth “S,” sustainability. Sustainability addresses the wellness of advocates; without it, there is a higher likelihood they may abandon their efforts. SJA can be an enriching and healing practice, but it can also be an emotionally draining pursuit, and one can feel helpless when attempting to combat the gravity and breadth of oppression (Toporek & Ahluwalia, 2020). Thus, the authors encourage budding advocates to take an inventory of the practices that replenish and nourish them in order to remain engaged in their work.
Group Structure
Sharma proposed structuring this SJA group as a biweekly, one-hour, peer-led, open (students were free to join at any point) psychoeducation group, whose grounding framework would be the S-Quad model (Toporek & Ahluwalia, 2020). Due to COVID-19 restrictions, we facilitated the group through Zoom. The objectives of the group were: to describe all components of the S-Quad model, to describe the ethical responsibility of being a social justice advocate, to create a solidarity network of fellow advocates, to increase awareness of how one’s positionality impacts their advocacy work, and to apply the S-Quad model (Toporek, 2018) through the creation of a social justice action plan (Sheely-Moore & Kooyman, 2011). Initially, the intention was to divide each group session into two parts. The first part of the session would be didactic, in which we would discuss the “S” of that week and ground it in a case study. The second half of the session would offer members the chance to process the content so they can apply what they are learning to their social justice plan. Upon reflection and discussion as co-facilitators, we recognized the challenges associated with attempting to address so much content in a 60-minute session and collectively agreed to shift the group and make it akin to a flipped classroom by including pre-recorded didactic videos. This afforded members the chance to view the videos at their own pace and come to the session prepared to engage in dialogue.
In our experiences, instructors who taught our counseling theories courses recommended for us to select one theory to learn about before declaring our theoretical orientation. Similarly, we asked members to narrow down their focus for the purposes of this group to a cause within a community that they feel passionately about. The other structural component we addressed with group members was that this curriculum is cumulative but not necessarily linear; so, an application of the previous “S” is necessary to study the following “S.” For example, once a group member identifies their strengths, we apply those strengths to inform what strategies they will use, but it does not necessarily mean that strengths are not revisited.
Given that this was a psychoeducation group rather than a traditional course, we did not want to use typical didactic methods to engage with this material. We intentionally paired each part of the S-Quad model with a story about an advocate from a minoritized community of whom others likely may not be aware. This demonstrated that SJA is not always done on a public stage. This narrative form of teaching (Hannam et al., 2015) allowed us to contextualize stories of advocates who are quietly resisting oppression in their respective communities. We spotlighted those stories so members could feel less intimidated by the prospect of SJA. In the interest of social justice and accessibility, the Chi Sigma Iota Counseling Honor Society’s Chi Sigma Mu chapter at Montclair State University funded books for interested members so they could follow along with the activities and didactic content. After the second session, we also introduced the idea of the social justice action plan. Table 1 shows the structure/syllabus of the group that we utilized for the semester and describes the ways in which we adapted to agreed-upon changes.
Table 1
Taking Action Group Structure
| Week |
Topic & Activity Assigned |
Content/Activities |
| Week 1 |
Introducing
Taking Action
S-Quad Model |
• Purpose, rationale, and structure of group
• Group agreements/norms
• Overview of S-Quad model (Toporek & Ahluwalia, 2020)
• ADDRESSING model (Hays, 2022), a framework that explores individual identity in context
• Difference between justice, charity, philanthropy |
| Week 2 |
1st S: Strengths
Activity 4.2, p. 29**
|
• Reviewing agreed-upon group norms
• Defining strengths
• Case study: Arunachalam Muruganantham (“The Pad Man”)
Processing case study as a group
• Introducing the social action plan |
| Week 3 |
Co-facilitators reflection meeting |
• This session was initially planned to address the 2nd S in the S-Quad, but no members attended the group this day. Instead, as co-facilitators, we met to discuss the progress of the group.
|
| Week 4* |
2nd S: Solidarity
Activity 5.1, p. 55 |
• Defining solidarity
• Case study: 4 young Black women, Black Lives Matter protests
Combining strengths and solidarity
Processing case study as a group |
| Week 5 |
3rd S:
Strategy
Activity 6.1, p. 66 |
• Defining strategy
• Case study: Cakmak
Strength, solidarity, and strategy
Processing case study as a group
Cakmak’s social action plan |
| Week 6 |
4th S:
Sustainability
Activity 7.6, p. 176
|
• Defining sustainability
• Case study: Alexandria Ocasio Cortez
Strength, solidarity, strategy, and sustainability
Processing the importance and guilt of self-care
Processing burnout |
| Week 7 |
Final Group
|
• Case study
Apply ADDRESSING, S-Quad model
• Feedback from members |
*Marks shift to videos for the didactic portion
**All activities listed are from Ahluwalia & Toporek (2020).
Reflections
In this section, we offer our reflections on the group and extract salient collective themes that have come about through our processing. In our first session, we informed the group members that we intended to write a reflection paper, and they gave implicit consent to this writing; we did not collect data from group members for the purposes of this article. We begin by grounding the discussion of the group by acknowledging our positionality and social location and how that influenced how we approached our facilitation and planning of the group. Sharma, Bianchini, and Cakmak will provide their most salient takeaways from the forming and facilitation of the Taking Action group.
Positionality
Sharma identifies as a cisgender, South Asian (Indian), middle-class, able-bodied woman who is a doctoral candidate in a CACREP-accredited counseling program and a full-time lecturer in a CACREP-accredited counseling program. I bring a bicultural perspective to my counseling practice and education, and I have attended primarily White institutions (PWIs) for most of my life. As a master’s and doctoral National Board for Certified Counselors Minority Fellowship Program fellow, I learned about the importance and practice of SJA. I am a practicing clinician in private practice (working mostly with White clients), and I engage in advocacy work with South Asian intimate partner violence survivors.
Bianchini identifies as a White, cisgender woman who grew up in a predominantly White community in the United States. My family has lived in the United States for several generations and the majority of my extended family identifies as part of the middle class. I do not have any disabilities and am a practicing Christian. I am a master’s-level graduate student and joined Chi Sigma Iota’s social justice committee in my first semester of coursework.
Cakmak identifies as a Muslim American, cisgender woman of Turkish origin. I do not have any physical disabilities, but I have been diagnosed with general anxiety disorder (GAD) and major depressive disorder (MDD). I identified as part of the upper middle class in Turkey as a child, and I am middle class as an immigrant in the United States. I have two graduate degrees, one in literature and one in counseling. I have done volunteer work with underrepresented religious and cultural communities since I was in high school.
Themes
As cocreators and coauthors, we reflected on our collective and individual experiences of facilitating our Taking Action group. We each completed individual reflection sheets within 48 hours of each group session to capture our takeaways, and we processed our experiences together after each group session. We reviewed our reflection sheets individually and noted themes that arose for each of us. We then collectively reviewed the sheets to determine what themes arose across our reflection sheets. We reengaged in the reflection process as we wrote this manuscript. In this section, we highlight the major themes among our experiences.
Fear
The most significant theme of our collective experience was fear. Throughout each session, fear came up under several different guises, which served as an umbrella for additional themes: judgment, self-efficacy, and humility. Fear was the main antagonist preventing us from doing social justice work before this program. Fear of not knowing the necessary information, fear of saying or doing the wrong thing, and fear of not helping enough or adequately were examples of how this feeling manifested. However, engaging in this group helped us alleviate that fear through resources, support, and a plan of action. In the first session, we felt tentative and timid, and optimistic yet stagnant. After providing members with more information and concrete steps to create real social justice action, our fear dissipated, our passion for working as a group was ignited, and the motivation to take action began.
Judgment
In our first session, when we engaged members in a dialogue about group agreements, we noticed that there was more focus on the importance of the group serving as a judgment-free space than as a confidential one. We felt that members wanted to feel safe in the group because they feared being judged due to their self-perceived incompetence. We recognized they did not want to feel judged by others if their ideas were deemed unacceptable or incorrect. Establishing a nonjudgmental space permitted members to try, even if the outcomes were not as they hoped. We believe it allowed members to have a safe space to begin processing what they understand about SJA.
Judgment was a recurrent theme and shifted from self-judgment to judging others. Members reported feeling frustrated and upset when their peers in the program were not at the same level of advocacy awareness and action as they were. They reported feeling angry about others’ ignorance. Through a shared reflection on these feelings, the group acknowledged that the judgment of others reinforces the barriers to change that we are trying to knock down. Members recognized the importance of being humble regarding other people (another theme discussed below) and empathetic to help manage feelings of judgment.
When discussing sustainability and self-care, members and facilitators shared our hesitations to implement sustainability practices, despite it being an ethical responsibility. This hesitancy revealed itself to be motivated by self-judgment of our productivity levels. It appeared that the group members would not allow themselves the breaks they needed to provide self-care because of the importance they gave to SJA. We then discussed the need to be unapologetic in our self-care as advocates and counselors.
Self-Efficacy
Related to judgment of self and others, we found self-efficacy was another significant and recurrent theme. Almost every group member expressed that they were struggling to feel like they could contribute enough to society to perform real social justice action rather than charity. Having members share similar insecurities resulted in an insightful and vulnerable conversation that helped us to feel connected and inspired. In the second session, members reported experiencing imposter syndrome, likely resulting from their low self-efficacy in social justice work. Our self-efficacy grew throughout the sessions as members received the information and tools they needed to take concrete steps in SJA. Once we clarified a reasonable idea of what was expected of them and had some direction, they felt more prepared to take action.
Humility
Lastly, the theme of humility appeared in several different iterations. The humility through humor with which we, as facilitators, approached this process helped break the ice and create a comfortable atmosphere in our initial meeting. Humility emerged in our second session when discussing the first “S” of the S-Quad model, strengths. In our reflection process, we noted that both facilitators and members appeared to be uncomfortable when sharing what they are “good” at. We, as female-identifying co-facilitators, noted the societal pressure and shame that have historically come with feelings of discomfort for behavior commonly regarded as boastful.
In the fourth session, the group discussed the importance of humility within their community. Members discussed how it was easy to humble oneself when trying to assist a community from the outside, but that it was an important lesson that we must be humble within our own communities. Members seemed to realize that their experience of their community and identity would not be the same as the next person’s, highlighting the importance of intersectionality within the human experience.
Humility was next discussed in the fifth session in terms of failure. Members acknowledged the importance of possessing humility and patience regarding our work because we will generally fail more than we will succeed in our efforts to create change. If we never failed, we would never learn from our mistakes and there would be no more SJA to do. However, knowing this instills the hope to persevere, for you never know what your planted seeds of action will grow into.
Combining Themes
As facilitators, we noticed a parallel between what we were experiencing and our members’ experiences. From the start of our group, we felt we needed to be more qualified to be teachers of SJA. This was our campus’s first peer-led advocacy group, which meant we did not have any models to reference, and we had to rely on our own ideas, skills, and judgment. With faculty support, we went outside the confines of our curriculum because we wanted to share and engage with this content in a meaningful way. This was a large undertaking, with little training and even less confidence. Similar to what we observed in our members, we were afraid of making mistakes in the content, direction, and discussion of this group because of the weight of the topic of social justice—especially as the first group any of us attempted to create or lead. We had to adapt to constantly developing circumstances, and this felt inappropriate for us as leaders. Something we recognized much later was that we could teach and learn simultaneously; we did not need to reach a point of expertise before developing this group. Although we do not consider ourselves experts in SJA, the work we did to prepare for each session, combined with the humility with which we presented ourselves and our work, effectively allowed us to lead the group to the best of our ability.
Another source of our fear was that there was an ulterior motivation for creating this group, which was not purely social justice–oriented. We sought a sense of community, particularly given the isolating COVID-19 pandemic we were living through, and running this group gave us that community, support, and friendship. This longing for connection played into our feelings of being unqualified to do social justice work because a few of us became involved in this project out of a desire to work with friends, and not solely because we wanted to devote ourselves to social justice. However, this search for connection and participation in this SJA group gave us a passion for this work if it was not present beforehand. That feeling of connection and belonging provided us with the inner power to attempt something bigger than ourselves. The bond we authors created while facilitating this group instilled the importance of collaboration, especially when doing something new, significant, and daunting. The “S” for solidarity was also particularly salient in this case; we recognize that we could not have created or run this group alone. We needed each other to not only complete all the work required but also to hold each other accountable, support each other in times of need, and encourage each other to keep going even when our hopes dimmed. In a sense, this group and the connection to each other provided the “S” for sustainability and wellness for ourselves and our work.
While reflecting on these two sources of our fear as facilitators, we discovered our desire to make this call to the counseling profession: to strengthen the bridge between academia and counseling in practice. Applying the knowledge gained from our courses to daily practice could be less intimidating and feel more like the natural progression of our nascent counseling careers. However, once the opportunity arose to test our skills, we felt hesitant and unprepared. Creating an advocacy group is not the only venue in which this fear of practice appears. As students, we authors felt a similar fear when stepping into our practicum and internship sites. It is natural to feel afraid when seeing clients for the first time as CITs, but this fear could be lessened by academic leaders guiding students into the field before their final year of studies. If more opportunities to work with real issues affecting communities were available to students and supported by faculty, the transition between the classroom and fieldwork would feel less daunting.
Discussion
Although this project was not an empirical study, our reflective process taught us about how it feels to learn about SJA and the labor required to teach about SJA. With this knowledge, we have identified potential implications for the counseling profession and counselor education training programs. We also acknowledge the limitations of the group we formed and facilitated.
Implications
Per our experience, we believe social justice counseling—and advocacy skills more specifically—must have a more prominent place in counseling curricula. Potential solutions may include consistently operationalizing social justice counseling and SJA in counselor training programs (CSJ, 2020). Furthermore, it is imperative to have more guidance from our institutional standards such as CACREP (2023) and to have more ethical standards regarding SJA in the next iteration of the ACA Code of Ethics. CACREP (2023) requirements establish content that should be covered throughout all coursework, rather than specific classes; however, each program might have a different approach to operationalize these standards because they are vaguely defined (Austin & Austin, 2020). For example, in the current CACREP (2023) standards, there is more frequent mention of social justice compared to the 2016 CACREP standards; however, there is still ambiguity about how this may present in a counseling course. Standard 3.B.1 (CACREP, 2023) says that counseling curricula must state how “theories and models of multicultural counseling, social justice, and advocacy” are addressed, but there is no mention of techniques, interventions, or skills for SJA. As a point of comparison, there are specific guidelines with respect to content like group counseling which delineate time that students must spend engaged in direct experience. However, it appears that social justice and SJA are still referred to in broader terms with fewer contingencies about how they must be addressed. We recognize that out-of-class work like advocacy might be left out of the curriculum because there are many required courses and training standards filling up students’ time in graduate school (Vera & Speight, 2003). However, we urge counseling leaders to consider the importance of SJA and the core role it plays in our healing work and our counseling identity.
Limitations and Future Directions
This group was developed and facilitated to encourage counseling students to develop their social justice advocate identity, but it was not an empirical study, and our collective reflections can only offer so much insight to facilitating such groups in the future. As this was an extracurricular group for which attendees took time out of their personal schedules, we do not know what motivated our peers to attend sessions that we offered. This would be important knowledge to address in future offerings of this group and to understand students’ attitudes toward social justice in counseling. Another limitation of our group was our inability to reach students who are unsure of what social justice is and might not recognize it as an inherent and imperative part of mental health counseling. Practicum and other service-learning opportunities for SJA within the profession have been explored in the literature (Farrell et al., 2020; Field et al., 2019; Langellier et al., 2020), but perhaps peer encouragement can help CITs to feel more confident as advocates. Although we intentionally kept the group open for accessibility, new introductions and catching up took time away from the group plan and content. We do not have data to explicate a group like this, but we hope our master’s and doctoral peers feel encouraged to start similar groups within their own programs. Finally, we wrote this article more than a year after our group ended; although we relied on our reflection sheets and notes from our experience, we are aware that there may be gaps in our recollections.
For future groups, we would be interested to complete an empirical study through an IRB in order to collect data regarding peer-led SJA groups. Screening or surveys before and after the group could not only provide valuable data, but also offer guidance for attendees even before the group starts and an opportunity for reflection after the group ends. Our decision to keep our group open led to attrition of members; thus, empirical studies might also investigate factors that contribute to student engagement. Collecting quantitative and qualitative data may provide further insight into effective strategies for describing and encouraging students to engage in concrete SJA skill development.
Conclusion
The experience of facilitating an SJA group was new, challenging, transformative, and important to our growth as CITs and budding counselor educators. As counselors, we understand our ethical duty to engage in SJA; however, we have not had adequate training in tangible strategies to utilize when advocating on behalf of our clients. The S-Quad model is an important guide that helped facilitate our understanding of how to implement SJA as mental health professionals. As co-facilitators and coauthors, we learned a great deal about ourselves as developing social justice advocates, CEs, and CITs and confronted fears parallel to those of the group members. Although SJA is a growing focus in the counseling literature, there is a great deal of research and training that must continue to occur so current and future counselors can develop their social justice advocate identities.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Abrams, S. (2019, January). 3 questions to ask yourself about everything you do [Video]. TED Talks. https://www.youtube.com/watch?v=3zJHwOwirjA
American Counseling Association. (2014). ACA code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-code-of-ethics-finaladdress.pdf?sfvrsn=96b532c_8
Austin, J. T., II, & Austin, J. A. (2020). The counselor educator’s guide: Practical in-class strategies and activities. Springer.
Chang, C. Y., Barrio Minton, C. A., Dixon, A. L., Myers, J. E., & Sweeney, T. J. (Eds.). (2012). Professional counseling excellence through leadership and advocacy (1st ed.). Routledge.
Chapman-Hilliard, C., & Parker, B. (2022). Embodied social justice learning: Considerations for curriculum development and training in counseling programs. Journal for Social Action in Counseling and Psychology, 14(1), 77–93. https://doi.org/10.33043/JSACP.14.1.77-93
Council for Accreditation of Counseling and Related Educational Programs. (2015). 2016 CACREP standards. https://www.cacrep.org/wp-content/uploads/2017/08/2016-Standards-with-citations.pdf
Council for Accreditation of Counseling and Related Educational Programs. (2023). 2024 CACREP standards. https://www.cacrep.org/wp-content/uploads/2023/06/2024-Standards-Combined-Version-6.27.23.pdf
Counselors for Social Justice. (2020). A call for social justice in the American Counseling Association (ACA). Journal for Social Action in Counseling and Psychology, 12(1), 2–12. https://doi.org/10.33043/JSACP.12.1.2-12
Farrell, I. C., DeDiego, A. C., & Marshall, R. C. (2020). Service learning to foster advocacy training in CACREP accredited programs. Journal of Creativity in Mental Health, 15(4), 522–534. https://doi.org/10.1080/15401383.2020.1733724
Field, T. A., Ghoston, M. R., Grimes, T. O., Sturm, D. C., Kaur, M., Aninditya, A., & Toomey, M. (2019). Trainee counselor development of social justice counseling competencies. Journal for Social Action in Counseling and Psychology, 11(1), 33–50. https://doi.org/10.33043/JSACP.11.1.33-50
Gummere, R. M., Jr. (1988). The counselor as prophet: Frank Parsons, 1854–1908. Journal of Counseling & Development, 66(9), 402–405. https://doi.org/10.1002/j.1556-6676.1988.tb00899.x
Hannam, F. D. (2015). Teaching through narrative. Forum on Public Policy Online, 2015(2).
Hays, P. A. (2022). Addressing cultural complexities in counseling and clinical practice: An intersectional approach (4th ed.). American Psychological Association.
hooks, b. (1994). Teaching to transgress: Education as the practice of freedom. Routledge.
Kaplan, D. M., Tarvydas, V. M., & Gladding, S. T. (2014). 20/20: A vision for the future of counseling: The new consensus definition of counseling. Journal of Counseling & Development, 92(3), 366–372. https://doi.org/10.1002/j.1556-6676.2014.00164.x
Kivel, P. (2020). Social service or social change? Who benefits from your work. https://paulkivel.com/wp-content/uploads/2011/07/Social-Service-or-Social-Change-2020-Update.pdf
Langellier, K. A., Astramovich, R. L., & Horn, E. A. D. (2020). Infusing service learning into the counselor education curriculum. The Professional Counselor, 10(2), 194–203. https://doi.org/10.15241/kal.10.2.194
Nadal, K. L., King, R., Sissoko, D. R. G., Floyd, N., & Hines, D. (2021). The legacies of systemic and internalized oppression: Experiences of microaggressions, imposter phenomenon, and stereotype threat on historically marginalized groups. New Ideas in Psychology, 63, 1–9. https://doi.org/10.1016/j.newideapsych.2021.100895
Ratts, M. J. (2009). Social justice counseling: Toward the development of a fifth force among counseling paradigms. The Journal of Humanistic Counseling, Education and Development, 48(2), 160–172.
https://doi.org/10.1002/j.2161-1939.2009.tb00076.x
Ratts, M. J., & Greenleaf, A. T. (2018). Counselor–advocate–scholar model: Changing the dominant discourse in counseling. Journal of Multicultural Counseling and Development, 46(2), 78–96. https://doi.org/10.1002/jmcd.12094
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K, & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48. https://doi.org/10.1002/jmcd.12035
Sheely-Moore, A. I., & Kooyman, L. (2011). Infusing multicultural and social justice competencies within counseling practice: A guide for trainers. Adultspan Journal, 10(2), 102–109. https://doi.org/10.1002/j.2161-0029.2011.tb00129.x
Toporek, R. L. (2018). Strength, solidarity, strategy and sustainability: A counseling psychologist’s guide to social action. The European Journal of Counselling Psychology, 7(1), 90–110. https://doi.org/10.5964/ejcop.v7i1.153
Toporek, R. L., & Ahluwalia, M. K. (2020). Taking action: Creating social change through strength, solidarity, strategy and sustainability. Cognella.
Toporek, R. L., & Daniels, J. (2018). American Counseling Association advocacy competencies (updated 2018). American Counseling Association. https://www.counseling.org/docs/default-source/competencies/aca-advocacy-competencies-updated-may-2020.pdf
Toporek, R. L., Lewis, J. A., & Crethar, H. C. (2009). Promoting systemic change through the ACA advocacy competencies. Journal of Counseling & Development, 87(3), 260–268. https://doi.org/10.1002/j.1556-6678.2009.tb00105.x
Vera, E. M., & Speight, S. L. (2003). Multicultural competence, social justice, and counseling psychology: Expanding our roles. The Counseling Psychologist, 31(3), 253–272. https://doi.org/10.1177/0011000003031003001
Sunanda M. Sharma, MS, NCC, LPC (NJ), LPCC (OH), is a lecturer at Wright State University. Jennifer E. Bianchini, BFA, is a master’s student at Montclair State University. Zeynep L. Cakmak, MA, LAC (NJ), is a mental health counselor at Montclair State University. MaryRose Kaplan, PhD, NCC, LPC, is a school counselor and adjunct professor at Montclair State University. Muninder K. Ahluwalia, PhD, is a professor at Montclair State University. Correspondence may be addressed to Sunanda M. Sharma, 3640 Colonel Glenn Hwy., Millett Hall 370, Dayton, OH 45435, sharmas1@montclair.edu.
Jan 17, 2024 | Volume 13 - Issue 4
Nelson Handal, Emma Quadlander-Goff, Laura Handal Abularach, Sarah Seghrouchni, Barbara Baldwin
Understanding the overlap of symptoms between oppositional defiant disorder (ODD) and obsessive-compulsive disorder (OCD) experienced by youth is pertinent for accurate diagnosis. A quantitative, retrospective, cross-sectional design format was used to assess the relationship between ODD and OCD in addition to evaluating the difference in ODD severity and symptoms based on OCD severity. Symptoms and severity ratings of ODD and OCD were collected from youth diagnosed with ODD (N = 179). Fisher’s exact test and a Wilcoxon signed-rank test were performed. There were significant relationships between frustration related to obsessions and compulsions and the ODD symptoms of annoyance and anger. Results suggested that OCD severity predicted an increase in scores for ODD severity and symptoms.
Keywords: oppositional defiant disorder, obsessive-compulsive disorder, overlap of symptoms, youth, severity
Children and adolescents who struggle with mental health disorders experience a decline in their quality of life related to psychological, physical, and social well-being (Celebre et al., 2021). The most common disorders diagnosed in childhood and adolescence are attention-deficit/hyperactivity disorder (ADHD), generalized anxiety disorder (GAD), major depressive disorder (MDD), obsessive-compulsive disorder (OCD) and other disruptive behavior disorders such as oppositional defiant disorder (ODD) and conduct disorder (CD; Ghandour et al., 2019; Perou et al., 2013). The array of disorders diagnosed in childhood and adolescence contributes to the probability of misdiagnosis or overdiagnosis (Merten et al., 2017). Moreover, approximately 7.4% of children between the ages of 3–17 are diagnosed with a behavioral problem (Centers for Disease Control and Prevention [CDC], 2021). According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), the prevalence of OCD in the United States is 1.2%, with the majority of cases being reported before the age of 14, while the prevalence of ODD has an average estimate of 3.3%. Behavioral problems as a result of mental health issues impact a child’s antisocial behaviors (Justicia-Arráez et al., 2021), further influencing performance at home and school.
Previous studies have documented the overlap of ODD with other mental disorders. For example, Garcia et al. (2009) found that approximately 12% of 4- to 8-year-old children who were diagnosed with OCD also presented with comorbid ODD. Furthermore, Thériault et al. (2014) suggested that irritability, a symptom affiliated with ODD, has been reported by individuals diagnosed with obsessive-compulsive behavior or OCD. A systematic review conducted by Stahnke (2021) revealed that OCD is commonly misunderstood by the general population as well as misdiagnosed by mental health professionals and primary care physicians. On the other hand, Grimmett et al. (2016) suggested that the diagnostic criterion of ODD is reflective of general child and adolescent behavior. This could result in the misdiagnosis or overdiagnosis of ODD. The interchangeable symptoms of OCD and ODD may suggest that children and adolescents are experiencing comorbidity or that they are misdiagnosed, resulting in the use of ineffective interventions and treatment for children and adolescents with OCD or ODD. The co-occurrence of ODD and OCD in youth may be attributed to the overlap of anger-related symptoms. Assessment of anger-related symptoms can provide further insight on the comorbidity of these disorders in addition to suggesting the potential for misdiagnosis.
Literature Review
Oppositional Defiant Disorder
According to Loeber et al. (2000), approximately 1%–16% of school-aged children and adolescents have been diagnosed with ODD. ODD is characterized by emotional disruptions such as anger and mood irritability in addition to behavioral issues, including argumentativeness and defiance (APA, 2013). One study suggested that ODD comprises three symptomatic components: headstrong (i.e., argumentative toward adults and defying their requests), irritable (i.e., temper dysregulation and resentfulness), and hurtful (i.e., aggression toward others; Stringaris & Goodman, 2009). ODD has demonstrated significant impairments related to emotional, social, educational, and vocational daily functioning (APA, 2013).
Pharmacological interventions that treat ODD include antipsychotics (Hood et al., 2015) and psychostimulants (Pringsheim et al., 2015). Additionally, children and adolescents diagnosed with ODD often receive therapeutic interventions such as cognitive behavioral therapy (CBT) and brief strategic family therapy (Ghosh et al., 2017). Accurate diagnosis of ODD is imperative for appropriate treatment interventions to be implemented.
Obsessive-Compulsive Disorder
OCD includes the presence of intrusive and unwanted thoughts, urges, or images that are often recurrent (obsessions) and/or repeated behaviors or mental acts that are completed as a result of obsessions (compulsions; APA, 2013). Moreover, individuals with OCD may experience intolerance of uncertainty with an emphasis on controlling their thoughts to lessen said uncertainty. A study conducted by Mancebo et al. (2008) suggested that common obsessions include contamination, catastrophic thoughts, and aligning objects to be symmetrical in addition to compulsions related to checking, repeating routine activities, and ordering or rearranging objects. Genetic, environmental, and familial factors can contribute to the severity of OCD symptoms. D. A. Geller (2006) described the average age of onset of OCD symptoms occurring between the ages of 7.5 and 12.5 years. Although the symptoms of OCD are focused on obsessions and compulsions, researchers have demonstrated that individuals with OCD experience issues with anger. For instance, Painuly et al. (2011) found that half of the participants in their study (N = 21) who were diagnosed with OCD reported anger attacks. Furthermore, individuals diagnosed with OCD (N = 48) reported increased frequency of anger along with higher anger suppression scores (Cludius et al., 2021). A third study conducted by Radomsky et al. (2007) suggested that individuals diagnosed with OCD who experience checking compulsions indicated heightened trait anger or an increased rate of anger over time. A longitudinal study that assessed children and adolescents (N = 563) demonstrated the developmental trajectories of ODD and obsessive-compulsive problems (OCP), which provided evidence that youth endorsed high scores of irritability and defiance in addition to increased scores of OCP (Ezpeleta et al., 2022). This study conceptualized OCP as a component of an OCD diagnosis. Hence, children may appear to have ODD when, in actuality, they may not be able to perform obsessions and compulsions, leading to irritability, defiance, and anger.
Pharmacological interventions for children and adolescents diagnosed with OCD include serotogenic medications (Nazeer et al., 2020) and selective serotonin reuptake inhibitors (Kotapati et al., 2019). Therapeutic interventions such as CBT and behavior therapy have demonstrated effectiveness in the treatment of OCD in children and adolescents (Avasthi et al., 2019). The differentiations in treatment approaches between OCD and ODD highlight the need for further research on the specific symptoms that lead to a diagnosis.
Comorbidity of ODD and OCD
Researchers have demonstrated that OCD is a highly comorbid disorder; approximately 80% of adults with OCD meet criteria for other conditions and 36.6% of children under the age of 17 with behavioral problems present with OCD (Ghandour et al., 2019). Moreover, a recent study by Ezpeleta et al. (2022) noted that ODD and obsessive-compulsive problems affect approximately 9.4% of children that are between the ages of 6 and 13. An additional study reported that one in five individuals experience depressive symptoms with OCD (Ghandour et al., 2019). However, there is inconclusive information regarding the comorbidity of ODD in association with OCD. Assessment tools such as the Child Behavior Checklist (Achenbach, 1991) can screen for comorbidity, including OCD, and the Children’s Yale-Brown Obsessive Compulsive Scale (Scahill et al., 1997) can evaluate the severity of obsessions and compulsions. But a thorough inventory that assesses for comorbidities in children and adolescents and considers OCD and ODD has yet to be developed. Coskun and colleagues (2012) suggested that comprehensive evaluation could screen for comorbidities with regard to OCD in children in addition to increasing understanding of severity and age of onset, as these components can vary according to coexisting disorders.
A study conducted by Storch et al. (2010) evaluated the comorbidity of disruptive behavior disorder, including adolescents diagnosed with ODD, OCD, and CD, and reported that comorbid disruptive behavior disorder is related to greater family accommodation, less symptom resistance to obsessions, and heightened OCD severity. Moreover, the DSM-5 suggested that males are more often diagnosed in childhood with OCD and ODD compared to females (APA, 2013). Although these two conditions are represented in distinct categories in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR; APA, 2022), clinical data and previous literature have suggested overlap. For example, one study stated that temper outbursts, which are described as behaviors such as anger outbursts, temper tantrums, and resentfulness, were two to three times more common in youth with OCD compared to those without (Krebs et al., 2013). Moreover, another study found that 53% of children diagnosed with OCD exhibited explosive anger outbursts, which were caused by perfectionism, modification to routine, or rules enforced by parents (Storch et al., 2012). Additionally, researchers have reported greater validity in OCD-diagnosed patients who exhibit increased behavioral and cognitive impulsivity (Boisseau et al., 2012). This finding has been observed and anecdotally reported by parents and teachers of youth diagnosed with OCD when compulsions cannot be acted on (Krebs et al., 2013). The influence of ODD and OCD symptoms can have lasting effects on children and adolescents, thus emphasizing the importance of mental health professionals’ accurate diagnoses and the appropriate treatment of these disorders.
The pattern of uncooperative and defiant behavior toward authority figures can pose challenges in diagnosis and assessment. Factors associated with the environment, such as externalizing behaviors secondary to trauma (Beltrán et al., 2021), psychiatric conditions that include symptoms related to aggression and defiance, and hyperactivity, can be difficult to discriminate (APA, 2013; Thériault et al., 2014). This is common in ODD-diagnosed children and adolescents who often do not comply with authority figures without reason, resulting in repetitive negative behavior patterns. Similarly, youth diagnosed with OCD might respond defiantly to their obsessive thoughts when they cannot be acted upon (J. Geller, 2022). Further, children and adolescents may experience obsessive thoughts of which parents and guardians are not aware. Ezpeleta et al. (2022) reported the coexistence of the two disorders:
The stubbornness of the oppositional child who wants to do their will and the rituals of the obsessive child who needs to do things a certain way, the low anger threshold in oppositionism and the anger attacks of the obsessive child when prevented from doing their rituals, the argumentativeness in both cases to be able to do what they want annoying others for fun or because they need to participate in the ritual, and defying rules may make the two disorders coexist. (p. 1090)
Similarly, a case study developed by Ale and Krackow (2011) described a 6-year-old boy who struggled with ritualized behaviors and avoidance that would lead to anger and aggression. The case study provided an example in which the boy feared small, round objects, and when the boy observed other children at school wearing buttons, the boy expressed his anger through name calling and kicking a peer. The distress from viewing buttons was due to an obsession that led the boy to become fearful of choking (Ale & Krackow, 2011). These explanations of anger or frustration that are an outcome of the child’s inability to engage in rituals emphasize the importance of considering the misdiagnosis and comorbidity of ODD.
Study Purpose
We hypothesized that children and adolescents diagnosed with ODD would report increased OCD severity and higher ratings of symptoms related to anger, providing further insight into the overlap in symptoms of ODD and OCD. For the purpose of this study, comorbidity was defined as the presence of two or more diagnosed disorders (Basu et al., 2018). Moreover, we hypothesized that children and adolescents would endorse higher scores on symptoms related to anger and frustration because of the inability to perform obsessions and compulsions. The research questions were:
Research Question 1: What is the relationship between ODD and OCD for youth diagnosed with ODD?
Research Question 2: Is there a difference in ODD severity and symptoms between youth that scored lower on OCD severity compared to those that had high scores of OCD severity?
Method
Design
This study followed a quantitative, retrospective, cross-sectional design format that utilized a purposive sampling technique. Purposive convenience sampling allowed for intentional selection of participants who were accessible based on location. Children and adolescents diagnosed with ODD were selected for the study in order to evaluate comorbidity with OCD. This methodological approach allowed for further insight into the overlap in symptoms experienced by children and adolescents with ODD. To answer the first research question, Fisher’s exact test was utilized, and to answer the second research question, a Wilcoxon signed-rank test was conducted.
Participants
The participants in this study (N = 179) included children and adolescents between the ages of 5 and 19 that had been referred by their parents or guardians to a mental health clinic located in the Southern region of the United States. Following the securing of IRB approval, participant documents containing diagnoses, symptoms, and severity from children and adolescents that reported to the clinic between 2017 and 2020 were retrospectively collected. Participants who were prescribed psychotropic medication or had received any other diagnosis were excluded from the study. All participants were clients at the clinic at the time of data collection. Participants gave assent through their parent or guardian’s completion of an informed consent form, which indicated that diagnostic information would be used for research purposes, including future studies that would retrospectively collect participant information while keeping their identifying information confidential. Participants did not receive any reimbursement for participation in this study.
The sample used in this study included 179 children and adolescents (121 boys and 58 girls) between 5 and 19 years of age (M = 13.34, SD = 3.56) that were diagnosed with ODD. Of the sample, 14 participants (8%) were between the ages of 5 and 8, 63 participants (35%) were between the ages of 9 and 12, 55 participants (31%) were between the ages of 13 and 16, and 47 participants (26%) were between the ages of 17 and 19. The average age of the sample was 13.34 years (SD = 3.56).
Data Collection
Measures
CliniCom™ Psychiatric Assessment Software. The CliniCom™ Psychiatric Assessment (hereafter referred to as CliniCom) is a validated and reliable web-based tool that uses algorithms based on mental health research and DSM-5 criteria to identify multiple psychiatric conditions (Handal et al., 2018). CliniCom is a self-guided measure that collects information including individual and family history, social history, responses to mental health questions, self-assessment of severity of symptoms, quality of life, and current and previous mental health treatments. Participants complete CliniCom at their own pace on a computer at a location of their preference (e.g., home, school). CliniCom assesses for 81 disorders and utilizes items from the Children’s Yale-Brown Obsessive Compulsive Scale (Scahill et al., 1997). CliniCom has undergone psychometric investigation, indicating 78% concordance in diagnosing the same disorder in test–retest analysis, including the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989; Handal et al., 2018).
The data were retrospectively collected from participants’ charts, which included a report from CliniCom. The participants completed CliniCom prior to their initial appointment with assistance from their parent or guardian. Participants received a suggested diagnosis from the assessment. Following the completion of the CliniCom assessment, semi-structured diagnostic interviews and parent questionnaires were conducted and completed. Diagnoses were verified and confirmed by a board-certified child and adolescent psychiatrist. CliniCom and the semi-structured diagnostic interviews utilized diagnostic criteria from the DSM-5 (APA, 2013) to assess the onset, duration, frequency, and severity of mental disorders in addition to the level of impairment experienced by the client. Symptoms were conceptualized based on clinical severity, which ranges from 0–10, with 10 as the most severe presentation of the symptom and 4 or higher indicating moderate to severe symptoms. A score of 4 is the threshold to be considered positive for the symptom. The overall severity ratings for ODD and OCD are determined by the Clinical Global Impressions Scale (CGI-S). The CGI-S uses a range between 1 and 7 to indicate illness severity with 1 = normal to 7 = extremely ill (Busner & Targum, 2007).
Assessment of ODD and OCD. To determine the overlap of symptoms related to ODD and OCD for children and adolescents, the following symptoms were collected from the responses to the CliniCom items: easily annoyed, bothered, or upset by others (ODD Symptom 1), often angry or resentful (ODD Symptom 2), often spiteful or vindictive (ODD Symptom 3), and frustrated and/or angry with relation to obsessions and compulsions (OCD Symptom 1). Descriptions of symptoms can be viewed in Table 1. To respond to the ODD symptom items in the assessment, participants submitted a rating between 1 and 10. A rating of 10 represents the most severe presentation of the symptom and 4 or higher represents a moderate to severe presentation; a score of 4 is the threshold to be considered positive for the symptom. Responses to the OCD symptom item were dichotomous, wherein participants indicated “yes” or “no” if they were experiencing the symptom. OCD and ODD severity ratings for each participant were recorded.
Table 1
Description of Symptoms Collected
| Disorder Term |
Description from CliniCom™ Psychiatric Assessment |
| ODD Symptom 1 |
“Easily annoyed, bothered, or upset by others” |
| ODD Symptom 2 |
“Often angry and resentful” |
| ODD Symptom 3 |
“Often spiteful or vindictive” |
|
| OCD Symptom 1 |
“Frustrated and/or angry with relation to obsessions and compulsions” |
Data Analysis
IBM SPSS 27 software was used for data analysis. Preliminary analysis included all clients in the sample. The Kolmogorov-Smirnov test of normality was conducted to determine the numerical distribution of variables. The test of normality showed that none of the variables were normally distributed, p < .05. Spearman correlation coefficients were calculated to determine significant associations between variables.
Fisher’s exact tests were conducted to determine non-random associations between variables. Phi was used to calculate the effect size for the Fisher’s exact test. A Wilcoxon signed-rank test was performed to analyze other variables in the sample through comparison of groups. The first group included participants who endorsed a score between 1–3 on the CGI-S for OCD severity (n = 47). The second group was composed of participants who reported a score between 4–7 on the CGI-S for OCD severity (n = 132). Correlation coefficients were calculated to determine the effect sizes for the Wilcoxon signed-rank test.
Results
The mean score for the characteristics of ODD Symptom 1 was 7.79 (SD = 2.39), ODD Symptom 2 was 6.09 (SD = 3.18), and ODD Symptom 3 was 4.58 (SD = 3.49). For OCD Symptom 1, 88% (n = 159) of participants endorsed experiencing the symptom and 12% (n = 20) did not endorse the symptom. The mean score for ODD severity was 6.05 (SD = 0.996) and OCD severity was 4.61 (SD = 1.92). Descriptive statistics and Spearman correlations are reported in Table 2.
Table 2
Spearman Correlation Coefficients (p Values), Mean, and Standard Deviations of Variables
| Measure |
M |
SD |
1 |
2 |
3 |
4 |
5 |
6 |
| 1. Age |
13.34 |
3.56 |
– |
|
|
|
|
|
| 2. ODD Severity |
6.05 |
0.996 |
−0.102 |
– |
|
|
|
|
| 3. OCD Severity |
4.61 |
1.92 |
−0.004 |
.286** |
– |
|
|
|
| 4. ODD Symptom 1 |
7.79 |
2.39 |
0.026 |
.246** |
0.112 |
– |
|
|
| 5. ODD Symptom 2 |
6.09 |
3.18 |
0.025 |
.240** |
0.172* |
.645** |
– |
|
| 6. ODD Symptom 3 |
4.58 |
3.49 |
0 |
.220** |
0.152* |
.522** |
.715** |
– |
*p < .05. **p < .01.
Fisher’s exact test was used to determine if there was a significant association between the OCD and ODD variables. There was no statistical significance between ODD Severity and OCD Symptom 1 (two-tailed, p = .196) or between OCD Symptom 1 and ODD Symptom 3 (two-tailed, p = .015). However, there was a strong positive relationship between OCD Symptom 1 and ODD Symptom 1
(ϕ = .43; two-tailed, p < .001) as well as a strong positive significant association between OCD Symptom 1 and ODD Symptom 2 (ϕ = .53; two-tailed, p < .001).
A Wilcoxon signed-rank test revealed a statistically significant difference between ODD Severity and OCD Severity (z = −8.803, p < .001) with a medium effect size (r = .60). The median score increased from 5 to 6 when ODD Severity was considered with OCD Severity, suggesting that OCD Severity scores predicted a significant increase in ODD Severity scores. Analysis indicated a statistically significant difference between OCD Severity and ODD Symptom 1 (z = −9.834, p < .001) with a large effect size (r = .735), suggesting that the median score of ODD Symptom 1 increased from 8 to 9 when OCD Severity was included. ODD Symptom 1 predicted a significant increase in OCD Severity scores. The results revealed a statistically significant difference between OCD Severity and ODD Symptom 2 (z = −5.114, p < .001) with a small effect size (r = .382). The median score for ODD Symptom 2 increased from 5 to 7 when OCD Severity was included. Results did not reveal a statistically significant difference between OCD Severity and ODD Symptom 3 (z = −.266, p = .790). The median score remained the same (Mdn = 5) when OCD Severity was considered with ODD Symptom 3. Results of the Wilcoxon signed-rank test are depicted in Table 3.
Table 3
Wilcoxon Signed-Rank Test for OCD Severity
| Measure |
Ranks |
Mean Rank |
Sum of
Rank |
Z |
p |
| ODD Severity |
Negative Ranks |
47.64 |
667.00 |
−8.083 |
< 0.001 |
|
Positive Ranks |
64.94 |
7208.00 |
|
|
| ODD Symptom 1 |
Negative Ranks |
61.72 |
987.50 |
−9.834 |
< 0.001 |
|
Positive Ranks |
88.51 |
13718.50 |
|
|
| ODD Symptom 2 |
Negative Ranks |
76.86 |
3766.00 |
−5.114 |
< 0.001 |
|
Positive Ranks |
86.28 |
10095.00 |
|
|
| ODD Symptom 3 |
Negative Ranks |
85.56 |
7700.50 |
−0.266 |
0.790 |
|
Positive Ranks |
88.56 |
7350.50 |
|
|
Discussion
The objective of the present study was to identify and assess children and adolescents for overlap in symptoms and severity of ODD and OCD to determine potential comorbidity and suggest misdiagnosis. The aim of this study was to better understand the potential for children and adolescents to be misdiagnosed with ODD rather than OCD based on the premise that OCD-diagnosed children and adolescents experience symptoms that mimic ODD, such as anger and frustration, because of the inability to perform compulsions.
According to the results of this study, there was a significant relationship between OCD Symptom 1 and ODD Symptom 1. This finding suggested that youth diagnosed with ODD demonstrated significant associations with anger/frustration related to obsessions, compulsions, and annoyance. Additionally, the results suggested a significant relationship between OCD Symptom 1 (feels very frustrated and or angry with relation to obsession and compulsions) and ODD Symptom 2 (often angry and resentful). These results are similar to the prior research conducted by Ezpeleta et al. (2022), which revealed that children with OCP and ODD experienced heightened severity with relation to irritability and defiance, which may be due to the inability to act on a compulsion or perform a ritual. Moreover, researchers have conceptualized that the inability to complete compulsions may result in defiance or temper/anger outbursts (Ale & Krackow, 2011; Krebs et al., 2013; Painuly et al., 2011). Perhaps the children and adolescents in this study were diagnosed with ODD because of the endorsement of symptoms associated with frustration and anger; however, these symptoms might be a result of the inability to complete compulsions.
Findings from this study suggested that ODD Severity, ODD Symptom 1 (easily annoyed, bothered, or upset by others), and ODD Symptom 2 (often angry and resentful) increased when OCD Severity was considered. The heightened severity and symptoms of ODD when OCD Severity was included in the analysis demonstrated the potential for comorbidity. These results are similar to the findings of Storch et al. (2010), who found that youth diagnosed with ODD and OCD (N = 192) reported increased OCD severity. Moreover, in a similar study, Coskun et al. (2012) found that 48% (n = 12) of children and adolescents who were diagnosed with OCD had comorbidity with ODD. Understanding the co-occurrence of these disorders is crucial because they have shown to be predictors of OCD in young adulthood (Bloch et al., 2009).
Implications
Clinical assessment is imperative to accurately diagnose children and adolescents who exhibit anger and frustration. The results of this study are imperative to understanding the potential for misdiagnosis and comorbidity among OCD and ODD. It is also important to note the overdiagnosis of ODD, which could contribute to the lack of consideration of OCD and misdiagnosis of ODD in children and adolescents. According to Grimmett et al. (2016), the DSM-5 criteria for ODD appear to be too general, which may make it more of a convenient diagnosis rather than an accurate one. Moreover, Merten et al. (2017) noted that misdiagnosis and overdiagnosis of mental disorders for children and adolescents could be due to the methods implemented in evaluation, reports of symptoms by parents or guardians, and differences in perspectives of diagnostic criteria. Consequently, clients may receive a fast and inadequate evaluation for ODD without a thorough consideration of the possibility of coexisting conditions, such as OCD. Clinicians can utilize this information by thoroughly evaluating the underlying cause or origin of the anger or frustration experienced by children and adolescents in order to engage in accurate conceptualization and planning of treatment modalities. We suggest that clinicians ask their clients about their cognitive thought processes prior to experiencing anger to determine if unwanted, intrusive, or upsetting thoughts (i.e., obsessions) are occurring prior to experiencing anger. To accurately diagnose, clinicians should ask if the client is engaging in compulsions in various environments to which the repetitive behaviors can be freely acted on and if the client experiences anger and frustration in all environments. Likewise, if the client reports experiencing anger or frustration mostly in the presence of authority figures, clinicians will be better able to rule out OCD. Additionally, clinicians should consider the onset of these disorders because ODD symptoms typically appear in preschool and OCD has an average onset of 19.5 years (APA, 2013). The assessment of both mental disorders can assist in the development of preventative efforts to better support emotional regulation of youth in the school and home settings (Ezpeleta et al., 2022). Lastly, Ale and Krackow (2011) touched on the importance of clinicians providing behavioral training to parents or guardians of children diagnosed with OCD and ODD that focused on differentiating defiant behaviors and anxiety-related behaviors. The American Academy of Children and Adolescent Psychiatry (AACAP; 2023) hosts the Oppositional Defiant Disorder Resource Center and the Obsessive-Compulsive Disorder Resource Center. These resource centers include psychoeducation on mental disorders and information on medications and treatment options (AACAP, 2023). Moreover, parents or guardians can find information, prevention, and intervention through government agencies, including the U.S. Department of Health and Human Services (2023) and state departments of mental health. Lastly, parents or guardians can seek information from nonprofit organizations, including the National Federation of Families (2023), the International OCD Foundation (2023), and the Child Mind Institute (2023).
Limitations and Future Research
This study has a few limitations. First, with relation to the CliniCom, only one symptom of OCD was collected. Future studies should consider collecting more information on OCD when evaluating for overlap in symptoms. Second, the study relied on self-report data completed by the participants and their guardians, although a semi-structured diagnostic interview was completed by a board-certified psychiatrist to verify and confirm the diagnosis. Third, the sample size for the study was small, which limited the power of the data analysis, and comprised far more boys than girls, limiting the generalizability of the results. However, this gender compilation was expected as more males are diagnosed with ODD compared to females (APA, 2013; Ezpeleta et al., 2022).
Despite limitations, this study contributes further evidence of the overlap in symptoms between ODD and OCD in addition to highlighting the challenges of accurate diagnosis. The findings of this study demonstrated that further research must be conducted to understand how frustration or anger related to obsessions and compulsions may be misinterpreted as symptoms of ODD for children and adolescents.
Conclusion
This study sought to assess the associations in symptoms and severity between ODD and OCD as reported by children and adolescents. Specifically, we examined anger and frustration with relation to obsessions and compulsions to further understand the overlap in these disorders. The premise of this study was that the inability to act on obsessions and compulsions may lead to increases in anger and frustration. The inconclusive information regarding the overlap in symptoms related to anger for youth experiencing symptoms of OCD demonstrates the need for further research. Identifying the source of defiance (i.e., anger, annoyance, resentfulness) should be considered in the development of comprehensive assessments. This will further impact accurate diagnosis and treatment planning. The associations between anger or frustration related to obsessions and compulsions with the ODD symptoms of annoyance and anger/resentfulness indicate the need for further assessment regarding comorbidity and additional consideration of misdiagnosis or overdiagnosis. Furthermore, the increases in ODD symptoms and severity when OCD severity was considered further suggest that clinicians should recognize the impact of one diagnosis on another. Accurate diagnosis of these disorders is pertinent to providing effective treatment, which will influence the daily functioning of youth diagnosed with these disorders.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4-18 and the 1991 profile. Department of Psychiatry, University of Vermont.
Ale, C. M., & Krackow, E. (2011). Concurrent treatment of early childhood OCD and ODD: A case illustration. Clinical Case Studies, 10(4), 312–323. https://doi.org/10.1177/1534650111420283
American Academy of Child and Adolescent Psychiatry. (2023). Resource centers. https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Home.aspx
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
https://doi.org/10.1176/appi.books.9780890425596
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176.appi.books.9780890425787
Avasthi, A., Sharma, A., & Grover, S. (2019). Clinical practice guidelines for the management of obsessive-compulsive disorder in children and adolescents. Indian Journal of Psychiatry, 61(2), 306–316. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_554_18
Basu, D., Basu, A., & Ghosh, A. (2018). Assessment of clinical co-morbidities. Indian Journal of Psychiatry, 60(4), 457–465. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_13_18
Beltrán, S., Sit, L., & Ginsburg, K. R. (2021). A call to revise the diagnosis of oppositional defiant disorder—Diagnoses are for helping, not harming. JAMA Psychiatry, 78(11), 1181–1182. https://doi.org/10.1001/jamapsychiatry.2021.2127
Bloch, M. H., Craiglow, B. G., Landeros-Weisenberger, A., Dombrowski, P. A., Panza, K. E., Peterson, B. S., & Leckman, J. F. (2009). Predictors of early adult outcomes in pediatric-onset obsessive-compulsive disorder. Pediatrics, 124(4), 1085–1093. https://doi.org/10.1542/peds.2009-0015
Boisseau, C. L., Thompson-Brenner, H., Caldwell-Harris, C., Pratt, E., Farchione, T., & Barlow, D. H. (2012). Behavioral and cognitive impulsivity in obsessive–compulsive disorder and eating disorders. Psychiatry Research, 200(2–3), 1062–1066. https://doi.org/10.1016/j.psychres.2012.06.010
Busner, J., & Targum, S. D. (2007). The Clinical Global Impressions Scale: Applying a research tool in clinical practice. Psychiatry, 4(7), 28–37. PMID: 20526405
Celebre, A., Stewart, S. L., Theall, L., & Lapshina, N. (2021). An examination of correlates of quality of life in children and youth with mental health issues. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.709516
Centers for Disease Control and Prevention. (2023, March 8). Children’s mental health: Data and statistics.
https://www.cdc.gov/childrensmentalhealth/data.html
Child Mind Institute. (2023, March). Complete guide to OCD. https://www.childmind.org/guide/parents-guide-to-ocd/
Cludius, B., Mannsfeld, A. K., Schmidt, A. F., & Jelinek, L. (2021). Anger and aggressiveness in obsessive-compulsive disorder (OCD) and the mediating role of responsibility, non-acceptance of emotions, and social desirability. European Archives of Psychiatry and Clinical Neuroscience, 271, 1179–1191.
https://doi.org/10.1007/s00406-020-01199-8
Coskun, M., Zoroglu, S., & Ozturk, M. (2012). Phenomenology, psychiatric comorbidity and family history in referred preschool children with obsessive-compulsive disorder. Child and Adolescent Psychiatry and Mental Health, 6. https://doi.org/10.1186/1753-2000-6-36
Ezpeleta, L., Penelo, E., Navarro, J. B., de la Osa, N., & Trepat, E. (2022). Irritability, defiant and obsessive-compulsive problems development from childhood to adolescence. Journal of Youth and Adolescence, 51, 1089–1105. https://doi.org/10.1007/s10964-021-01528-7
Garcia, A. M., Freeman, J. B., Himle, M. B., Berman, N. C., Ogata, A. K., Ng, J., Choate-Summers, M. L., & Leonard, H. (2009). Phenomenology of early childhood onset obsessive compulsive disorder. Journal of Psychopathology and Behavioral Assessment, 31, 104–111. https://doi.org/10.1007/s10862-008-9094-0
Geller, D. A. (2006). Obsessive-compulsive and spectrum disorders in children and adolescents. Psychiatric Clinics of North America, 29(2), 353–370. https://doi.org/10.1016/j.psc.2006.02.012
Geller, J. (2022, October). What is obsessive-compulsive disorder? American Psychiatric Association. https://www.psychiatry.org/patients-families/obsessive-compulsive-disorder/what-is-obsessive-compulsive-disorder
Ghandour, R. M., Sherman, L. J., Vladutiu, C. J., Ali, M. M., Lynch, S. E., Bitsko, R. H., & Blumberg, S. J. (2019). Prevalence and treatment of depression, anxiety, and conduct problems in US children. The Journal of Pediatrics, 206, 256–267. https://doi.org/10.1016/j.jpeds.2018.09.021
Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: Current insight. Psychology Research and Behavior Management, 2017(10), 353–367. https://doi.org/10.2147/PRBM.S120582
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006–1011. https://doi.org/10.1001/archpsyc.1989.01810110048007
Grimmett, M. A., Dunbar, A. S., Williams, T., Clark, C., Prioleau, B., & Miller, J. S. (2016). The process and implications of diagnosing oppositional defiant disorder in African American males. The Professional Counselor, 6(2), 147–160. https://doi.org/10.15241/mg.6.2.147
Handal, N., LePage, J., Dayley, P., Baldwin, B., Roeser, A., Kay, J., Theobald, H. A., Nellamattathil, M., Drotar, S., Weir, C., Tindell, N., & Tice, K. (2018). Validation, reliability, and specificity of Clinicom™ psychiatric assessment software. Psychiatry Research, 265, 334–340.
https://doi.org/10.1016/j.psychres.2018.05.029
Hood, B. S., Elrod, M. G., & DeWine, D. B. (2015). Treatment of childhood oppositional defiant disorder. Current Treatment Options in Pediatrics, 1, 155–167. https://doi.org/10.1007/s40746-015-0015-7
International OCD Foundation. (2023). For parents and families. https://kids.iocdf.org/for-parents/
Justicia-Arráez, A., Pichardo, M. C., Romero-López, M., & Alba, G. (2021). Can we manage behavioral problems through the development of children’s social-emotional regulated behavior? Longitudinal study of a preschool program. International Journal of Environmental Research Public Health, 18(16), 8447. https://doi.org/10.3390/ijerph18168447
Kotapati, V. P., Khan, A. M., Dar, S., Begum, G., Bachu, R., Adnan, M., Zubair, A., & Ahmed, R. A. (2019). The effectiveness of selective serotonin reuptake inhibitors for treatment of obsessive-compulsive disorder in adolescents and children: A systematic review and meta-analysis. Frontiers in Psychiatry, 10(523). https://doi.org/10.3389/fpsyt.2019.00523
Krebs, G., Bolhuis, K., Heyman, I., Mataix-Cols, D., Turner, C., & Stringaris, A. (2013). Temper outbursts in pediatric obsessive-compulsive disorder and their association with depressed mood and treatment outcome. Journal of Child Psychology and Psychiatry, 54(3), 313–322.
https://doi.org/10.1111/j.1469-7610.2012.02605.x
Loeber, R., Burke, J. D., Lahey, B. B., Winters, A., & Zera, M. (2000). Oppositional defiant and conduct disorder: A review of the past 10 years, part I. Journal of the American Academy of Child and Adolescent Psychiatry, 39(12), 1468–1484. https://doi.org/10.1097/00004583-200012000-00007
Mancebo, M. C., Garcia, A. M., Pinto, A., Freeman, J. B., Przeworski, A., Stout, R., Kane, J. S., Eisen, J. L., & Rasmussen, S. A. (2008). Juvenile-onset OCD: Clinical features in children, adolescents and adults. Acta Psychiatrica Scandinavica, 118(2), 149–159. https://doi.org/10.1111/j.1600-0447.2008.01224.x
Merten, E. C., Cwik, J. C., Margraf, J., & Schneider, S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and Adolescent Psychiatry and Mental Health, 11(5). https://doi.org/10.1186/s13034-016-0140-5
National Federation of Families. (2023). Oppositional defiant disorder resources. https://www.Ffcmh.org/esources-odd
Nazeer, A., Latif, F., Mondal, A., Azeem, M. W., & Greydanus, D. E. (2020). Obsessive-compulsive disorder in children and adolescents: Epidemiology, diagnosis and management. Translational Pediatrics, 9(1), S76–S93. https://doi.org/10.21037/tp.2019.10.02
Painuly, N. P., Grover, S., Mattoo, S. K., & Gupta, N. (2011). Anger attacks in obsessive compulsive disorder. Industrial Psychiatry Journal, 20(2), 115–119. https://doi.org/10.4103/0972-6748.102501
Perou, R., Bitsko, R. H., Blumberg, S. J., Pastor, P., Ghandour, R. M., Gfroerer, J. C., Hedden, S. L., Crosby, A. E., Visser, S. N., Schieve, L. A., Parks, S. E., Hall, J. E., Brody, D., Simile, C. M., Thompson, W. W., Baio, J., Avenevoli, S., Kogan, M. D., & Huang, L. N. (2013). Mental health surveillance among children – United States, 2005-2011. Morbidity and Mortality Weekly Report Supplements, 62(02), 1–35. PMID: 23677130
Pringsheim, T., Hirsch, L., Gardner, D., & Gorman, D. A. (2015). The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: A systematic review and meta-analysis. Part 1: Psychostimulants, alpha-2 agonists, and atomoxetine. The Canadian Journal of Psychiatry, 60(2), 42–51. https://doi.org/10.1177/070674371506000202
Radomsky, A. S., Ashbaugh, A. R., & Gelfand, L. A. (2007). Relationships between anger, symptoms, and cognitive factors in OCD checkers. Behaviour Research and Therapy, 45(11), 2712–2725. https://doi.org/10.1016/j.brat.2007.07.009
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., Cicchetti, D., & Leckman, J. F. (1997). Children’s Yale-Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(6), 844–852.
https://doi.org/10.1097/00004583-199706000-00023
Stahnke, B. (2021). A systematic review of misdiagnosis in those with obsessive-compulsive disorder. Journal of Affective Disorders Reports, 6, 1–7. https://doi.org/10.1016/j.jadr.2021.100231
Storch, E. A., Jones, A. M., Lack, C. W., Ale, C. M., Sulkowski, M. L., Lewin, A. B., De Nadai, A. S., & Murphy, T. K. (2012). Rage attacks in pediatric obsessive-compulsive disorder: Phenomenology and clinical correlates. Journal of the American Academy of Child and Adolescent Psychiatry, 51(6), 582–592. https://doi.org/10.1016/j.jaac.2012.02.016
Storch, E. A., Lewin, A. B., Geffken, G. R., Morgan, J. R., & Murphy, T. K. (2010). The role of comorbid disruptive behavior in the clinical expression of pediatric obsessive-compulsive disorder. Behaviour Research and Therapy, 48(12), 1204–1210. https://doi.org/10.1016/j.brat.2010.09.004
Stringaris, A., & Goodman, R. (2009). Longitudinal outcome of youth oppositionality: Irritable, headstrong, and hurtful behaviors have distinctive predictions. Journal of the American Academy of Child and Adolescent Psychiatry, 48(4), 404–412. https://doi.org/10.1097/CHI.0b013e3181984f30
Thériault, M.-C. G., Lespérance, P., Achim, A., Tellier, G., Diab, S., Rouleau, G. A., Chouinard, S., & Richer, F. (2014). ODD irritability is associated with obsessive–compulsive behavior and not ADHD in chronic tic disorders. Psychiatry Research, 220(1–2), 447–452. https://doi.org/10.1016/j.psychres.2014.07.039
U.S. Department of Health and Human Services. (2023). Youth mental health. https://www.hhs.gov/surgeon
general/priorities/youth-mental-health/index.html
Nelson Handal, MD, DFAPA, is Founder, Chairman, and Medical Director for Dothan Behavioral Medicine Clinic and Harmonex Neuroscience Research. Emma Quadlander-Goff, PhD, NCC, LPC, is a clinical researcher at Harmonex Neuroscience Research and an assistant professor at Troy University. Laura Handal Abularach, MD, is a researcher at Harmonex Neuroscience Research and PGY-1 Psychiatry Resident at Louisiana State University. Sarah Seghrouchni, BS, is a research assistant at Alabama College of Osteopathic Medicine. Barbara Baldwin, MS, is Director of Clinical Research at Harmonex Neuroscience Research. Correspondence may be addressed to Emma Quadlander-Goff, 408 Healthwest Dr., Dothan, AL 36303, equadlander@troy.edu.
Jan 17, 2024 | Volume 13 - Issue 4
K. Lynn Pierce
Persistent ableism in higher education, counseling practice, and society necessitates disability justice advocacy. In this article, the author explores the historical context of disability and the importance of disability knowledge for counselors and counselor educators. In addition to discrimination and inaccessibility, able privilege and lack of representation present significant barriers to equity and empowerment of disabled people. Better awareness of disability culture and community-oriented frameworks for the collective liberation of disabled people, such as disability justice, can improve disability equity and allyship within counseling and counselor education.
Keywords: ableism, disability justice, advocacy, allyship, counseling
The disability rights motto, “Nothing about us without us,” highlights the importance of including disabled people in decisions that affect them. However, in a society dominated by able privilege, this motto has at times translated into “Nothing at all.” The absence of disabled representation and empowerment leads to a lack of understanding, empathy, and action toward improving the lived experiences of the disability community.
Over 60 million Americans live with a disability, making them the largest minority group in the United States (Centers for Disease Control and Prevention, 2023). The Americans with Disabilities Act (ADA) defines a person with a disability as “a person who has a physical or mental impairment that substantially limits one or more major life activity” (ADA National Network, 2024, para. 1). These activities include daily tasks like breathing, walking, talking, hearing, seeing, sleeping, taking care of oneself, doing manual tasks, and working. The year 2020 marked the 30th anniversary of the ADA, the major law granting protections to disabled individuals. Yet institutional ableism continues to persist in higher education, counseling practice, and public life. Disabled people face various obstacles, including unresolved barriers to physical access (including of health care and mental health services), social stigma, and insufficient funding for rehabilitation programs. Able privilege (also referred to as ability privilege or able-bodied privilege) is a viewpoint in which non-disabled bodies are considered normative (Lewis, 2022). Able privilege is pervasive in society and continues to contribute to societal stigmatization of and discrimination against disabled bodies, minds, and lives.
Positionality
The positionality of authors engaged in disability justice work is crucial for acknowledging biases and perspectives that influence the writing process. This practice also allows for transparency for readers to better understand the context this article is situated in. This is particularly important given the diversity of cultural norms within and between disability subcommunities and the differences of perception of ableism, access, and disability equity shaped by individuals’ unique experiences of disability.
I identify as a White, queer, disabled academic who aligns with crip culture. The term “crip” is a reclamation of the derogatory slang “cripple,” much as “queer” has been reclaimed by the LGBTQ+ community. I integrate the principles of disability justice and bring lived experience into advocacy, clinical, and research work pertaining to the disability community. I have navigated ableism personally and professionally and am invested in critical examination of ableist systems and advancement of cross-disability liberation. I use an anti-ableist and identity-affirming ideological lens to approach disability advocacy. The use of identity-first language throughout this paper reflects this positionality and is an acknowledgement of many disability subcommunities’ preference for this language.
A Brief History of Disability in the United States
Attitudes and policies surrounding the disability experience in the United States have historically imposed harsh restrictions and exclusions grounded in ableism. In the late 19th and early 20th centuries, the eugenics movement promoted the view that disability was undesirable and needed to be purged from society (Rutherford, 2022). Many proponents of eugenics were scientists, doctors, and policymakers. This contributed to forced sterilization and institutionalization of disabled people, restrictive immigration policies, and segregation in education. These policies, along with social stigma, led to disabled people being socially and economically disadvantaged and pushed to the fringes of society (RespectAbility, 2021).
In the 1970s, The Independent Living Movement and Centers for Independent Living (CILs) emerged as a civil rights campaign spearheaded by and for the disability community (Hayman, 2019). This movement pushed back against the discriminatory environments and paternalistic professionals of the time and focused on providing peer support, dignity, civil rights, and autonomy through direct service and advocacy. At this same time, the 504 protests (referring to section 504 of the Rehabilitation Act) paved the way for the civil rights work that eventually culminated in the passage of the ADA in 1990, which finally extended similar federally protected rights to disability as those that cover race and gender (Cone, n.d.).
Since 2000, disability-related activism has been most prominent online. Within this environment, community-based efforts such as the #SayTheWord movement and disability-related hashtags began to trend on social media. Many within the disability community have embraced X, formerly known as Twitter, specifically because it is free, has accessibility features, and allows for global connection and unprecedented reach to businesses and public figures, as well as other individuals and organizations within the disability community (Wilson-Beattie, 2018). Facebook and other social media groups have been important gathering places for disabled individuals to connect, obtain information about their conditions and available treatments, and find others who can relate to their experiences.
Exclusion of Disability in Education and Practice
The Rehabilitation Act of 1973 and the ADA both extended disability protections into higher education settings. However, because of the lack of protections in these settings prior to these laws, colleges and universities were already built on inaccessible foundations both physically and socially (Dolmage, 2017). This has led to a continued lack of equity for disabled people within higher education.
The National Center for Education Statistics (2018) reported that 19.4% of the undergraduate student body report having a disability, but only 11.9% at the graduate level. The Center for College Students with Disabilities reported that less than 4% of faculty members have disabilities (Grigely, 2017).
This suggests barriers to recruitment and retention and/or biases that prevent disclosure of disability identity. Despite the requirements under the Rehabilitation Act and ADA to provide equitable access, providing disability-related supports is often in conflict with ableist systems within higher education. For example, very few universities and colleges embrace a holistic and affirming model to support disability inclusion on their campuses and instead use an accommodation-only–focused approach. Most colleges and universities do not have a disability cultural center or student organizations focused on disability, despite the benefits for students and the community that such a center can provide (Elmore et al., 2018).
Disability and Counselor Education
Unfortunately, there is very little research available on disability within counseling and counselor education. Disability is often absent from captured demographics in our research, including when studies focus on the experiences of diverse counselors, counselor educators, and students. There is no information currently available regarding disability representation among counselor educators or counseling leadership, and very little about the experiences of disabled individuals within the profession or even the experiences of disabled clients with professional counselors.
Counselor education programs, apart from rehabilitation-specific classes, seldom focus on disability topics. According to Feather and Carlson (2019), 36% of faculty surveyed believed their program was ineffective at addressing disability topics, while only 10.6% believed their program to be “very effective” in this content area. Faculty self-assessment of competence to teach disability-related content correlated significantly with previous work or personal experience with disability, underscoring the importance of exposure to and training about disability-related concepts being infused across core areas. Key elements related to disability competence such as accessibility, able privilege, disability culture, and disability justice are explored in the following sections.
Considering Accessibility
Accessibility is a word that is often co-opted in diversity, equity, and inclusion (DEI) spaces to mean attainability, affordability, inclusion, etc. However, accessibility is a concept that is legally related to the ability of disabled people to equitably interact with built environments and services. The Office for Civil Rights (OCR) defines accessibility as:
When a person with a disability is afforded the opportunity to acquire the same information, engage in the same interactions, and enjoy the same services as a person without a disability in an equally integrated and equally effective manner, with substantially equivalent ease of use. (U.S. Department of Education, 2013, p. 3)
Physical accessibility includes factors such as ample accessible parking, pathways without stairs, clear curb cuts, even paving, wide doors and pathways, clear signage, clear spaces for wheelchairs and mobility devices, and accessible bathrooms. Accessibility of websites and other digital services is also covered under the ADA. The accessibility of learning management systems, captioning and transcripts for videos, and accessible file types are all important factors in classroom accessibility. Despite the ADA requirements, many spaces fall short, emphasizing the need for continual self-evaluation and consultation (ADA National Network, 2016).
Accessibility is often viewed only as what must be done at a minimum legally, and sometimes it is unclear within a given structure who exactly is responsible for ensuring accessibility. This often results in a reactive approach that places the burden on disabled people to experience barriers and report them. Another common approach is an accommodation mindset, in which disability is seen as so unlikely within a setting that those who need disability supports are seen as burdensome and must request them in advance. This can be contrasted with a barrier reduction or universally designed approach, in which disability would be proactively considered and planned for within a system or space. The resistance to these more equitable approaches is largely the result of lack of awareness of disability prevalence and needs, rooted in ableism and able privilege (Dolmage, 2017).
Able Privilege
Able privilege (also referred to as ability privilege or able-bodied privilege) is a viewpoint in which non-disabled bodies are considered normative. This condition lends itself to the continuation of inaccessible environments and attitudes, which, in turn, further entrenches able privilege within society. To illustrate the implications of able privilege, one may consider the day-to-day experiences of non-disabled individuals and the stark contrast with the experiences of disabled people. The simple act of opening a door without strategizing your approach or having the liberty to choose any seat at a movie theater or concert are further indicators of able privilege. If you have always been able to access materials showcasing individuals of your ability as role models or had access to mentors who mirror your ability, you have experienced able privilege. The ability to move around with the assurance that housing options will generally be accessible to you is a distinct advantage, one that disabled people, particularly those who use mobility devices or who have physical limitations often cannot take for granted. The invisibility of these privileges to those who benefit from them is precisely what fuels the cycle of able privilege, leading to a lack of representation and empowerment for disabled individuals (Dolmage, 2017).
Able privilege is a major but often neglected aspect of social inequality, mostly because disabled individuals are systematically underrepresented. This exclusion is deeply ingrained in our society, impacting policies, cultural norms, and current structures, which further magnify able privilege. “Ugly laws,” a discriminatory legislation active in certain parts of the United States through the ’70s and ’80s, literally pushed disabled people out of public view, further contributing to their erasure (Schweik, 2011). The discomfort with the disabled body being seen and acknowledged in public continues, with organizations like the Ford Foundation finding a lack of disability representation in popular media (Heumann et al., 2019). Despite increasing emphasis on diversity, equity, inclusion, and accessibility (DEIA) in counseling, the reality is that the disability community often finds itself on the outskirts of these crucial conversations because of historical inequalities that are unchallenged or a continued lack of equitable access (Dolmage, 2017).
This cycle of exclusion parallels a common physical accessibility challenge: The lack of disabled people present in a space is often used to justify a lack of priority given to accessibility. However, the inaccessibility itself is the barrier preventing disabled people from entering and remaining in these spaces in the first place. Inaccessibility precludes disabled presence and advocacy, and barriers often then stand unchallenged.
Our educational systems and programs are no exception to the impacts of the exclusion of disabled bodies and minds. Ableist ideologies are often left unchallenged and unknowingly promoted, shaping the understanding of disability at crucial developmental stages. The exposure that most people have to disabilities is also skewed, leading to the formation of harmful stereotypes and stigmas discussed further below.
Disability Culture
Disability culture encompasses a group identity with shared experiences, a history of oppression, literature, art, language, and expression. This is highlighted through various forms of art and literature and through movements advocating for disability rights and inclusion (Brown, 2015). However, the disability community boasts a rich and diverse culture that’s often absent from mainstream media and popular culture.
Representation
As with other minoritized and marginalized populations, the representation of disability in mainstream media, film, and literature can have significant impacts on the societal view of disability and bias and stigma experienced by disabled individuals. Because of the various challenges in access presented by society and the taboos regarding discussions of disability, media is a primary way many people may form opinions about disability and disabled people. Unfortunately, these depictions are few and often convey misinformation and harmful tropes. In a review of 100 top movies in 2016, fewer than 3% of characters had a disability (Smith et al., 2017). Heumann and colleagues (2019) found in their examination of disability in media that most disabled characters in film fell into four stereotypes: the Super Crips who triumph over disability and provide the message that disability is merely a negative thing to be overcome; Villains who are often portrayed with disfigurement of some kind and play on fear and discomfort of disability and difference; Victims who are defined only by their disability and often are shown as better off dead than disabled; or Innocent Fools who embody negative stereotypes of those with intellectual disabilities or neurological differences. These issues with one-dimensional and negative representation in the small number of examples of disability shown on the screen are compounded by a lack of input from disabled writers, actors, or directors. Most disabled characters are played by non-disabled actors, and disability is the most underrepresented minority in the Hollywood film industry (Woodburn & Kopić, 2016).
Within the disability community, a starkly different narrative emerges, often directly hitting back at the misrepresentation and villainization of disability that is commonplace in mainstream media. For example, Disfigured: On Fairy Tales, Disability, and Making Space by Amanda Leduc (2020) critically analyzes the narratives ingrained in our culture around disability. Leduc particularly explores the impact of fairy tales and their modern retellings on identity development and belonging for disabled people, centering her own story and other disabled people’s narratives. Crip Camp, a Netflix documentary, discusses the disability rights movement through the personal stories of advocates such as the late Judy Heumann (Hale & LeBrecht, 2020). Heumann’s autobiography, Being Heumann: An Unrepentant Memoir of a Disability Rights Activist (2020), is a powerful work in the disability space along with early commentaries on empowered language and identity choice such as Nancy Mairs’s essay, On Being a Cripple (1986).
“Crip culture” is one notable aspect of disability culture. In the anthology Criptiques, compiled by Caitlin Wood (2014), crip, slang for cripple, is embraced as a powerful self-descriptor, representing audacity, noncompliance, and a direct challenge to disability being pushed into the shadows. It is an example of the arts and expression of “crip culture,” which draws on shared experiences of ableism, creating a community that affirms and reflects its members’ originality and beauty. Criptiques presents a diverse set of essays embodying this revolutionary spirit and fostering discussions about disability experiences (Wood, 2014).
Social media platforms, particularly X/Twitter, have catalyzed the formation of a global disability community. Hashtags like #DisabledandCute and #AbledsAreWeird have trended, fostering discussions and highlighting the shared experiences within the disability community. “The disability revolution will be tweeted” because of the critical role social media plays in fostering community in accessible formats (Wilson-Beattie, 2018).
Emerging trends in disability spaces include the #SayTheWord movement, which seeks to reclaim the term disability and challenges forced person-first, euphemistic language often pressed on the disability community by able-bodied individuals, discussed further below. Spoonie communities are also prevalent in chronic illness and even some mental health circles. These spaces use the spoon theory by Christine Miserandino (2003), which describes how there is a set amount of energy for daily tasks that can be lowered by disability-related factors such as pain or fatigue. Spoon theory seeks to help disabled people and those close to them understand the fluctuating nature of chronic illness and better communicate about it.
Language and Empowered Expression
It is essential to understand how to talk about disabilities and disabled people in an empowering and inclusive way. Person-first language (e.g., “person with a disability” and “person with [condition]”) emphasizes the person before the disability. While this language is used primarily in academic spaces and was mandatory until the seventh edition of the American Psychological Association style manual (APA; 2020), it is often criticized for being avoidant and contributing to perpetuating rather than confronting stigma (Collier, 2012).
Alternatively, identity-first language proposes that the identity of an individual should lead the conversation. This mode of language is used more commonly within disability spaces, such as “disabled individuals” or “autistic people.” Some subgroups, like the Deaf and autistic communities, strongly identify with their disability factors, promoting a sense of disability pride.
Disabling language, such as “handicapped,” “wheelchair-bound,” or “crippled,” are terms that are outdated, inaccurate, and offensive. These terms can be stigmatizing based on social and historical contexts, like referring to someone diagnosed with schizophrenia as “schizophrenic.” The exception to this is in usages such as those outlined above in which some subcommunities have reclaimed words like “crippled” or find them accurate and therefore identity affirming. This highlights a trend that language and slang within the disability community often focuses on relevant factors of assistive technology or the disabilities themselves (e.g., “wheelies” for wheelchair users, “spoonies” for those who endorse spoon theory, or “potsies” for those with postural orthostatic tachycardic syndrome [POTS]), whereas out-of-group language typically rejected by disabled people is often designed to avoid using the word disability (e.g., “differently abled,” “diverse-ability,” or “special needs”).
While person-first language is valid and should be used when it is the preference of the individual with a disability, there are many compelling arguments for normalizing and empowering identity-based language. Person-first language can be incongruent with people’s self-concept and with their experience of the perception others have of them. Person-first language can perpetuate stigmatization of disability, leading to perceived hypocrisy (Collier, 2012). The language choices made by able-bodied allies often disregard the preferences of the disabled community, echoing a history of erasure and opposing the principle of “nothing about us without us.” This has sometimes extended to able-bodied academics imposing their preference for person-first language on disabled people through academic standards and publishing norms. It can be argued that these restrictions historically have inhibited self-identification, language preference, and the ability to produce scholarship that accurately represents disabled people and community values. This impedes collaborative research with the disability community and reinforces a division and lack of understanding between the disability community and counselors or other medical and mental health providers.
Allyship and Disability Justice
Allyship is not an identity but a practice. Allies for the disability community must operate in solidarity with and advocate for the rights of those oppressed by systems in ways that do not reinforce the system’s oppression (Brown, 2015). This involves actively listening, observing dynamics of power, focusing on impact rather than intent, leaning into discomfort, modeling inclusive language, and offering kind and constructive feedback. In this context, it’s vital to understand ableism, defined as, “a system of assigning value to people’s bodies and minds based on societally constructed ideas of normalcy, productivity, desirability, intelligence, excellence, and fitness” (Lewis, 2022, para. 4). Ableism devalues and discriminates against disabled people and gives preference and normative status to able-bodied people.
The Disability Justice framework (Sins Invalid, 2015) offers a comprehensive and inclusive perspective on human bodies and experiences. The Disability Justice framework was originally developed by the activist Patty Berne, a co-founder of the organization Sins Invalid, to reflect the collaborative work occurring in community spaces. Sins Invalid is a performance project that deconstructs the dehumanizing practices disabled people face and centers intersectionality and diversity of identities.
The Disability Justice framework emphasizes that every body is unique, important, and powerful. This framework understands that people are shaped by complex intersections of factors like ability, race, gender, sexuality, social class, nationality, religion, and more. Instead of isolating these factors, it insists on viewing them collectively. This viewpoint stresses that our pursuit of a fair society is rooted in these intertwined identities and points out a critical observation: Our current global system is essentially “incompatible with life” (Berne, 2015, para. 13). Disability Justice principles include “leadership of the most impacted,” “interdependence,” “collective access,” “cross-disability solidarity,” and “collective liberation” and focus strongly on intersectionality and cross-movement organizing to ensure no one is left behind or excluded (Sins Invalid, 2015, p. 1).
Although there are voices advocating for disability rights, these are predominantly from within the disability community itself, a testament to the lack of understanding and allyship from broader society. Historically, those who could have been allies—abled caregivers, academics, medical professionals, and others—have often worked against the community, whether consciously or not (Dolmage, 2017). This can be combated first by ensuring access to spaces so that disabled voices are present. Then, allies can elevate these voices while implementing a framework like disability justice to ensure that those impacted are leading and that cross-disability approaches are being implemented around equity and liberation work, in line with community priorities.
Implications for the Counseling Profession
Counselor Education and Preparation
Instructors have a critical role in supporting disabled counselors-in-training. Not only is this support mandated by law, but it also increases visibility, representation, and lived experiences of disability in the profession, thereby improving services for clients. Implementing Universal Design for Learning (UDL) can minimize the need for accommodations and provide access, engagement, and learning motivation to the widest possible audience of learners (CAST, 2018). UDL is grounded in Universal Design principles, which are architectural strategies to make physical spaces usable by the widest number of people possible. The UDL principles include strategies such as multiple means of representing information to capture various learning types and multiple means of expression to allow learners to demonstrate learning in various ways (CAST, 2018). Adopting these principles can significantly contribute to making materials and learning environments more accessible. Instructors should consider how they can better focus on curriculum, activities, and assessments that increase exposure of counseling students to disability as a common multicultural factor and client identity. In addition, it is highly advisable to approach accessibility proactively in assignments and course materials and to become comfortable with the process required to swiftly provide equitable accommodations for students when a request is made.
Where a need for access or accommodations is established for a student, an opportunity also exists to proactively advocate for and support students in ensuring accessibility and equity in their practicum and internship placements, graduate assistantships, and other duties required for or connected to their program of study. Sometimes a student’s disability and related accommodation needs are new. Even for those who have established what they need to succeed in a classroom, counseling programs with their clinical requirements are a new setting and students may not always know what they need in advance. It is therefore the responsibility of counselor educators to take a barrier reduction approach, take on the labor of researching the accessibility of approved sites and processes of accommodations specific to graduate students within their universities, and work collaboratively with the student at all stages of a program.
Counseling Practice
It is an ethical mandate that counselors become competent in working with disabled clients as addressed in the ACA Code of Ethics pertaining to nondiscrimination and multicultural issues (American Counseling Association, 2014). It is also important for counselors to work in ways that are respectful and promote client autonomy. This can begin with ensuring that proper etiquette is understood. Examples include speaking directly to a person, not their interpreter or attendant; not drawing attention to, commenting on, or interfering with assistive technology (including service animals); and asking questions rather than making assumptions. Working from a disability-affirming perspective is important, as well as being engaged in self-reflective work around disability bias and seeking appropriate supervision. Supervision might be with a peer to check for bias and process reactions to disability topics, or with someone with disability identity or rehabilitation training to consult on best practices around accessibility and disability-affirming approaches.
The physical counseling environment needs to be accessible according to ADA guidelines, and this should be determined based on the checklist for existing facilities and/or a professional consultant (ADA National Network, 2016). Continuing to offer telehealth as an option while still ensuring spaces are accessible helps to meet a long-standing need expressed by disabled people in ensuring access to mental health care. Websites need to meet web accessibility guidelines, and it is advisable to ensure accessible formats are available for documentation (e.g., large font and digital options). Within spaces, common triggers for various conditions should be considered. For example, fluorescent lights may trigger migraines or neurological conditions, while chemical sensitivities could be triggered by anything from bleach and other cleaning supplies to perfume, room fresheners, or lavender and other essential oils.
In working with clients, it should not be assumed a client is not disabled merely because they are not visibly disabled or have not disclosed a disability. If a client is visibly disabled or has disclosed but not elaborated, signaling openness to further discussion while respecting boundaries and client priorities is warranted. Intrusive questioning is never appropriate, and client autonomy and treatment goals should always be respected. In my own work, I think of this similarly to when I may diffuse a question regarding trauma on an intake by acknowledging the client may not yet trust me; we can come back to discuss it further at any time in our work together, and I invite them to share to their level of comfort. An example of broaching a visible or previously disclosed disability might be simply asking if there is anything that can be done to increase accessibility or comfort in the space. Another approach might be to reflect the client’s own language to describe the disability, chronic illness, assistive technology, etc. and to simply ask if there is anything specific that the client would like for you to know up front that would support your work together, or whether they would like to address things as they come up.
Conclusion
Disability culture is rich and complex, asserting its place in sharp contrast to mainstream narratives with defiance. It is a culture that celebrates wholeness and intersectionality and challenges ableist norms without apology for occupying space.
By understanding how ableism in counseling and counselor education fits into the broader history of disability oppression and increasing awareness of disability culture and disability justice, the counseling profession can better serve the disability community. Normalizing conversation about disability allows us to prepare ourselves, our students, and our supervisees to work with this large and diverse population. When we act intentionally to proactively make spaces accessible, we are providing disabled people with the same rights we provide to other clients. This allows them to share their stories gradually and comfortably, without having to disclose too early or fight for their basic rights.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
ADA National Network. (2016). ADA checklist for existing facilities. https://www.adachecklist.org/doc/fullcheck
list/ada-checklist.pdf
ADA National Network. (2024). Top ADA frequently asked questions. https://adata.org/top-ada-frequently-asked-questions
American Psychological Association. (2020). Publication manual of the American Psychological Association 2020: The official guide to APA style (7th ed.).
Berne, P. (2015). Disability justice – a working draft. Sins Invalid. https://www.sinsinvalid.org/blog/disability-justice-a-working-draft-by-patty-berne
Brown, S. E. (2015). Disability culture and the ADA. Disability Studies Quarterly, 35(3). https://doi.org/10.18061/dsq.v35i3.4936
CAST. (2018). Universal design for learning guidelines. https://udlguidelines.cast.org
Centers for Disease Control and Prevention. (2023). Disability impacts all of us. https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html
Collier, R. (2012). Person-first language: Noble intent but to what effect? Canadian Medical Association Journal, 184(18), 1977–1978. https://doi.org/10.1503/cmaj.109-4319
Cone, K. (n.d.). Short history of the 504 sit in. Disability Rights Education and Defense Fund. https://dredf.org/504-sit-in-20th-anniversary/short-history-of-the-504-sit-in/
Dolmage, J. T. (2017). Academic ableism. University of Michigan Press.
Elmore, K., Saia, T., & Thomson, E. A. (2018). Special feature: An introduction to disability cultural centers in U.S. higher education, part I. Association on Higher Education and Disability. https://www.ahead.org/professional-resources/publications/hub/hub-nov-2018/hub-nov-2018-special-feature-disability-cultural-centers
Feather, K. A., & Carlson, R. G. (2019). An initial investigation of individual instructors’ self-perceived competence and incorporation of disability content into CACREP-accredited programs: Rethinking training in counselor education. Journal of Multicultural Counseling and Development, 47(1), 19–36.
http://doi.org/10.1002/jmcd.12118
Grigely, J. (2017). The neglected demographic: Faculty members with disabilities. The Chronicle of Higher Education. https://www.chronicle.com/article/The-Neglected-Demographic-/240439
Hale, J., & LeBrecht, N. (Directors). (2020). Crip camp [Film]. Higher Ground Productions.
Hayman, B. (2019). Independent living history. Access Living. https://www.accessliving.org/newsroom/blog/independent-living-history/
Heumann, J. (2020). Being Heumann: An unrepentant memoir of a disability rights activist. Beacon Press.
Heumann, J., Salinas, K., & Hess, M. (2019). Road map for inclusion: Changing the face of disability in media. Ford Foundation. https://www.fordfoundation.org/wp-content/uploads/2019/02/judyheumann_report_2019_final.pdf
Leduc, A. (2020). Disfigured: On fairy tales, disability, and making space. Coach House Books.
Lewis, T. A. (2022, January 1). Working definition of ableism: January 2022 update. https://www.talilalewis.com/blog/working-definition-of-ableism-january-2022-update
Mairs, N. (1986). On being a cripple. https://faculty.uml.edu/bmarshall/mairsonbeingacripple.pdf
Miserandino, C. (2003). The spoon theory. But You Don’t Look Sick. https://butyoudontlooksick.com/articles/written-by-christine/the-spoon-theory/
National Center for Education Statistics. (2018). Table 311.10. Number and percentage distribution of students enrolled in postsecondary institutions, by level, disability status, and selected student characteristics: 2015–16. Digest of Education Statistics. https://nces.ed.gov/programs/digest/d20/tables/dt20_311.10.asp
RespectAbility. (2021). A brief history of the disability rights movement. https://www.respectability.org/people-with-disabilities-at-work/history/
Rutherford, A. (2022). Control: The dark history and troubling present of eugenics. Abrams Press.
Schweik, S. M. (2011). Kicked to the curb: Ugly law then and now. Harvard Civil Rights-Civil Liberties Law Review Amicus, 46, 1–16. https://journals.law.harvard.edu/crcl/wp-content/uploads/sites/80/2013/01/Schweik_Vol46_Amicus.pdf
Sins Invalid. (2015, September 17). 10 principles of disability justice. https://www.sinsinvalid.org/blog/10-principles-of-disability-justice
Smith, S. L., Choueiti, M., Pieper, K., Case, A., Yao, K., & Choi, A. (2017). Inequality in 900 popular films: Examining portrayals of gender, race/ethnicity, LGBT, and disability from 2007-2016. Annenberg Foundation. https://annenberg.usc.edu/sites/default/files/Dr_Stacy_L_Smith-Inequality_in_900_Popular_Films.pdf
U.S. Department of Education. (2013). South Carolina technical college system OCR compliance review no. 11-11-6002. https://www2.ed.gov/about/offices/list/ocr/docs/investigations/11116002-b.html
Wilson-Beattie, R. (2018, September 18). …And the disability revolution will be tweeted. Open Transcripts.
http://opentranscripts.org/transcript/disability-revolution-will-be-tweeted/
Wood, C. (2014). Criptiques. May Day Publishing.
Woodburn, D., & Kopić, K. (2016, July). The Ruderman white paper on employment of actors with disabilities in television. Ruderman Family Foundation. https://rudermanfoundation.org/wp-content/uploads/2016/07/TV-White-Paper_7-1-003.pdf
K. Lynn Pierce, PhD, NCC, ACS, LPC, CRC, is an assistant professor and Counselor Education and Supervision PhD Program Coordinator at Mercer University. Correspondence may be addressed to K. Lynn Pierce, Mercer University College of Professional Advancement, 2930 Flowers Rd. S., Chamblee, GA 30341, pierce_k03@mercer.edu.
Dec 21, 2023 | Book Reviews
by James P. Sampson, Jr., and Janet G. Lenz
While the importance of developing and implementing career interventions is widely recognized, there is less clarity as to how to initiate this process. The second edition of Designing and Implementing Career Interventions: A Handbook for Effective Practice addresses this issue by offering a comprehensive approach to career intervention implementation. Dr. James P. Sampson, Jr., and Dr. Janet G. Lenz detail each step of the design and implementation process in a succinct but thorough manner.
The centerpiece of the handbook is its “Eight-Step Model for Implementing Improved Career Interventions.” This model takes into account every aspect of the intervention process, from evaluation to training to implementation. The model’s depth helps both experienced and inexperienced career service providers to address aspects of the intervention process that are often overlooked. The model is dynamic in that it can be tailored to best address the needs and makeup of a specific organization. The authors emphasize that the model is not intended to be a one-size-fits-all approach and that “no two organizations are likely to create the same implementation plan.” For this reason, staff members incorporating this model can be sure that they are covering the necessary bases in their intervention plan while not abandoning their organization’s unique style.
The authors encourage the reader to adopt as much or as little of the model as they need, depending on factors such as organization size, typical client concerns, and available technology. In a similar vein, the handbook is useful for staff members in a variety of roles, both in person and virtual, and the authors provide recommendations regarding which sections of the handbook are most relevant based on the specific position that the staff member occupies within their organization. The text’s appendices include tools, such as a Career Intervention Plan and Implementation Checklist, that can help staff members to translate the teachings of this handbook into daily practice. Supplemental resource suggestions, such as career assessments, information guides, and career service professional standards, are also provided throughout the text.
Along with presenting the eight-step model, the authors provide additional guidance on how to effectively implement an intervention plan. They highlight the significance of career theory, research, professional standards, and policy in the intervention process, and they discuss how the interconnection of these aspects contributes to improved career interventions. The handbook also stresses the importance of collecting evaluation and accountability data. The authors discuss various evaluation techniques and the specific situations in which to utilize each type of evaluation. In addition, a five-step model of accountability provides an outline for staff members seeking to monitor the impact of their interventions. This discussion of evaluation and accountability is helpful for career service organizations striving to implement evidence-based practices, as the enactment of these practices often leads to additional funding opportunities.
The section on cognitive information processing (CIP) and Holland’s RIASEC theory provides an outline of how career interventions can be tailored based on the theoretical orientation of a particular organization. Career staff members not trained in CIP or RIASEC theory may not be familiar with the specific CIP or RIASEC terminology mentioned in this chapter, but they can still come away with an understanding of how career theory, in general, can be integrated with practice. This chapter also highlights the various modalities—such as assessment, psychoeducation, and modeling—that staff members should consider when designing and implementing interventions. This discussion of the myriad techniques available in the intervention process reminds the reader that career interventions can take many different forms in a range of settings.
Another strength of the handbook is its recognition that intervention design and implementation is not done in a vacuum. Throughout the text, the authors encourage the reader to consider how leadership and collaboration affect the efficacy of career interventions. They provide examples of effective and ineffective techniques related to leadership and staff beliefs, as well as the outcomes that are likely to result from the application of those techniques. The inclusion of these interpersonal considerations can help career service leaders to embrace and navigate the inevitable change that occurs in organizations.
Overall, this handbook is a valuable tool for career service practitioners in a variety of settings and roles, and its methods can easily be adapted to align with the values and needs of specific organizations.
Sampson, J. P., Jr., & Lenz, J. (2023). Designing and implementing career interventions: A handbook for effective practice (2nd ed.). National Career Development Association.
Reviewed by: Danny Chiarodit, MS
