Feb 26, 2021 | Volume 11 - Issue 1
Ryan M. Cook, Heather J. Fye, Janelle L. Jones, Eric R. Baltrinic
This study explored the self-reported symptoms of burnout in a sample of 246 novice professional counselors. The authors inductively analyzed 1,205 discrete units using content analysis, yielding 12 categories and related subcategories. Many emergent categories aligned with existing conceptualizations of burnout, while other categories offered new insights into how burnout manifested for novice professional counselors. Informed by these findings, the authors implore counseling scholars to consider, in their conceptualization of counselor burnout, a wide range of burnout symptoms, including those that were frequently endorsed symptoms (e.g., negative emotional experience, fatigue and tiredness, unfulfilled in counseling work) as well as less commonly endorsed symptoms (e.g., negative coping strategies, questions of one’s career choice, psychological distress). Implications for novice professional counselors and supervisors are offered, including a discussion about counselors’ experiences of burnout to ensure they are providing ethical services to their clients.
Keywords: novice professional counselors, burnout, content analysis, conceptualization, symptoms
The term high-touch professions refers to the fields that require professionals to provide ongoing and intense emotional services to clients (Maslach & Leiter, 2016). Although such work can be highly rewarding, these professionals are also at risk for burnout (Bardhoshi et al., 2019). In counseling, professionals are called to provide ongoing and intensive mental health services to clients with trauma histories (Foreman, 2018) and complicated needs (Freadling & Foss-Kelly, 2014). The risk of burnout is exacerbated by the fact that counselors often work in professional environments that are highly demanding and lack resources to serve their clients (Freadling & Foss-Kelly, 2014; Maslach & Leiter, 2016).
The consequences of burnout for counselors and clients can be considerable (Bardhoshi et al., 2019). Potential impacts include a decline in counselors’ self-care, strain of personal relationships, and damage to their overall emotional health (Bardhoshi et al., 2019; Cook et al., 2020; Maslach & Leiter, 2016). Unaddressed burnout might also lead to more serious professional issues like impairment (e.g., substance use, mental illness, personal crisis, or illness; Lawson et al., 2007). Thus, self-monitoring symptoms of burnout is of the utmost importance for counselors to ensure they are providing ethical services to their clients (American Counseling Association [ACA], 2014).
Although burnout is an occupational risk to all counselors (e.g., Bardhoshi et al., 2019; J. Lee et al., 2011; S. M. Lee et al., 2007), novice professional counselors may be especially vulnerable to burnout (Thompson et al., 2014; Westwood et al., 2017; Yang & Hayes, 2020). In the current study, we define novice professional counselors as those who are currently engaged in supervision for licensure in their respective states. Novice professional counselors face a multitude of challenges, such as managing large caseloads, working long hours for low wages, and receiving limited financial support for client care (Freadling & Foss-Kelly, 2014). Even though their professional competencies are still developing (Freadling & Foss-Kelly, 2014; Rønnestad & Skovholt, 2013), these counselors receive minimal direct oversight from a supervisor (Cook & Sackett, 2018). However, to date, no study has exclusively examined novice professional counselors’ descriptions of their experiences of burnout. Input from these counselors is important to understand their specific issues of counselor burnout. Other helping professionals have studied a rich context of practitioners’ burnout experiences. For example, Warren et al. (2012) examined open-ended text responses of people who treated clients with eating disorders and found nuanced contributors to burnout among these providers, including patient descriptors (e.g., personality, engagement in treatment), work-related descriptors (e.g., excessive work hours, inadequate resources), and therapist descriptors (e.g., negative emotional response, self-care). Accordingly, we employed a similar approach to examine the open-ended qualitative responses of 246 novice professional counselors’ self-reported symptoms of burnout.
Conceptual Framework of Burnout
Burnout is defined as “a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job” (Maslach & Leiter, 2016, p. 103). Although there are multiple conceptual frameworks of burnout (e.g., Kristensen et al., 2005; S. M. Lee et al., 2007; Maslach & Jackson, 1981; Shirom & Melamed, 2006; Stamm, 2010), the predominant model used to study burnout is the one developed by Maslach and Jackson (1981), which is measured by the Maslach Burnout Inventory (MBI). Informed by qualitative research, Maslach and Jackson (1981) developed the MBI and conceptualized burnout for all human service professionals as a three-dimensional model consisting of Exhaustion, Depersonalization, and Decreased Personal Accomplishment. Exhaustion is signaled by emotional fatigue, loss of energy, or feeling drained. Depersonalization is characterized by cynicism or negative attitudes toward clients, while Decreased Personal Accomplishment is indicated by a lack of fulfillment in one’s work or feeling ineffective. This conceptualization of burnout has been used to develop several versions of the MBI that are targeted for different professions (e.g., human services, education) and for professionals in general.
Despite the prominence of the MBI model in the burnout literature (Koutsimani et al., 2019), other scholars (e.g., Kristensen et al., 2005; Shirom & Melamed, 2006) have argued for a different conceptualization of burnout, noting several shortcomings of Maslach and Jackson’s (1981) three-dimensional model. Shirom and Melamed (2006) criticized the lack of theoretical framework of the MBI and noted that the factors were derived via factor analysis. They developed the Shirom-Melamed Burnout Measure (Shirom & Melamed, 2006), a measure informed by the Conservation of Resources theory (Hobfoll, 1989), which measures burnout as a depletion of physical, emotional, and cognitive resources using two subscales: Physical Fatigue and Cognitive Weariness.
Kristensen et al. (2005) also criticized the utility of the MBI for numerous reasons, including the lack of theoretical underpinnings of the instrument. Therefore, they developed the Copenhagen Burnout Inventory to capture burnout in professionals across disciplines, most notably human service professionals. From Kristensen et al.’s perspective, the underlying cause of burnout is physical and psychological exhaustion, which occurs across three domains: Personal Burnout (i.e., burnout that is attributable to the person themselves), Work-Related Burnout (i.e., burnout that is attributable to the workplace), and Client-Related Burnout (i.e., burnout that is attributable to their work with clients; Kristensen et al., 2005).
Stamm (2010) conceptualized the construct of professional quality of life for helping professionals, which included three dimensions: Compassion Satisfaction, Burnout, and Secondary Traumatic Stress. Burnout, as theorized by Stamm, is marked by feelings of hopelessness, frustration, and anger, as well as a belief that one’s own work is unhelpful to others, which results in a decline in professional performance. The experience of burnout may also be caused by an overburdening workload or working in an unsupportive environment (Stamm, 2010). Stamm’s model is reflected in the Professional Quality of Life Scale (ProQOL), and this instrument has been used by counseling scholars (e.g., Lambert & Lawson, 2013; Thompson et al., 2014).
A reason for variations in the conceptualization of burnout is that it manifests differently across professions (Maslach & Leiter, 2016). The only counseling-specific model of burnout is conceptualized by S. M. Lee et al. (2007), who developed the Counselor Burnout Inventory (CBI). The CBI was informed by the three dimensions of the MBI and additionally captured the unique work environment of professional counselors and its impact on their personal lives. As such, the CBI poses a five-dimensional model consisting of Exhaustion, Incompetence, Negative Work Environment, Devaluing Client, and Deterioration in Personal Life. In recent years, the CBI has been the instrument predominantly used by researchers to study counselor burnout (e.g., Bardhoshi et al., 2019; Fye et al., 2020; J. Lee et al., 2011).
The Current Study
J. Lee et al. (2011) noted the challenges of studying counselor burnout across diverse samples. They encouraged scholars to examine burnout within homogenous samples of counselors in order to offer more nuanced implications for each group. Prior scholarship (e.g., Freadling & Foss-Kelly, 2014; Thompson et al., 2014) suggested that novice professional counselors may be at risk of burnout, and despite the aforesaid vulnerabilities (e.g., low wages, work with high need clients, professional competency limitations), their self-reported manifestation of burnout symptoms have yet to be studied.
We acknowledge the critical importance of studying burnout in the profession of counseling. However, repeatedly relying on data from similar instruments to measure burnout may fail to capture new or relevant information about the phenomenon (Kristensen et al., 2005) for human service professionals (e.g., Maslach & Jackson, 1981) or professional counselors (e.g., S. M. Lee et al., 2007). Alternatively, content analysis, which focuses on the analysis of open-ended qualitative text (Krippendorff, 2013), may better capture the intricacies of burnout that could not be measured using quantitative instruments (e.g., Warren et al., 2012). Thus, we aimed to address the following research question: What are novice professional counselors’ self-reported symptoms of burnout?
Methodology
Participants
Participants in the current study were 246 postgraduate counselors who were currently receiving supervision for licensure. The age of participants ranged from 23 to 69, averaging 36.91 (SD = 10.15) years. The majority of participants identified as female (n = 195, 79.3%), while 22 participants identified as male (8.9%), four identified as non-binary (1.6%), nine indicated that they did not want to disclose their gender (3.7%), and 16 participants did not respond to the item (6.5%). The participants’ race/ethnicity was reported as follows: White (n = 186; 75.6%), Multiracial (n = 15, 6.1%), Latino/Hispanic (n = 7, 3.3%), Black (n = 6, 2.4%), Asian (n = 6, 2.4%), American Indian or Alaska Native (n = 3, 0.8%), Native Hawaiian or Pacific Islander (n = 1, 0.4%), and Other (n = 7, 3.3%), while 15 participants declined to respond to the item (6.1%). The self-reported race/ethnicity demographic information is comparable to all counselors in the profession, based on DataUSA (2018). The participants’ client caseload ranged from 1 to 650 (M = 41.88; Mdn = 30.0; SD = 53.74). On average, participants had worked as counselors for 5 years (Mdn = 3.3; SD = 4.87). The provided percentages may not total to 100 percent because of rounding and because participants were afforded the option to select more than one response.
Procedure
To answer our research question, we used data from a larger study of novice professional counselor burnout, which included both quantitative and qualitative data. After receiving IRB approval, we obtained lists of names and email addresses of counselors engaged in supervision for licensure from the licensing boards in seven states: Florida, Nebraska, New Mexico, Oregon, Utah, Washington, and Wisconsin. We aimed to recruit a nationally representative sample by purposefully choosing at least one state from each of the ACA regions. In addition, states were selected based upon our ability to obtain a list of counselors who were engaged in supervision for licensure from the respective licensure boards. We were able to survey at least one state from each ACA region except the North Atlantic Region. After removing invalid email addresses, we invited 6,874 potential participants by email to complete an online survey in Qualtrics. This survey was completed by 560 counselors, yielding a response rate of 8.15%. This response rate is consistent with other studies that employed a similar design (Gonzalez et al., 2020). All participants were asked, Do you believe you are currently experiencing symptoms of burnout?, to which participants responded (a) yes or (b) no. Participants who responded yes were then prompted with the direction, Describe your symptoms of burnout, using an open-ended text box, which did not have a character limit. A total of 246 participants (43.9%) responded yes and qualitatively described their symptoms of burnout. On average, participants provided 30.31 words (SD = 36.30). We answered our research question for the current study using only the qualitative data, which aligns with the American Psychological Association’s Journal Article Reporting Standards for Qualitative Research (JARS-Qual; Levitt et al., 2018).
Data Analysis
To answer our research question, we analyzed participants’ open-ended responses using content analysis, which allows for systematic and contextualized review of text data (Krippendorff, 2013). As recommended by Krippendorff (2013), we followed the steps of conducting content analysis: unitizing, sampling, recording, and reducing. We first separated the responses of the 246 participants into discrete units. For example, “feeling exhausted and back pain” was coded as two units: (a) feeling exhausted and (b) back pain. This process resulted in a total of 1,205 discrete units. We reduced our data into categories using an inductive approach, which allowed for new categories to emerge from the data without an a priori theory (Krippendorff, 2013). Although there are multiple conceptualizations of burnout (Maslach & Jackson, 1981; S. M. Lee et al., 2007) that could have informed our analysis (i.e., deductive approach; Krippendorff, 2013), we chose an inductive approach to capture the conceptualization of burnout for novice professional counselors—generating categories based on participants’ explanations of their own symptoms of burnout (Kondracki et al., 2002).
To that end, we developed a codebook by randomly selecting roughly 10% of the discrete units to code as a pretest. Our first and third authors, Ryan M. Cook and Janelle L. Jones, independently reviewed the discrete units, met to discuss and develop categories and corresponding definitions, and coded the pretest data together to enhance reliability. This process yielded a codebook that consisted of 12 categories. Cook and Jones then used the codebook (categories and definitions) to independently code the remaining 90% of the data across three rounds (i.e., 30% increments). After each round, Cook and Jones met to discuss discrepancies and to reach consensus on the final codes. The overall agreement between Cook and Jones was 97% and the interrater reliability was acceptable (Krippendorff α = .80; Krippendorff, 2013), which was calculated using ReCal2 (Freelon, 2013). At the end of the coding process, Cook and Jones reviewed their notes for each code and further organized them into subcategories based on commonalities. The second author, Heather J. Fye, served as the auditor (see Researcher Trustworthiness section) and reviewed the entire coding process.
Researcher Trustworthiness
The research team consisted of four members, three counselor educators and one counselor education and supervision doctoral student. The first and third authors, Cook and Jones, served as coders, while the second author, Fye, served as the auditor and the fourth author, Eric R. Baltrinic, served as a qualitative consultant. The counseling experience of the four authors ranged from 4 to 18 years, and the supervision experience of the authors ranged from 3 to 9 years. Cook, Fye, and Baltrinic are licensed professional counselors and three of the authors are credentialed as either a National Certified Counselor or Approved Clinical Supervisor.
We all acknowledged our personal experiences of burnout to some degree as practicing counselors as well as observing the consequences of burnout to our students and supervisees. All members of the research team had prior experience studying counselor burnout. Although these collective experiences enriched our understanding of the subject matter, we also attempted to bracket our assumptions and biases throughout the research process. To increase the trustworthiness of the coding process, the auditor, Fye, reviewed the codebook, categories and subcategories, discreteness, and two coders’ notes coding process after the pretest and rounds of coding. Fye provided feedback on the category definitions, coding process, and coding decisions during the analysis process.
Results
Using an inductive approach, 12 categories and related subcategories emerged from the 1,205 discrete self-reported symptoms of burnout. Full results, including the 12 categories and subcategories, as well as the frequencies of the categories and subcategories, are presented in the Appendix. We discuss each category in detail and provide illustrative examples of each category using direct participant quotes (Levitt et al., 2018).
Negative Emotional Experience
Of the 1,205 coded units, 218 units (18.1%) were coded into the category negative emotional experience. This category reflected participants’ descriptions of experiencing negative feelings related to their work as counselors (e.g., anxiety, depression, irritability) or unwanted negative emotions (e.g., crying spells). This category included 15 subcategories, and the units coded into these subcategories reflected the participants’ descriptions of a wide range of negative feelings. For example, one participant reported she was “struggling to feel happy,” while another participant shared that she “is carrying a heavy burden [that] no one understands or is aware of.” Some participants also reported crying spells. One participant shared she “has fits of crying,” while another reported she “[cries] in the bathroom at work.”
Fatigue and Tiredness
The category fatigue and tiredness was coded 195 times (16.2%) and included four subcategories. This category captured participants’ descriptions of feeling exhausted, fatigued, or tired. Units coded into this category included the participants’ indications that they feel exhausted, despite sleeping well. For example, one participant described feeling perpetually exhausted—“nothing recharges my batteries”— while another participant stated that her fatigue worsened as the week progressed: “[I feel] more and more exhausted throughout the week.”
Unfulfilled in Counseling Work
The category unfulfilled in counseling work captured the participants’ descriptions of no longer deriving joy at work, dread in going to work or completing work-related responsibilities, or lacking motivation to do work. This category was coded 140 times (11.6%) and subcategories included five subcategories. Avoidance of burdensome administrative responsibilities (e.g., paperwork) were commonly reported units that were captured in this category. For example, a participant noted “putting off doing notes.” Units also captured in this category reflected participants’ self-report of no longer feeling motivated or deriving joy from their work, which ultimately led some participants to stop seeking training. For instance, a participant described herself as “going through the motions at work,” and another added that she was no longer “motivated to improve [her] skills.”
Unhealthy Work Environment
Across all coded units, 128 units (10.6%) were coded in the category unhealthy work environment, which included 15 subcategories. This category captured participants’ descriptions of their work environment that contribute to a counselor experiencing burnout. For example, units captured in this category commonly described participants’ reports of working long hours with few or no breaks throughout the day, and participants feeling pressured to take on additional clients. Some participants described managing large client caseloads or caseloads with “high risk or high needs” clients. The units reflecting participants’ perceived lack of supervisor support were also coded into this category. For example, a participant noted that she was “scared to make a mistake or ask questions about doing my job,” while another participant described a supervisor as not “supportive or trustworthy.” Finally, units that signaled participants’ feelings of being inadequately compensated were coded into this category, such as this participant’s response: “I do not get paid enough for the work that I do.”
Physical Symptoms
The category physical symptoms reflected participants’ descriptions of physical ailments, physical manifestations of burnout (e.g., soreness, pain), physical illnesses, or physical descriptors (e.g., weight gain, weight loss). There were 107 coded units (8.9%) that referenced physical symptoms. The seven subcategories captured in this category reflected a wide range of physical ailments. The most commonly coded units were participants’ descriptions of headaches, illnesses, and weight changes, although some less commonly coded units reflected more serious physical and medical issues. For example, a participant noted, “I have TMJ [temporomandibular joint dysfunction] pain most days from clenching my jaw,” while another participant stated that she “recently began to have debilitating stomach symptoms, which were identified as small ulcerations.”
Negative Impact on Personal Interest or Self-Care
Across all coded units, 101 units (8.4%) were coded in the category negative impact on personal interest or self-care, which included eight subcategories. This category reflected the participants’ descriptions of reduced self-care or inability to engage in self-perceived healthy behaviors (e.g., cannot fall asleep), or lacking personal interest. Units coded in this category most commonly reflected participants’ experience of sleep issues—difficulty either falling asleep or staying asleep. Other units reflected participants’ lessening desire to engage in once-enjoyable activities. For example, one participant noted, “I find myself knowing that I need more time for play, rest, recovery, socializing, and personal interests, but [I am] feeling confused about how to fit that in.” Another participant described her self-care as unconstructive: “It often feels like no amount of self-care is helpful, which makes it more difficult to engage in any self-care.”
Self-Perceived Ineffectiveness as a Counselor
We coded 127 units (10.5%) into the category self-perceived ineffectiveness as a counselor, which included six subcategories. This category reflected the participants’ descriptions of their self-perceived decrease in self-efficacy as a counselor, difficulty in developing or maintaining therapeutic relationships with clients, decreased empathy toward clients, or questioning of their own abilities as counselors (e.g., ability to facilitate change). For example, one participant noted that she did not “have as much empathy for clients as before,” while another participant expressed, “I often feel like clients are being demanding and trying to waste my time.” Units coded into this category also reflected participants’ feelings of inadequacy or struggles to develop a meaningful professional relationship with clients. One participant stated that she must “reach very deep every morning for the presence of mind and spirit to pay close attention and to care deeply for each of these people.” Although less frequently coded, some units described participants’ feelings of compassion satisfaction or self-reported secondary traumatic stress. For example, one participant shared that she was “personally disturbed” by her work.
Cognitive Impairment
Across all coded units, 75 units (6.2%) were coded in the category cognitive impairment, and this category included seven subcategories. The units coded into this category reflected the participants’ descriptions of their cognitive abilities being negatively impacted in different ways. For example, one participant described “feeling like I am in a fog at work,” while another participant shared that she found it “hard to concentrate at work.” Some units captured in this category reflected participants’ rumination of clients or work; for example, one participant noted “shifting my attention to ruminating about dropouts at times, when I need to be present with a [current] client.”
Negative Impact on Personal Relationships
The category negative impact on personal relationships captured 63 coded units (5.2%). Participants’ descriptions of strained relationships as a result of their self-reported burnout were coded into this category, which included three subcategories. For example, one participant described “not [feeling] available for emotional connects with others in my personal life,” while another participant said that they “lashed out sometimes at family members after a stressful day of work.” Another example of the negative impact on personal relationships was a participant’s description of “struggling to find joy at home with my wife and two kids.”
Negative Coping Strategies
We coded 22 units (1.8%) into the category negative coping strategies. This category included five subcategories that captured participants’ descriptions of using unhealthy or negative coping strategies to cope with burnout. Units coded into this category described participants’ use of a variety of negative coping strategies. For example, participants noted an increase in “alcohol consumption” or “smoking.” Relatedly, a participant expressed one of her coping strategies was “the excessive use of Netflix,” while another participant stated that she was “not eating or eating way too much.”
Questioning of One’s Career Choice
Units that reflected participants’ descriptions of the questioning of one’s career choice and potential or planned desire to leave the profession were coded into the category questioning of one’s career choice. There were 21 coded units (1.7%) for this category, which included two subcategories. An example of units coded into this category is a participant who stated that she has “thoughts that I have made a mistake in pursuing this line of work.” Another participant shared feelings of “wanting to quit [my] job.” Some units coded into this category captured participants who were already making plans to leave their jobs or the field. For example, one participant shared that she “recently put in [my] notice at agency,” while another participant stated plans to leave the profession “within one year.”
Psychological Distress
The least number of units were coded into the category psychological distress, which was coded eight times (0.7%) and included two subcategories. This category captured the participants’ discussions of a mental health diagnosis, which they attributed as a symptom of burnout, or suicidal ideations. For example, one participant shared, “I have been diagnosed with major depressive disorder and my job is a factor,” while another participant stated, “I sought therapy for myself and I had to increase my anti-depressant medication.” Finally, two participants endorsed experiencing suicidal ideations at some previous point related to their burnout.
Discussion
The content analysis yielded insights of self-reported burnout symptoms by capturing the phenomenon in novice professional counselors’ own words. Many of the 12 categories that emerged from the data generally aligned with prior conceptualizations of burnout for human service professionals (e.g., Maslach & Jackson, 1981) and counselors (S. M. Lee et al., 2007), while some categories provided novel insights into how burnout manifested in this sample. Further, we observed trends in common self-reported descriptors of burnout for novice professional counselors (negative emotional experiences) to the least commonly endorsed descriptors (psychological distress). We assert that these findings enrich the scholarly understanding of the burnout phenomenon in novice professional counselors.
Discussion of the Conceptual Framework of Burnout
Maslach and Jackson (1981) emphasized in their earlier work that exhaustion and fatigue are core features of burnout, and the category of fatigue and tiredness was the second most commonly coded category (16.2% of all coded units) in our study. Our findings reaffirm exhaustion (or fatigue or tiredness) as a central feature of burnout, and specifically self-reported symptoms of burnout in novice professional counselors. Scholars (e.g., Kristensen et al., 2005; Maslach & Jackson, 1981; Shirom & Melamed, 2006) have conceptualized that the interconnectedness between the emotional, physical, and psychological fatigue of burnout is different. Shirom and Melamed (2006) distinguished emotional, physical, and cognitive resources, while Kristensen et al. (2005) made no distinction between physical and psychological exhaustion. Stamm (2010) also viewed exhaustion as a feature of burnout but did not specify how this exhaustion manifested in human service professionals. In the current study, we chose to distinguish emotional, physical, and cognitive symptoms to best capture the participants’ experiences in their own words (Kondracki et al., 2002). However, we found supportive evidence that novice professional counselors’ burnout included emotional, physical, and cognitive symptoms. Our findings suggest that all three components should be examined to adequately capture this phenomenon.
The category negative emotional experience, which reflected participants’ reports of experiencing negative feelings associated with their work as counselors, was the most commonly endorsed symptom of burnout (18.1% of all coded units). In other models of burnout (e.g., Kristensen et al., 2005; Shirom & Melamed, 2006), feelings or emotions are most often conceptualized as emotional exhaustion, emotional fatigue, or emotional distress. However, the participants in the current study richly described their negative emotional experiences, as captured in the subcategories, with irritability, anxiety, depression, and stress being the most commonly endorsed negative emotions. These findings most closely align with Stamm’s (2010) conceptualization of burnout, which suggested that feelings of hopelessness, anger, frustration, and depression are evidence of burnout. Relatedly, a similar content analysis performed with eating disorder treatment professionals also found that their participants most frequently described emotional distress (61% of their sample, n = 94) as a way in which their worry for clients impacts their personal and professional lives (Warren et al., 2012). Scholars (e.g., Maslach & Leiter, 2016) have postulated about the relationship between workplace burnout and affectional distress (e.g., depression, anxiety, stress); however, such an investigation has yet to be conducted in the profession of counseling. Our findings suggest that novice professional counselors commonly describe their manifestation of burnout as an emotional experience, and as such, this represents a gap in the current conceptualization of counselor burnout.
Two other categories captured in the current study were physical symptoms and cognitive impairment symptoms. Physical symptoms were coded for 8.9% of the 1,205 units coded, while cognitive symptoms were coded for 6.1% of all coded units. In the existing burnout literature (e.g., Maslach & Jackson, 1981; Shirom & Melamed, 2006), physical symptoms of burnout often paralleled or referenced fatigue or exhaustion. For example, in Shirom and Melamed’s (2006) model, physical symptoms were reflective of feeling physically tired. However, in the current study, participants most commonly described their physical symptoms as back pain, illnesses, and headaches. This finding aligns with Kaeding et al. (2017), who found that counseling and clinical psychology trainees attributed their back and neck pain to sitting for long periods of time. We assert that specific physical symptoms may have been inadequately captured by the existing models of burnout.
Relatedly, Shirom and Melamed (2006) suggested that psychological fatigue or psychological manifestations of burnout should be distinguished from those of emotional and physical symptoms, while Kristensen et al. (2005) made no such distinctions. The participants in the current study described numerous cognitive manifestations of burnout, and the most commonly coded subcategories included concentration or focus, rumination, and forgetfulness. These self-reported symptoms closely align with the model of Shirom and Melamed, which describes psychological fatigue as an inability to think clearly and difficulty processing one’s own thoughts. Further, Kristensen et al. described one symptom of personal burnout as being at risk of becoming ill. However, no items of cognitive impairment or worsening cognitive abilities are included in the CBI. Informed by our findings, descriptors of cognitive impairment should be considered to understand burnout in novice professional counselors.
Two of the three dimensions of burnout as conceptualized by Maslach and Jackson (1981) were Depersonalization (i.e., cynicism or negative attitudes toward clients) and Decreased Personal Accomplishment (i.e., diminished fulfillment in one’s work or feeling ineffective in their work). These two dimensions are similar to Stamm’s (2010) conceptualization of burnout for human service professionals, which included the features of perceiving that one’s own work is unhelpful and no longer enjoying the work. In the current study, two of the categories that emerged closely aligned with these conceptualizations of burnout: unfulfilled in counseling work (11.6% of all coded units) and self-perceived ineffectiveness as a counselor (10.5% of all coded units). Collectively, these two categories and related subcategories provide rich descriptors of how novice professional counselors experience their own depersonalization and diminished personal accomplishment (Maslach & Jackson, 1981).
Our findings align with qualitative studies of novice professional counselors’ experiences (e.g., Freadling & Foss-Kelly, 2014; Rønnestad & Skovholt, 2013). For example, Freadling and Foss-Kelly (2014) found that novice professional counselors sometimes question if their graduate training adequately prepared them for their current positions. As such, questioning of one’s clinical abilities by counselors at this developmental level was also a common experience by participants in our study (Freadling & Foss-Kelly, 2014).
Our findings were consistent with the counselor-specific burnout model in which S. M. Lee et al. (2007) noted the importance of including the unique work environment of counselors and related impact on their personal life. Our findings support the burnout conceptualization with novice professional counselors. For example, participants in the current study described an unhealthy work environment (10.6% of all coded units). The most commonly coded subcategories included unsupportive employer or supervisor, frustrated with system, burdened by documentation, and overburdened by amount of work or multiple roles.
In terms of the impact of counseling work on their personal lives (S. M. Lee et al., 2007), evidence of this dimension was captured in the current study in two categories: negative impact on personal interest or self-care and negative impact on personal relationships. There is a high degree of interconnectedness between burnout and self-care (Maslach & Leiter, 2016; Warren et al., 2012). Thus, it is unsurprising that participants reported a decrease in their self-care; however, some of the specific self-care behaviors that are affected as a result of novice professional counselors experiencing burnout are less understood. In the current study, the most commonly coded subcategory was difficulty falling asleep or staying asleep, followed by lack of interest in hobbies, poor work/life balance, and general decrease in self-care. As defined in the CBI, lack of time for personal interest and poor work/life balance are both indicators of Deterioration in Personal Life. While sleep onset and maintenance issues are associated with burnout (Yang & Hayes, 2020), counselors’ experiences with sleep issues appears to be a novel finding. Another indicator of deterioration in counselors’ personal lives as theorized by S. M. Lee et al. was a lack of time to spend with friends, which was also observed in our study. Relatedly, some participants indicated that they isolated from their social support system. Other participants described strained personal relationships (i.e., conflict in personal relationships, poor emotional connection with others), which are unique findings.
Counselor Burnout Versus Counselor Impairment
Although uncommonly reported, some participants in the current study described using negative coping strategies (1.8% of all coded units) and psychological distress (0.7% of all coded units) as evidence of their self-reported burnout. Examples of negative coping strategies reported by participants included increased substance use (e.g., alcohol, caffeine, nicotine) and overeating or skipping meals, while examples of psychological distress included having received a psychological diagnosis and experiencing increased suicidal ideations, which participants attributed to burnout. These self-reported symptoms of burnout align more closely with the definition of counselor impairment (Lawson et al., 2007) as opposed to the definition of counselor burnout. Our findings are significant for two reasons. First, any study of counselor burnout that utilized one of the commonly used instruments of burnout (e.g., CBI, MBI) would have failed to capture these participants’ experiences. Second, these findings suggest that a small number of counselors may be experiencing significant impairment in their personal and professional lives, despite being early in their professional careers. Finally, another infrequently coded category was questioning of one’s career choice (1.7% of all coded units). Coded units in this category indicated that some counselors were wondering if counseling was a good professional fit for them, while others expressed their intention to seek employment in another profession. It is possible that prolonged disengagement from one’s professional work (i.e., cynicism; Maslach & Jackson, 1981) could result in counselors wanting to explore other career options.
Limitations
There are limitations of this study which we must address. The purpose of content analysis is not to generalize findings, so our findings may only reflect the experiences of burnout for the participants in the current study. Their experiences may be influenced by developmental levels, experiences in their specific state, or other reasons that we did not capture.
Another limitation is our response rate of 8.15%. A possible reason for our low response rate is self-selection bias—counselors who were currently experiencing burnout responded to the open-ended items as opposed to those who were not feeling burnout. Future research is needed to see how burnout presents in larger or different populations of counselors. It might also be important to study the career-sustaining behaviors and work environments of those counselors who did not endorse burnout. The final limitation is that this study was descriptive in nature. Future researchers are encouraged to explore the factors that may predict burnout while also considering the novel findings generated from this study.
Implications
Our findings offer implications for counseling researchers, counselors, and supervisors. Although many of the findings from the current study align with prior research, there appears to be some degree of discrepancy between how burnout is conceptualized by scholars and how novice professional counselors describe symptoms of burnout. We implore scholars to further examine the specific descriptors of burnout as reported by participants in this study and to see if the frequency of these self-reported symptoms can be duplicated. Specifically, scholars should focus on the emotional experience of novice professional counselors, fatigue and tiredness, and feeling unfulfilled in their work, which were the most commonly reported symptoms. It also seems critically important to explore the less commonly reported descriptors of burnout, like negative coping strategies, questioning of one’s career choice, and psychological distress. Each of these categories could signal counselor impairment and would have been otherwise missed by scholars who relied exclusively on existing Likert-type burnout inventories.
Novice professional counselors sometimes experience self-doubt about their counseling skills or even the profession (Rønnestad & Skovholt, 2013), given the difficult work conditions in which these counselors practice (e.g., low wages, long hours; Freadling & Foss-Kelly, 2014). Novice professional counselors should understand that experiences of burnout appear to be commonly occurring. The illumination of these descriptors may encourage other novice professional counselors to seek guidance from their supervisors on how best to manage these feelings. For those novice professional counselors who are experiencing more serious personal and professional issues associated with burnout (e.g., using negative coping strategies and psychological distress), they should consider whether they are presently able to provide counseling services to clients and seek consultation from a supervisor (ACA, 2014).
Our findings have implications for supervisors. For example, supervisors should be willing to openly discuss burnout with their supervisees. Our results can provide supervisors with descriptors that capture novice professional counselors’ experiences of burnout. Supervisors might find it helpful to disclose some of their own experiences of burnout (or mitigating burnout) with their supervisees, which can normalize the supervisees’ experiences (Knox et al., 2011). Finally, to the extent that supervisors are able, they should protect novice professional counselors from experiencing an unhealthy work environment or potentially harmful behaviors. For example, in response to supervisees’ self-reported symptoms of burnout, supervisors could limit caseloads, allow counselors time to complete documentation, or mandate regular breaks throughout the day (including lunchtime).
Conclusion
There are many novice professional counselors experiencing a wide range of symptoms of burnout. A career in counseling can be rewarding, but prolonged burnout can lead to both personal and professional consequences, as evidenced by the findings from this study. Counselors must attend to their own symptoms of burnout in order to provide quality care to their clients and lead a fulfilling personal life. Supervisors and educators can support these counselors by discussing the experiences of burnout, and future scholars can better understand the experiences of counselor burnout by studying the phenomenon using definitions and symptoms in the words of counselors as opposed to generic definitions.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Ryan M. Cook, PhD, ACS, LPC, is an assistant professor at the University of Alabama. Heather J. Fye, PhD, NCC, LPC, is an assistant professor at the University of Alabama. Janelle L. Jones, MS, NCC, is a doctoral student at the University of Alabama. Eric R. Baltrinic, PhD, LPCC-S (OH), is an assistant professor at the University of Alabama. Correspondence may be addressed to Ryan M. Cook, 310A Graves Hall, Box 870231, Tuscaloosa, AL 35475, rmcook@ua.edu.
Feb 26, 2021 | Volume 11 - Issue 1
Priscilla Rose Prasath, Peter C. Mather, Christine Suniti Bhat, Justine K. James
This study examined the relationships between psychological capital (PsyCap), coping strategies, and well-being among 609 university students using self-report measures. Results revealed that well-being was significantly lower during COVID-19 compared to before the onset of the pandemic. Multiple linear regression analyses indicated that PsyCap predicted well-being, and structural equation modeling demonstrated the mediating role of coping strategies between PsyCap and well-being. Prior to COVID-19, the PsyCap dimensions of optimism and self-efficacy were significant predictors of well-being. During the pandemic, optimism, hope, and resiliency have been significant predictors of well-being. Adaptive coping strategies were also conducive to well-being. Implications and recommendations for psychoeducation and counseling interventions to promote PsyCap and adaptive coping strategies in university students are presented.
Keywords: university students, psychological capital, well-being, coping strategies, COVID-19
In January 2020, the World Health Organization declared the outbreak of a new coronavirus disease, COVID-19, to be a public health emergency of international concern, and the effects continue to be widespread and ongoing. For university students, the pandemic brought about disruptions to life as they knew it. For example, students had to stay home, adapt to online learning, modify internship placements, and/or reconsider graduation plans and jobs. The aim of this study was to understand how the sudden changes and uncertainty resulting from the pandemic affected the well-being of university students during the early period of the pandemic. Specifically, the study addresses coping strategies and psychological capital (PsyCap; F. Luthans et al., 2007) and how they relate to levels of well-being.
University Students and Mental Health
Although mental health distress has been an issue on college campuses prior to the pandemic (Flatt, 2013; Lipson et al., 2019), COVID-19 has and will continue to magnify this phenomenon. Experts are projecting increases in depression, anxiety, post-traumatic stress disorder, and suicide in the United States (Wan, 2020). Johnson (2020) indicated that 35% of students reported increased anxiety associated with a move from face-to-face to online learning in the spring 2020 semester, matching the early phases of the COVID-19 outbreak. Stress associated with adapting to online learning presented particular challenges for students who did not have adequate internet access in their homes (Hoover, 2020).
Researchers have reported that high levels of technology and social media use are associated with depression and anxiety among adolescents and young adults (Huckins et al., 2020; Primack et al., 2017; Twenge, 2017). Given the current realities of physical distancing, there are fewer opportunities for traditional-age university students attending primarily residential campuses to maintain social connections, resulting in social fragmentation and isolation. Research has demonstrated that this exacerbates existing mental health concerns among university students (Klussman et al., 2020).
The uncertainties arising from COVID-19 have added to anticipatory anxiety regarding the future (Ray, 2019; Witters & Harter, 2020). From the Great Depression to 9/11 and Hurricane Katrina, victims of these life-shattering events have had to deal with their present circumstances and were also left with worries about how life and society would be inexorably altered in the future. University students are dealing with uncertain current realities and futures and may need to bolster their internal resources to face the challenges ahead. In this context, positive coping strategies and PsyCap may be increasingly valuable assets for university students to address the psychological challenges associated with this pandemic and to maintain or enhance their well-being.
Coping Strategies
Coping is often defined as “efforts to prevent or diminish the threat, harm, and loss, or to reduce associated distress” (Carver & Connor-Smith, 2010, p. 685). There are many ways to categorize coping responses (e.g., engagement coping and disengagement coping, problem-focused coping and emotion-focused coping, accommodative coping and meaning-focused coping, proactive coping). Engagement coping includes problem-focused coping and some forms of emotion-focused coping, such as support seeking, emotion regulation, acceptance, and cognitive restructuring. Disengagement coping includes responses such as avoidance, denial, and wishful thinking, as well as aspects of emotion-focused coping, because it involves an attempt to escape feelings of distress (Carver & Connor-Smith, 2010; de la Fuente et al., 2020). Findings on the effectiveness of problem-focused coping strategies versus emotion-focused coping strategies suggest the effectiveness of the particular strategy is contingent on the context, with controllable issues being better addressed through problem-focused strategies, while emotion-focused strategies are more effective with circumstances that cannot be controlled (Finkelstein-Fox & Park, 2019). In general, problem-focused coping strategies, also known as adaptive coping strategies, include planning, active coping, positive reframing, acceptance, and humor (Carver & Connor-Smith, 2010). Other coping strategies, such as denial, self-blame, distraction, and substance use, are more often associated with negative emotions, such as shame, guilt, lower perception of self-efficacy, and psychological distress, rather than making efforts to remediate them (Billings & Moos, 1984). These strategies can be harmful and unhealthy with regard to effectively coping with stressors. Researchers have recommended coping skills training for university students to modify maladaptive coping strategies and enhance pre-existing adaptive coping styles to optimal levels (Madhyastha et al., 2014).
Flourishing: The PERMA Well-Being Model
Positive psychologists have asserted that studies of wellness and flourishing are important in understanding adaptive behaviors and the potential for growth from challenging circumstances (Joseph & Linley, 2008; Seligman, 2011). Flourishing (or well-being) is defined as “a dynamic optimal state of psychosocial functioning that arises from functioning well across multiple psychosocial domains” (Butler & Kern, 2016, p. 2). Seligman (2011) proposed a theory of well-being stipulating that well-being was not simply the absence of mental illness (Keyes, 2002), but also the presence of five pillars with the acronym of PERMA (Seligman, 2002, 2011). The first pillar, positive emotion (P), is the affective component comprising the feelings of joy, hope, pleasure, rapture, happiness, and contentment. Next are engagement (E), the act of being highly interested, absorbed, or focused in daily life activities, and relationships (R), the feelings of being cared about by others and authentically and securely connected to others. The final two pillars are meaning (M), a sense of purpose in life that is derived from something greater than oneself, and accomplishment (A), a persistent drive that helps one progress toward personal goals and provides one with a sense of achievement in life. Seligman’s (2011) PERMA model is one of the most highly regarded models of well-being.
Seligman’s multidimensional model integrates both hedonic and eudaimonic views of well-being, and each of the well-being components is seen to have the following three properties: (a) it contributes to well-being, (b) it is pursued for its own sake, and (c) it is defined and measured independently from the other components (Seligman, 2011). Studies show that all five pillars of well-being in the PERMA model are associated with better academic outcomes in students, such as improved college life adjustment, achievement, and overall life satisfaction (Butler & Kern, 2016; DeWitz et al., 2009; Tansey et al., 2018). Additionally, each pillar of PERMA has been shown to be positively associated with physical health, optimal well-being, and life satisfaction and negatively correlated with depression, fatigue, anxiety, perceived stress, loneliness, and negative emotion (Butler & Kern, 2016). At a time of significant stress, promoting the highest human performance and adaptation not only helps with well-being in the midst of the challenge but also can provide a foundation for future potential for optimal well-being (Joseph & Linley, 2008).
Psychological Capital (PsyCap)
PsyCap is a state-like construct that consists of four dimensions: hope (H), self-efficacy (E), resilience (R), and optimism (O), often referred to by the acronym HERO (F. Luthans et al., 2007). F. Luthans et al. (2007) developed PsyCap from research in positive organizational behavior and positive psychology. PsyCap is defined as an
individual’s positive psychological state of development characterized by (1) having confidence (self-efficacy) to take on and put in the necessary effort to succeed at challenging tasks; (2) making a positive attribution (optimism) about succeeding now and in the future; (3) persevering toward goals and, when necessary, redirecting paths to goals (hope) in order to succeed; and (4) when beset by problems and adversity, sustaining and bouncing back and even beyond (resilience) to attain success. (F. Luthans et al., 2015, p. 2)
Over the past decade, PsyCap has been applied to university student development and mental health. There is robust empirical support suggesting that individuals with higher PsyCap have higher levels of performance (job and academic); satisfaction; engagement; attitudinal, behavioral, and relational outcomes; and physical and psychological health and well-being outcomes. Further, they have negative associations with stress, burnout, negative health outcomes, and undesirable behaviors at the individual, team, and organizational levels (Avey, Reichard, et al., 2011; Newman et al., 2014). Researchers have also examined the mediating role of PsyCap in the relationship between positive emotion and academic performance (Carmona-Halty et al., 2019; Hazan Liran & Miller, 2019; B. C. Luthans et al., 2012; K. W. Luthans et al., 2016); relationships and predictions between PsyCap and mental health in university students (Selvaraj & Bhat, 2018); and relationships between PsyCap, well-being, and coping (Rabenu et al., 2017).
Aim of the Study and Research Questions
The aim of the current study was to examine the relationships among well-being in university students before and during the onset of COVID-19 with PsyCap and coping strategies. The following research questions guided our work:
- Is there a significant difference in the well-being of university students prior to the onset of COVID-19 (reported retrospectively) and after the onset of COVID-19?
- What is the predictive relationship of PsyCap on well-being prior to the onset of COVID-19 and after the onset of COVID-19?
- Do coping strategies play a mediating role in the relationship between PsyCap and well-being?
Method
Participants
A total of 806 university students from the United States participated in the study. After cleaning the data, 197 surveys were excluded from the data analyses. Of the final 609 participants, 73.7% (n = 449) identified as female, 22% (n = 139) identified as male, and 4.3% (n = 26) identified as non-binary. The age of participants ranged from 18 to 66 (M = 27.36, SD = 9.9). Regarding race/ethnicity, most participants identified as Caucasian (83.6%, n = 509), while the remaining participants identified as African American (5.3%, n = 32), Hispanic or Latina/o (9.5%, n = 58), American Indian (0.8%, n = 5), Asian (3.6%, n = 22), or Other (2.7%, n = 17). Fifty-four percent of the participants were undergraduate students (n = 326), and the remaining 46% were graduate students (n = 283). The majority of the participants were full time students (82%, n = 498) compared to part-time students (18%, n = 111). Sixty-three percent of the students were employed (n = 384) and the remaining 37% were unemployed (n = 225).
Data Collection Procedures
After a thorough review of the literature, three standardized measures were identified for use in the study along with a brief survey for demographic information. Instruments utilized in the study measured psychological capital (Psychological Capital Questionnaire [PCQ-12]; Avey, Avolio et al., 2011), coping (Brief COPE; Carver, 1997), and well-being (PERMA-Profiler; Butler & Kern, 2016). Data were collected online in May and June 2020 using Qualtrics after obtaining approval from the IRBs of our respective universities. An invitation to participate, which included a link to an informed consent form and the survey, was distributed to all university students at two large U.S. public institutions in the Midwest and the South via campus-wide electronic mailing lists. The survey link was also distributed via a national counselor education listserv, and it was shared on the authors’ social media platforms. Participants were asked to complete the well-being assessment twice—first, by responding as they recalled their well-being prior to COVID-19, and second, by responding as they reflected on their well-being during the pandemic.
Instruments
Demographic Questionnaire
A brief questionnaire was used to capture participant information. The questionnaire included items related to age, gender, race/ethnicity, relationship status, education classification, and employment status.
Psychological Capital Questionnaire – Short Version (PCQ-12)
The PCQ-12 (Avey, Avolio et al., 2011), the shortened version of PCQ-24 (F. Luthans et al., 2007), consists of 12 items that measure four HERO dimensions: hope (four items), self-efficacy (three items), resilience (three items), and optimism (two items), together forming the construct of psychological capital (PsyCap). The PCQ-12 utilizes a 6-point Likert scale with response options ranging from strongly disagree to strongly agree. Cronbach’s alpha coefficients as a measure of internal consistency of the HERO subscales in the current study were high—hope (α = .86), self-efficacy (α = .86), resilience (α = .73), and optimism (α = .83)—consistent with the previous studies.
Brief COPE Questionnaire
Coping strategies were evaluated using the Brief COPE questionnaire (Carver, 1997), which is a short form (28 items) of the original COPE inventory (Carver et al., 1989). The Brief COPE is a multidimensional inventory used to assess the different ways in which people generally respond to stressful situations. This instrument is used widely in studies with university students (e.g., Madhyastha et al., 2014; Miyazaki et al., 2008). Fourteen conceptually differentiable coping strategies are measured by the Brief COPE (Carver, 1997): active coping, planning, using emotional support, using instrumental support, venting, positive reframing, acceptance, denial, self-blame, humor, religion, self-distraction, substance use, and behavioral disengagement. The 14 subscales may be broadly classified into two types of responses—“adaptive” and “problematic” (Carver, 1997, p. 98). Each subscale is measured by two items and is assessed on a 5-point Likert scale. Thus, in general, internal consistency reliability coefficients tend to be relatively smaller (α = .5 to .9).
PERMA-Profiler
The PERMA-Profiler (Butler & Kern, 2016) is a 23-item self-report measure that assesses the level of well-being across five well-being domains (i.e., positive emotion, engagement, relationships, meaning, accomplishment) and additional subscales that measure negative emotion, loneliness, and physical health. Each item is rated on an 11-point scale ranging from never (0) to always (10), or not at all (0) to completely (10). The five pillars of well-being are defined and measured separately but are correlated constructs that together are considered to result in flourishing (Seligman, 2011). A single overall flourishing score provides a global indication of well-being, and at the same time, the domain-specific PERMA scores provide meaningful and practical benefits with regard to the possibility of targeted interventions. The measure demonstrates acceptable reliability, cross-time stability, and evidence for convergent and divergent validity (Butler & Kern, 2016). For the present study, reliability scores were high for four pillars—positive emotion (α = .88), relationships (α = .83), meaning (α = .89), accomplishment (α = .82); high for the subscales of negative emotion (α = .73) and physical health (α = .85); and moderate for the pillar of engagement (α = .65). The overall reliability coefficient of well-being items is very high (α = .94).
Data Analysis Procedure
The data were screened and analyzed using Statistical Package for the Social Sciences (SPSS, v25). Changes in PERMA elements were calculated by subtracting PERMA scores reported retrospectively by participants before the pandemic from scores reported at the time of data collection during COVID-19, and a repeated-measures ANOVA was conducted to examine the difference. Point-biserial correlation and Pearson product moment correlation coefficients were calculated to examine the relationships of demographic variables, PsyCap, and coping strategies with change in PERMA scores. Multivariate multiple regression was carried out to understand the predictive role of PsyCap on PERMA at two time points (before and during COVID-19). Structural equation modeling in Analysis of Moment Structures (AMOS, v23) software was used to test the mediating role of coping strategies on the relationship between PsyCap and change in PERMA scores. Mediation models were carried out with bootstrapping procedure with a 95% confidence interval.
Results
Prior to exploring the role of PsyCap and coping strategies on change in well-being due to COVID-19, an initial analysis was conducted to understand the characteristics and relationships of constructs in the study. Correlation analyses (see Table 1) revealed significant and positive correlations between four PsyCap HERO dimensions (i.e., hope, self-efficacy, resilience, and optimism; Avey, Avolio et al., 2011) and the six PERMA elements (i.e., positive emotion, engagement, relationships, meaning, accomplishment, and physical health; Butler & Kern, 2016). Further, PsyCap HERO dimensions were negatively correlated to negative emotion and loneliness. Age was positively correlated with change in PERMA elements, but not gender. Similarly, approach coping strategies such as active coping, positive reframing, and acceptance (Carver, 1997) were resilient strategies to handle pandemic stress whereas using emotional support and planning showed weaker but significant roles. Similarly, religion also tended to be an adaptive coping strategy during the pandemic. Behavioral disengagement and self-blame (Carver, 1997) were found to be the dominant avoidant coping strategies that were adopted by students, which led to a significant decrease in well-being during the pandemic. Overall, as seen in Table 1, all three variables studied—PsyCap HERO dimensions, eight PERMA elements, and coping strategies—were highly related.
Table 1
Relationship of Demographic Factors, Psychological Capital, and Coping Strategies With Change in PERMA Elements
| Variables |
Mean |
SD |
P |
E |
R |
M |
A |
N |
H |
L |
| Age |
27.36 |
9.91 |
.15** |
.11** |
.14** |
.16** |
.14** |
.01 |
.03 |
-.17** |
| Course Ф |
– |
– |
.19** |
.10* |
.19** |
.16** |
.06 |
-.05 |
.09* |
-.14** |
| Nature of course Ф |
– |
– |
.06 |
.06 |
.12** |
.13** |
.09* |
.03 |
.03 |
-.10** |
| Gender Ф |
– |
– |
-.01 |
-.06 |
.01 |
-.02 |
-.02 |
.02 |
-.02 |
.03 |
| Employment Ф |
– |
– |
-.17** |
-.11** |
-.13** |
-.19** |
-.10* |
.04 |
-.11** |
.11** |
| Self-Efficacy |
13.80 |
3.21 |
.11** |
.13** |
.14** |
.18** |
.16** |
-.05 |
.15** |
-.03 |
| Hope |
18.68 |
3.92 |
.24** |
.26** |
.20** |
.34** |
.40** |
-.17** |
.21** |
-.10* |
| Resilience |
13.41 |
3.08 |
.23** |
.22** |
.20** |
.32** |
.33** |
-.16** |
.15** |
-.13** |
| Optimism |
8.61 |
2.39 |
.21** |
.27** |
.23** |
.32** |
.30** |
-.11** |
.16** |
-.10* |
| Self-Distraction |
6.32 |
1.41 |
-.09* |
.01 |
.03 |
-.02 |
.01 |
.08* |
.02 |
.11** |
| Active Coping |
5.83 |
2.01 |
.24** |
.28** |
.20** |
.28** |
.32** |
-.09* |
.23** |
-.08* |
| Denial |
2.96 |
1.42 |
-.19** |
-.14** |
-.18** |
-.16** |
-.16** |
.24** |
-.16** |
.12** |
| Substance Use |
3.60 |
2.02 |
-.18** |
-.15** |
-.15** |
-.20** |
-.20** |
.11** |
-.09* |
.17** |
| Using Emotional Support |
5.07 |
1.81 |
.12** |
.11** |
.32** |
.18** |
.11** |
.04 |
.10* |
-.02 |
| Using Instrumental Support |
4.35 |
1.70 |
.01 |
.04 |
.20** |
.07 |
.02 |
.10* |
.04 |
.07 |
| Behavioral Disengagement |
3.96 |
2.11 |
-.43** |
-.37** |
-.40** |
-.46** |
-.44** |
.31** |
-.26** |
.27** |
| Venting |
4.58 |
1.54 |
-.24** |
-.16** |
-.08* |
-.17** |
-.16** |
.29** |
-.09* |
.16** |
| Positive Reframing |
5.12 |
1.78 |
.28** |
.27** |
.21** |
.26** |
.25** |
-.15** |
.18** |
-.14** |
| Planning |
5.42 |
1.75 |
.07 |
.12** |
.11** |
.13** |
.11** |
.08 |
.08* |
-.04 |
| Humor |
4.93 |
2.00 |
-.02 |
-.02 |
-.02 |
-.04 |
-.06 |
-.02 |
.02 |
.05 |
| Acceptance |
6.47 |
1.43 |
.33** |
.27** |
.27** |
.34** |
.31** |
-.25** |
.21** |
-.15** |
| Religion |
3.93 |
2.03 |
.21** |
.16** |
.16** |
.22** |
.13** |
-.08 |
.15** |
-.05 |
| Self-Blame |
4.08 |
1.72 |
-.33** |
-.27** |
-.29** |
-.36** |
-.36** |
.29** |
-.22** |
.20** |
Note. P = Positive Emotion, E = Engagement, R = Relationships, M = Meaning, A = Accomplishment, N = Negative Emotion, H = Physical Health, L = Loneliness.
Ф Point-biserial correlation
* p < .05, ** p < .01
Research Question 1
Results of a repeated-measures ANOVA presented in Figure 1 indicate that mean scores of PERMA decreased significantly during COVID-19: λ = .620; F (5,604) = 73.99, p < .001. Partial eta squared was reported as the measure of effect size. The effect size of the change in well-being for PERMA elements was 38%, ηp2 = .380, a high effect size (Cohen, 1988). As expected, negative emotion and loneliness significantly increased during the period of COVID-19, impacting overall well-being in an adverse manner. The average scores of negative emotion and loneliness increased from 4.46 and 3.86 to 5.85 and 5.94, respectively. Physical health significantly reduced from 6.58 to 5.91. The effect size of the change in the scores of individual PERMA elements ranged between 12.1% and 32.5%. Among the PERMA elements, engagement and physical health were least impacted by COVID-19, whereas students’ experiences of positive emotion and negative emotion were the factors that were largely affected.
Figure 1
Changes in the PERMA Prior to the Onset of COVID-19 and After the Onset of COVID-19
Note. P = Positive Emotion, E = Engagement, R = Relationships, M = Meaning, A = Accomplishment, N = Negative Emotion, H = Physical Health, L = Loneliness.
Research Question 2
The predictive role of PsyCap on well-being at two time points (before and after the onset of COVID-19) was analyzed using multivariate multiple regression (see Table 2). Coefficients of determination for models predicting well-being from PsyCap dimensions ranged from 4% to 28%. Before the onset of COVID-19, 23% of the variance in well-being was explained by the PsyCap dimensions (R2 = .23, p < .001), with self-efficacy and optimism as the most significant predictors of well-being. However, during the pandemic, the covariance of the PsyCap dimensions with well-being increased to 39% (R2 = .39, p < .01). Interestingly, after the onset of the pandemic, the predictor role of certain PsyCap dimensions shifted. For example, optimism became the strongest predictor of overall well-being and hope emerged as a predictor of engagement, meaning, accomplishment, and physical health during the pandemic. The predictive role of hope was negligible before COVID-19. The predictive role of resilience on positive emotion, accomplishment, negative emotion, and loneliness also became significant during COVID-19. Self-efficacy was a consistent predictor of PERMA elements before COVID-19. But during COVID-19, the relevance of self-efficacy in predicting PERMA elements was limited to controllable factors—relationships, meaning, and physical health—and the predictive role of self-efficacy overall was no longer significant (see Table 2).
Table 2
Predicting PERMA Elements From Psychological Capital Prior to the Onset of COVID-19 and After the Onset of COVID-19
|
PERMA |
Self-Efficacy |
Hope |
Resilience |
Optimism |
Adj. R2 |
F |
| Before COVID-19 |
|
|
|
|
|
|
|
Positive Emotion |
.10* |
-.06 |
-.01 |
.44** |
.19 |
37.66** |
| Engagement |
.10* |
.06 |
.01 |
.11* |
.05 |
8.80** |
| Relationships |
.10* |
.07 |
-.09 |
.29** |
.12 |
21.33** |
| Meaning |
.21** |
.06 |
-.03 |
.38** |
.28 |
58.68** |
| Accomplishment |
.24** |
.06 |
.04 |
.13* |
.14 |
25.62** |
| Negative Emotion |
-.13** |
.10 |
-.05 |
-.29** |
.11 |
18.97** |
| Physical Health |
.16** |
.08 |
-.04 |
.12* |
.07 |
12.16** |
| Loneliness |
-.10* |
0 |
-.01 |
-.19** |
.04 |
7.36** |
| Well-Being |
.19** |
.04 |
-.02 |
.35** |
.23 |
45.41** |
| During COVID-19 |
|
|
|
|
|
|
|
Positive Emotion |
.04 |
.09 |
.10* |
.41** |
.30 |
67.05** |
| Engagement |
.02 |
.21** |
.05 |
.26** |
.21 |
40.86** |
| Relationships |
.09* |
.1 |
-.01 |
.33** |
.19 |
36.72** |
| Meaning |
.11** |
.18** |
.09 |
.38** |
.39 |
99.93** |
| Accomplishment |
.05 |
.37** |
.14** |
.17** |
.39 |
96.96** |
| Negative Emotion |
-.03 |
-.07 |
-.13* |
-.23** |
.14 |
26.80** |
| Physical Health |
.16** |
.19** |
-.03 |
.14** |
.15 |
27.25** |
| Loneliness |
-.04 |
.01 |
-.11* |
-.20** |
.08 |
13.34** |
| Well-Being |
.07 |
.22** |
.08 |
.37** |
.39 |
97.48** |
* p < .05, ** p < .01
Research Question 3
Structural equation modeling was used to examine whether coping strategies mediate PsyCap’s effect on well-being. Coping strategies that predicted change in PERMA were used for mediation analysis. Indirect effects describing pathways from PsyCap factors to PERMA factors through identified coping strategies were tested for mediating roles. Results indicated that PsyCap affected well-being both directly and indirectly through coping strategies. Optimism had a significant indirect effect on change in well-being compared to hope and resilience (see Table 3). Among adaptive coping strategies, active coping, positive reframing, and using emotional support mediated the relationship between optimism and overall well-being. Interestingly, using emotional support also showed a similar mediating link between resilience and PERMA, but not for the factors of loneliness and negative emotion. On the other hand, self-blame and behavioral disengagement were two problematic coping strategies that mediated the relationship between optimism and all PERMA elements. Specifically, we found coping through self-blame playing a mediating role between PERMA factors and two of the HERO dimensions—resilience and hope.
Table 3
Indirect Effect of Psychological Capital on PERMA Factors Through Coping Strategies (Mediators)
| PsyCap |
Standardized Beta (ß, Indirect effect) |
| L |
H |
N |
A |
M |
R |
E |
P |
| Active Coping Ф |
|
|
|
|
|
|
|
|
Optimism |
-.016* |
.043** |
-.017* |
.06** |
.052** |
.037** |
.052** |
.044** |
|
Resilience |
-.005 |
.014 |
-.006 |
.02 |
.017 |
.012 |
.017 |
.015 |
|
Hope |
-.007 |
.018 |
-.007 |
.025 |
.022 |
.015 |
.022 |
.018 |
|
Self-Efficacy |
-.009 |
.025 |
-.01 |
.034 |
.03 |
.021 |
.03 |
.025 |
| Positive Reframing Ф |
|
|
|
|
|
|
|
|
|
Optimism |
-.047** |
.06** |
-.05** |
.085** |
.088** |
.07** |
.094** |
.096** |
|
Resilience |
-.005 |
.007 |
-.006 |
.01 |
.01 |
.008 |
.011 |
.011 |
|
Hope |
.003 |
-.003 |
.003 |
-.005 |
-.005 |
-.004 |
-.005 |
-.005 |
|
Self-Efficacy |
-.005 |
.006 |
-.005 |
.009 |
.009 |
.007 |
.01 |
.01 |
| Using Emotional Support Ф |
|
|
|
|
|
|
|
|
Optimism |
-.007 |
.02* |
.012 |
.03* |
.049** |
.086** |
.029* |
.032** |
|
Resilience |
.003 |
-.012 |
-.005 |
-.013* |
-.021* |
-.037* |
-.012* |
-.014* |
|
Hope |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
|
Self-Efficacy |
-.001 |
.006 |
.002 |
.006 |
.01 |
.018 |
.006 |
.007 |
| Self-Blame Ф |
|
|
|
|
|
|
|
|
|
Optimism |
-.038** |
.043** |
-.056** |
.07** |
.07** |
.056** |
.054** |
.065** |
|
Resilience |
-.03** |
.034** |
-.044** |
.055** |
.055** |
.044** |
.042** |
.051** |
|
Hope |
-.023* |
.025* |
-.033* |
.042* |
.041* |
.033* |
.032* |
.038** |
|
Self-Efficacy |
-.005 |
.006 |
-.007 |
.009 |
.009 |
.007 |
.007 |
.008 |
| Behavioral Disengagement Ф |
|
|
|
|
|
|
|
Optimism |
-.07** |
.067** |
-.081** |
.113** |
.118** |
.104** |
.097** |
.112** |
|
Resilience |
-.02 |
.02 |
-.023 |
.033 |
.034 |
.03 |
.028 |
.033 |
|
Hope |
-.032 |
.03 |
-.036 |
.051 |
.053 |
.047 |
.044 |
.051 |
|
Self-Efficacy |
-.009 |
.009 |
-.011 |
.015 |
.016 |
.014 |
.013 |
.015 |
Note. Coping strategies with insignificant mediating role are not included in the table. P = Positive Emotion,
E = Engagement, R = Relationships, M = Meaning, A = Accomplishment, N = Negative Emotion, H = Physical Health,
L = Loneliness.
Ф Mediator coping strategies.
* p < .05, ** p < .01
Discussion
The current study investigated the PERMA model of well-being (Seligman, 2011) with university students before and during the COVID-19 pandemic, as well as the relationships between PsyCap (F. Luthans et al., 2007), coping strategies, and well-being of university students. We examined whether the COVID-19 context shaped the efficacy of particular strategies to promote well-being. Findings are discussed in three areas: reduction in well-being related to COVID-19, shift in predictive roles of PsyCap HERO dimensions, and coping strategies as a mediator.
Reduction in Well-Being Related to COVID-19
Well-being scores across all PERMA elements, including physical health, were lower than those reported retrospectively prior to the pandemic. Such a decline in well-being following a pandemic is consistent with previous occurrences of public health crises or natural disasters (Deaton, 2012). Participants reported higher levels of negative emotion and loneliness after the onset of COVID-19, and a decrease in positive emotion. It is this balance of positive and negative emotions that contributes to life satisfaction (Diener & Larsen, 1993), and our findings support the notion that fostering particular positive psychological states (PsyCap), as well as engaging in related coping strategies, promotes well-being in the context of this large-scale crisis.
Shift in Predictive Roles of PsyCap HERO Dimensions
Consistent with prior research (Avey, Reichard et al., 2011; F. Luthans & Youssef-Morgan, 2017; Youssef-Morgan & Luthans, 2015), we found that PsyCap predicted well-being. PsyCap’s positive psychological resources (HERO dimensions) may enable students to have a “positive appraisal of circumstances” (F. Luthans et al., 2007, p. 550) by providing mechanisms for reframing and reinterpreting potentially negative or neutral situations. There was however an interesting shift in the predictive role of PsyCap dimensions before and after the onset of COVID-19. Prior to COVID-19, self-efficacy and optimism were the two major psychological resources that predicted university student well-being. However, after COVID-19, self-efficacy did not present as a predictor of well-being in this study. Although the reason for this result is uncertain, it is conceivable that attending to an uncertain future (i.e., hope) and recovering from immediate losses (i.e., resilience) became more salient, and one’s self-efficacy in managing normal, everyday challenges receded in importance. Indeed, optimism and hope each uniquely predict a major proportion of variance of the change in well-being and may together help students to face an uncertain future (M. W. Gallagher & Lopez, 2009). Resilience, the ability to recover from setbacks when pathways are blocked (Masten, 2001), had a predictive role on positive emotion and accomplishment in this study.
Coping Strategies as a Mediator
While PsyCap directly relates to well-being and coping strategies relate to well-being, our findings indicated that coping strategies also played a significant mediating role in the relationship between PsyCap and well-being. Specifically, adaptive coping strategies played a significant role in enhancing the positive effects of PsyCap on well-being. Adaptive coping strategies—such as active coping, acceptance, using emotional support, and positive reframing—were found to better aid in predicting well-being. In this study, accepting the realities, using alternative affirmative explanations, seeking social support for meeting emotional needs, and engaging in active problem-focused coping behaviors seem to be the most helpful ways to counter the negative effects of the pandemic on well-being. Conversely, when individuals employed problematic coping strategies such as behavioral disengagement and self-blame (Carver, 1997), the negative impacts were much stronger than the positive effect of adaptive coping strategies.
Implications for Counselors
Given findings of the relationship between PsyCap and well-being in the current study, as well as in prior research (F. Luthans et al., 2006; F. Luthans et al., 2015; McGonigal, 2015), counselors may wish to focus on developing PsyCap to help university students flourish both during the pandemic and in a post-pandemic world. Two significant challenges to counseling professionals on college campuses are the lack of resources to adequately respond to mental health concerns among students and the stigma associated with accessing services (R. P. Gallagher, 2014; Michaels et al., 2015). Thus, efficient interventions that are not likely to trigger stigma responses are helpful in this context. Several researchers have found that relatively short training in PsyCap interventions, including web-based platforms (Dello Russo & Stoykova, 2015; Demerouti et al., 2011; Ertosun et al., 2015; B. C. Luthans et al., 2012, 2013) have been effective. Recently, the use of positive psychology smartphone apps such as Happify and resilience-building video games such as SuperBetter have been suggested and tested as motivational tools, especially with younger adults, to foster sustained and continued engagement with PsyCap development (F. Luthans & Youssef-Morgan, 2017; McGonigal, 2015). These are potential areas of practice for college counselors and counselors serving university students.
Interventions that are described as well-being approaches rather than those that highlight pathologies are less stigmatizing (Hunt & Eisenberg, 2010; Umucu et al., 2020) than traditional deficit-based therapeutic approaches. There are a number of research-based approaches offered in the field of positive psychology to guide mental health professionals to facilitate development of PsyCap and other important well-being correlates. These include approaches to building positive emotions (Fredrickson, 2009); coping strategies, which were found in this study to boost well-being (Jardin et al., 2018; Lyubomirsky, 2008); and effective goal pursuits (F. Luthans & Youssef-Morgan, 2017). One of the distinguishing characteristics of PsyCap is its malleability and openness to change and development (Avey, Reichard et al., 2011; F. Luthans et al., 2006). Thus, there is potential for counselors to develop well-being promotion initiatives for students on university campuses targeting PsyCap and its constituting positive psychological HERO resources with the end goal of strengthening well-being (Avey, Avolio et al., 2011; F. Luthans et al., 2015; F. Luthans & Youssef-Morgan, 2017).
Strategies and programming to develop wellness can be delivered in one-on-one sessions with students, as well as in group settings, and may have either a prevention or intervention focus. They could also be adapted to provide services online. A variety of free online assessments are also available for use by counselors, including tools that measure well-being, positive psychological resources, and character strengths of university students in addition to existing assessment batteries. By administering the PERMA-Profiler to university students, counselors could identify and understand what dimension of well-being should be further developed (Umucu et al., 2020). With each PERMA element individually rendering to flourishing mental health, specific targeted positive psychology interventions might be offered as domain-specific interventions.
Counselors could help university students benefit from attending to, appreciating, and attaining life’s positives (Sin & Lyubomirsky, 2009) and from enhancing the strength and frequency of employing positive coping strategies through targeted psychoeducational or counseling interventions. Teaching university students active coping strategies, such as positive reframing and how to access emotional support, could help them cope with adverse situations. Sheldon and Lyubomirsky (2006) indicated that practicing gratitude helps people to cope with negative situations because it enables them to view such situations through a more positive lens. Among university students, healthy coping strategies could buffer them from some of the unique challenges associated with acculturating and adjusting to college experiences (Jardin et al., 2018), especially during a pandemic.
Limitations and Directions for Future Research
The findings of this study should be considered in light of certain limitations. Foremost among these is that data were collected using self-report measures, and in the case of the PERMA-Profiler, data were collected using the retrospective recall of participants as they considered their well-being prior to the onset of COVID-19. Retrospective recall may be inaccurate (Gilbert, 2007) with participants under- or overestimating their well-being. Given the ongoing repercussions of the pandemic, we recommend continued and longitudinal studies on well-being, coping strategies, and PsyCap. Additionally, data collection methods and sample demographics would likely limit generalizability. We utilized a correlational cross-sectional study design; therefore, although PsyCap was predictive of change in well-being before and during COVID-19, neither causation nor directionality can be assumed. In future, researchers may wish to investigate whether PsyCap predicts longitudinal changes in well-being in the COVID-19 context.
A further consideration is that the PERMA model of well-being (Seligman, 2011) may not be associated with similar outcomes for people of other cultures and backgrounds during COVID-19. Future researchers examining well-being in university students in different regions of the country or internationally may wish to further investigate the applicability of the PERMA model as a measure of university students’ well-being during the pandemic. Finally, the moderate Cronbach’s alpha reliability scores of < .70 (Field, 2013) for the subscales of the Brief COPE inventory and the engagement subscale of the PERMA-Profiler are of concern, which has also been expressed by prior researchers (Goodman et al., 2018; Iasiello et al., 2017). Future researchers should consider issues of internal consistency as they choose scales and interpret results.
Conclusion
To conclude, the present findings contribute to existing literature on PsyCap and well-being, using the PERMA model of well-being (Seligman, 2011) among university students in the United States in the context of COVID-19. Key findings are that the optimism, hope, and resilience dimensions of PsyCap are significant predictors of well-being, explaining a large amount of variance, with adaptive coping being conducive to flourishing. Further, the present findings highlight the importance of examining the relationships between each element of well-being and with each HERO dimension. Both individual counseling and group-based programming focused on PsyCap and positive coping strategies could support the well-being of university students as they experience ongoing stressors related to the pandemic or as they face other setbacks.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Priscilla Rose Prasath, PhD, MBA, LPC (TX), is an assistant professor at the University of Texas at San Antonio. Peter C. Mather, PhD, is a professor and department chair at Ohio University. Christine Suniti Bhat, PhD, LPC, LSC (OH), is a professor and the interim director of the George E. Hill Center for Counseling & Research at Ohio University. Justine K. James, PhD, is an assistant professor at University College in Kerala, India. Correspondence may be addressed to Priscilla Rose Prasath, 501 W. Cesar E. Chavez Boulevard, Durango Building, University of Texas at San Antonio, San Antonio, TX 78207, priscilla.prasath@utsa.edu.
Feb 26, 2021 | Volume 11 - Issue 1
Dorrie Williams, Marcella Melanson, Bradley T. Erford
This meta-study evaluates publication patterns and trends occurring in the first 9 years of The Professional Counselor (TPC). Both author (e.g., gender, domicile, employment setting, top individual and university contributors) and article characteristics (e.g., topic, research design, participant type, sample size, statistics) are identified, with a particular focus on research articles. Almost 64% of lead authors and all authors were women, 92.1% of lead authors were affiliated with universities, and 3.4% of lead authors were internationally domiciled. From 2011–2019, the University of Central Florida featured the greatest number of lead authors, and the top author overall was Dr. Kathleen Brown-Rice. About 58% of published works were research articles, and of those, 69% used quantitative design methodology. Nearly all coded research variables were stable over time, except for participant types, as the proportion of adult participant samples increased while undergraduate participant samples decreased over time.
Keywords: meta-study, author characteristics, article characteristics, publication patterns, quantitative design
The Professional Counselor (TPC) is an electronic journal published by the National Board for Certified Counselors (NBCC; The Professional Counselor, n.d.). Beginning publication in 2011, this peer-reviewed and open-access journal publishes research and practice-based articles related to school counseling, marriage and family counseling, counseling supervision, theory development, counseling ethics, mental and behavioral health counseling, and multicultural and international counseling. The primary goal of this quarterly journal is to provide relevant and interesting resources and information for individuals all across the counseling profession, including counselors, counselor educators, mental health practitioners, graduate students, and supervisors. Thus, TPC is meant to address the professional development and informational needs of all counselors, regardless of specialty, work setting, or discipline. Each issue of TPC is released alongside a digital reader’s digest, a collection of summaries of the articles that are included within the issue.
Myriad characteristics within the counseling profession have evolved over the last decade, and along with this evolution, counseling research also has changed. Just as it is important to periodically review changes to the counseling profession, it also is vital to review journal characteristics to observe and analyze how journals evolve in relation to societal and cultural changes (Erford et al., 2010). Such an analysis informs the editorial board, authors, and readership about who and what is published in a journal, characteristics of methodological considerations, and the trajectories of those characteristics. As TPC began publication in 2011, this is the first multi-year review of the journal’s characteristics, providing an opportunity to examine trends within this journal that have yet to be studied. Historical reviews such as this allow for longitudinal monitoring of the advancement of, and challenges occurring within, the counseling profession.
Erford et al. (2010) identified several viable processes for analyzing and recording journal publication patterns. These methods include content analysis of published special issues and sections, qualitative synthesis, and quantitative meta-studies. From 2011–2019, five special issues were published in TPC—Counseling the Military and Their Families (Volume 4, Issue 2); Counseling and the DSM-5 (4.3); School Counseling (4.5); Counseling Children With Special Needs and Circumstances (5.2); and School Counselors and a Multi-Tiered System of Supports: Cultivating Systemic Change and Equitable Outcomes (6.3)—along with one special section (Counselor Education and Supervision [5.1]). To date, no qualitative syntheses of TPC content have been published in TPC. Qualitative syntheses are usually conducted by a scholar with expertise in qualitative analysis and provide an in-depth scholarly treatise of the content published by a journal.
This current article is the first meta-study of TPC content. A meta-study involves conducting a quantitative review and trend analysis of patterns found within the published literature. Quantitative meta-studies typically include an analysis of the author and article characteristics, as well as the use of descriptive and univariate statistical procedures in order to identify trends over time within the characteristics analyzed. These studies can be as narrowly focused as a single journal or topic or can span across multiple journals focusing on specific concepts. Quantitative meta-studies have the advantage of allowing objective, numerical, statistical analysis of changing trends across a large variety of variables using hypothesis testing to determine statistical significance and effect sizes. This quantitative meta-study focused on the scholarly content of TPC from the first nine volumes (2011–2019) and attempted to answer two basic questions: (a) What is published within The Professional Counselor (article characteristics), particularly with regard to research? and (b) Who publishes in The Professional Counselor (author characteristics)? These questions are also analyzed for trends to determine changes occurring in journal characteristics over time.
Method
Mirroring the methods of Saks et al. (2020), all articles published from 2011 through 2019 in TPC were examined, analyzed, and coded to describe article and author characteristics in order to answer the primary research questions of who and what is published in TPC and how those characteristics have changed over time. This systematic approach also allowed comparisons of these variable displays across journals. Scholarly contributions were accepted into the analysis while less scholarly works were rejected and not included in the analysis (e.g., editorials, introductions to special issues, biographies, profiles). Identified author characteristics included the number of authors, name, gender, and employment setting of all authors, and university and domicile (national or international) of the lead author. Identified article characteristics included type of article (i.e., expository/other and research), topical content (e.g., professional issues, symptoms/disorders, technique/theory, multicultural issues), and focus (i.e., research or not research). Additional characteristics were identified specifically in research articles. These research characteristics included: intervention or nonintervention; research paradigm (i.e., quantitative or qualitative); type of research design (i.e., qualitative, true or quasi-experimental, test development, descriptive/survey, comparative, correlational, meta-analysis/other); use of random or nonrandom sampling/assignment procedures; types of participants (i.e., adults, counselors/providers, youth, undergraduate students, graduate students or counselor trainees, nonhuman); sample size; sample size category (i.e., small, medium, large, or very large); sophistication of statistical applications (basic, intermediate, or advanced); primary statistical analyses used (i.e., descriptive, correlation, regression analysis, t-test/ANOVA/ANCOVA, nonparametric, MANOVA/MANCOVA, factor analysis); and inclusion of sample effect size estimate, reliability, and validity as indicators of quantitative reporting standards. Qualitative designs (e.g., grounded theory, phenomenological, case study) were further disaggregated and analyzed.
Our first two authors, Dorrie Williams and Marcella Melanson, independently coded each article for these characteristics into separate Microsoft Excel spreadsheets, sequenced by article release date. The data were then assessed for discrepancies and resolved by consensus. Analysis included descriptive statistics and one-way ANOVA using weighted proportions to analyze trends over time. Post hoc tests of significant results were conducted using Scheffe tests and significance for Type I error was set at α < .05. The interpretive guidelines of .01 = small effect, .09 = medium effect, and .25 = large effect were used to report ANOVA effect sizes (η2). These effect size estimates help demonstrate the power or relevance of the observed effects; larger effect sizes indicate more important or relevant changes being observed.
Results
From 2011–2019, 272 articles were published in TPC. Of these, 265 articles were accepted into this analysis, with only seven articles rejected because they were less scholarly submissions (e.g., editorials, introductions to special issues, biographies, profiles). Results were analyzed for trends over time using ANOVA with weighted proportions after being aggregated into two time windows (2011–2014 and 2015–2019). The following results were segmented by author and article characteristics.
Author Characteristics
Author demographic variables, such as the gender of the lead author and all authors and employment setting and domicile of lead author, were used to assess TPC author characteristics. We also identified the most prolific author contributors and sponsoring institutions and monitored collaboration trends by computing the average number of authors per article. A consistent, solid majority of lead and all authors from 2011–2019 self-identified as women. Women lead authors formed a proportion of 64.2%—F(1, 263) = 0.543, p = .462, η2 = .002—with a similar result for all authors (63.8% women): F(1, 703) = 1.134, p = .287, η2 = .002. Reflecting a slight collaboration trend, the average number of authors per article has risen slightly over time. In 2011–2014, TPC reflected an average of 2.43 authors per article, while in 2015–2019, the average increased slightly to 2.83 authors per article.
TPC lead author employment affiliation in university and non-university settings was very stable over time: F(1, 263) = 0.953, p = .330, η2 = .004. A consistent proportion of 92.1% of all lead authors were employed or primarily affiliated within a university work setting. During 2011–2019, only 3.4% (n = 9) internationally domiciled lead authors published in TPC: F(1, 263) = 2.80, p = .133, η2 = .009.
The most frequently contributing individual authors (weighted as the lead author receives 3 points, second author receives 2 points, and subsequent authors receive 1 point each) from 2011–2019 included the following, listed from highest rank to lowest: Kathleen Brown-Rice, with 17 points; Jeffrey M. Warren, with 15 points; Robert C. Reardon, with 12 points; Patrick R. Mullen, with 11 points; Sejal M. Barden, Ashley J. Blount, and Emily Goodman-Scott, with 10 points each; M. Ann Shillingford-Butler, with nine points; Randall M. Moate, with eight points; and Simone Lambert, James P. Sampson, Jr., Richard A. Wantz, and Laura E. Welfare, with seven points each. Using a weighted point system allows more credit to be allotted to primary article contributors over time, whereas a unit weighting system (one point of credit per article authored) benefits contributors who served in secondary or tertiary capacities. From 2011–2019, the following universities supported the highest number of TPC lead authors, listed from highest to lowest: the University of Central Florida, with 12 articles; the University of South Dakota, with 10 articles; Virginia Tech, with six articles; East Carolina University, Florida State University, University of North Carolina – Charlotte, and University of North Carolina – Pembroke, each with five articles; and Wake Forest University and Walden University, with four articles each. These universities align well with productive contributing authors in the list above or clusters of contributing authors, representing counseling faculty and counselor education programs with high degrees of dedication to enhancing the counseling literature in TPC.
Article Characteristics
Table 1 shows that topical content appearing in TPC publications from 2011–2019 was consistent and diverse: F(1, 530) = 0.666, p = .415, η2 = .001. The topics of counselor education and training, school counseling, and multicultural issues each occurred in more than 10% of TPC articles, each benefitting as foci in special issues/sections over the years. When inspecting article typology from the perspective of the tables of contents, it is noted that TPC only designates two major categories of articles: research and expository, the latter of which we combined with an “other” category, as specialized, non-research articles do appear in TPC from time to time. This TPC table of contents bi-factor typology was consistent from 2011–2019: F(1, 263) = 2.033, p = .155, η2 = .008. Given this result, it is then not surprising that TPC also displayed a consistent proportion of published research articles (58.1% from 2011–2019): F(1, 263) = 2.357, p = .126, η2 = .009. The remainder of this Results section reviews various characteristics of the 154 research articles published in TPC between 2011 and 2019.
Table 1
Issue Categories in TPC Articles From 2011–2019
| Content Topic |
2011–2014 |
2015–2019 |
Total |
| Counselor Education/Training |
35 (16.9%) |
52 (16.0%) |
87 (16.4%) |
| Multicultural Issues |
26 (12.6%) |
29 (8.9%) |
55 (10.3%) |
| School Counseling |
19 (9.2%) |
36 (11.1%) |
55 (10.3%) |
| Health/Wellness |
15 (7.2%) |
30 (9.2%) |
45 (8.4%) |
| Treatment/Intervention |
11 (5.3%) |
32 (9.8%) |
43 (8.1%) |
| Counseling Process |
7 (3.4%) |
33 (10.2%) |
40 (7.5%) |
| Symptoms/Disorders |
21 (10.1%) |
15 (4.6%) |
36 (6.8%) |
| Professional Issues |
16 (7.7%) |
16 (4.9%) |
32 (6.0%) |
| Ethical/Legal Issues |
10 (4.8%) |
19 (5.8%) |
29 (5.4%) |
| Academic/Career |
7 (3.4%) |
18 (5.5%) |
25 (4.7%) |
| Career Development |
12 (5.8%) |
13 (4.0%) |
25 (4.7%) |
| Assessment/Evaluation |
11 (5.3%) |
13 (4.0%) |
24 (4.5%) |
| Supervision |
10 (4.8%) |
9 (2.8%) |
19 (3.6%) |
| Identity Development |
7 (3.4%) |
10 (3.1%) |
17 (3.2%) |
| Totals |
207 |
325 |
532 |
Note. Many articles were coded to reflect multiple content issues. Thus, totals exceed the number of accepted articles.
The proportions of quantitative and qualitative research studies appearing in TPC have changed significantly over time—F(1, 176) = 9.025, p = .003, η2 = .049—constituting the highest effect size of any analysis in this study, albeit still a small effect. Quantitative designs shifted from a slight minority (46.9%) of research designs in 2011–2014 to a substantial proportional majority (69.3%) in 2015–2019, while the qualitative studies displayed converse proportions. We noted that about one-third of the qualitative studies did not specify an approach or methodological tradition. When qualitative approaches/methodologies were specified: 15.4% used a generic “content analysis”, 30.7% were phenomenological, 9.6% used grounded theory, 7.7% used case study, 5.8% used consensual qualitative research, 5.8% used narrative, 3.8% used constant comparative, and 1.9% simply specified an ethnographic approach.
Intervention studies maintained a stable presence among TPC research articles at 12.3%: F(1, 152) = 0.020, p = .889, η2 = .000. Likewise, the types of research designs appearing in TPC research articles (see Table 2) have been relatively stable over time: F(1, 156) = 1.232, p = .269, η2 = .008. Non-experimental designs dominated TPC research articles and were heavily weighted toward descriptive/survey (42.4%), qualitative (18.4%), and correlational designs (18.4%). The most rigorous experimental designs (true/quasi-experimental designs) comprised only 4.4% of TPC research studies.
Table 2
Proportion of Research Designs Used in TPC Research Studies
| Time |
2011–2014 |
2015–2019 |
Total |
| Descriptive/Survey |
22 (35.5%) |
45 (46.9%) |
67 (42.4%) |
| Qualitative |
16 (25.8%) |
13 (13.5%) |
29 (18.4%) |
| Correlation |
17 (27.4%) |
12 (12.5%) |
29 (18.4%) |
| SSRD |
1 (1.6%) |
7 (7.3%) |
8 (5.1%) |
| Comparative |
2 (3.2%) |
5 (5.2%) |
7 (4.4%) |
| True/Quasi-Experiment |
3 (4.8%) |
4 (4.2%) |
7 (4.4%) |
| Meta-Analysis/Other |
0 (0.0%) |
6 (6.2%) |
6 (3.8%) |
| Test Development |
1 (1.6%) |
4 (4.2%) |
5 (3.2%) |
| Totals |
62 |
96 |
158 |
Note. SSRD = Single-subject research design
Proportions of types of participants have shifted significantly across TPC research studies—F(1, 224) = 5.573, p = .019, η2 = .024—the second highest effect size of this meta-study. From the 2011–2014 to 2015–2019 time windows, adult participant samples increased from 28.0% to 41.7%, while undergraduate samples dropped from 17.3% to 6.0% (see Table 3). TPC research article sample sizes by category were consistent over time: F(1, 153) = 0.901, p = .344, η2 = .006. Small samples (< 30 participants) composed 33.5% of all studies, medium samples (30–99 participants) 20.0%, large samples (100–499 participants) 36.1%, and very large samples (500+ participants) only 10.3% of research studies. At the same time, the median sample size increased from 65 participants in 2011–2014 to 107 participants in 2015–2019, commensurate with the slight decrease in qualitative studies. Finally, the proportions of use of randomization in assignment procedures was also consistent—F(1, 152) = 1.172, p = .281, η2 = .008—holding steady at 11.7% of studies.
Table 3
Types of Participants Used in TPC Research Articles
| Time |
2011–2014 |
2015–2019 |
Total |
| Adults |
21 (28.0%) |
63 (41.7%) |
84 (37.2%) |
| Counselors/Providers |
14 (18.7%) |
39 (25.8%) |
53 (23.5%) |
| Graduate Students/Trainees |
15 (20.0%) |
19 (12.6%) |
34 (15.0%) |
| Undergraduates |
13 (17.3%) |
9 (6.0%) |
22 (9.7%) |
| Youth |
9 (12.0%) |
15 (9.9%) |
24 (10.6%) |
| Nonhumans |
3 (4.0%) |
6 (4.0%) |
9 (4.0%) |
| Totals |
75 |
151 |
226 |
Categorization of statistical procedures into basic, intermediate, or advanced designations was used as an indicator of statistical sophistication, which remained stable over time: F(1, 152) = 0.141, p = .707, η2 = .001. Articles were specifically categorized as research and non-research articles, and all types of statistical procedures from Table 4 were aggregated into the collapsed categories of basic, intermediate, and advanced statistics. Based on this categorization, over the 9 years, 59.1% of TPC research studies used basic statistical procedures (e.g., descriptive, correlation, t-test, chi-square), 31.8% used intermediate statistical procedures (e.g., ANOVA, regression analysis, other nonparametric), and only 9.1% used advanced procedures (e.g., MANOVA, factor analysis). Likewise, when specific statistical procedures used were analyzed, no significant shifts over time occurred (see Table 4): F(1, 290) = 0.055, p = .814, η2 = .000. Descriptive statistics were used in 29.8%, ANOVA/t in 13.4%, and content analysis or thematic coding in 21.2% of TPC research studies.
Table 4
Proportion of Various Statistical Procedures Used in TPC Research Studies
| Time |
2011–2014 |
2015–2019 |
Total |
| Descriptive |
29 (27.4%) |
58 (31.2%) |
87 (29.8%) |
| Content Analysis |
25 (23.6%) |
37 (19.9%) |
62 (21.2%) |
| Correlation |
14 (13.2%) |
29 (15.6%) |
43 (14.7%) |
| ANOVA/t |
18 (17.0%) |
21 (11.3%) |
39 (13.4%) |
| Regression |
10 (9.4%) |
19 (10.2%) |
29 (9.9%) |
| Factor Analysis |
3 (2.8%) |
13 (7.0%) |
16 (5.5%) |
| MANOVA |
3 (2.8%) |
7 (3.8%) |
10 (3.4%) |
| Nonparametric |
4 (3.8%) |
2 (1.1%) |
6 (2.1%) |
| Totals |
106 |
186 |
292 |
TPC consistently reported study effect sizes at a rate of 23.5% of all research articles published from 2011–2019: F(1, 152) = 1.172; p = .281; η2 = .008. Sample reliability and validity reports were also stable over time with reports of sample reliability at a steady rate of 39.2%—F(1, 151) = 1.961; p = .161; η2 = .012—and sample score validity at a consistent proportion of 36.6% from 2011–2019: F(1, 151) = 0.299; p = .585; η2 = .002.
Discussion
TPC published an average of about 30 articles per year from 2011–2019, 57.7% of which have been research articles. TPC mirrors the evolution of the counseling profession and through research and expository articles helps to address new professional issues, topics, and challenges that contribute to the advancement and growth of the counseling profession (TPC, 2020). The online publishing format makes this information freely available to professional counselors and the public; no print edition exists. This section discusses TPC author and article characteristics from the journal’s inception in 2011 to 2019. Interestingly, only two variables displayed trends between the two time windows, demonstrating an admirable focus and stability of decision making among TPC editorial board members for a new counseling journal. That is, in just 9 years, TPC already appears to have attracted and published broadly consistent types of articles from authors with similar characteristics.
Author Characteristics: Who Publishes in TPC?
In the first 9 years of publication, only nine (3.4%) TPC lead authors were domiciled outside the United States. Other counseling journals have also historically displayed international publishing rates of less than 5%, including the Journal of Addictions & Offender Counseling (MacInerney et al., 2020), The Journal of Humanistic Counseling (Sylvester et al., in press), the Journal of College Counseling (Milowsky et al., in press), and the Journal of LGBT Issues in Counseling (Gayowsky et al., in press). Still, TPC has an opportunity to reach out to the international counseling community and invite more diverse expository and research contributions, thereby expanding into the international counseling domain. Perhaps a call for articles from international authors could form a special issue of TPC, contributing multicultural insights, evaluating cross-cultural perspectives, or helping to establish a focus for global connectivity. This is particularly important given NBCC’s historic leadership in developing international counseling initiatives through its International Capacity Building department (NBCC, n.d.). International outreach is consistent with the mission of NBCC’s international collaborations with organizations such as the African Union – Southern Africa Regional Office (AU-SARO) and around the world, and TPC is positioned to aid in that international scope of activities. As such, TPC could become a leader in international focus among counseling journals. Currently, two counseling journals do exceptional jobs attracting international scholars. The Journal of Employment Counseling (Siegler et al., in press) featured a 53% internationally domiciled lead author proportion from 2010–2019, and Measurement and Evaluation in Counseling and Development published 28% of its articles from international lead authors over the same period (Saks et al., 2020).
A consistent majority of women composed the lead authors (64.2%) and all authors (63.8%) of published TPC articles from 2011–2019. A near 2-to-1 proportion is acknowledgement of the importance and majority standing of women counselor educator scholars in the United States (U.S. Census Bureau, 2016). A nearly two-thirds majority is consistent with many other counseling journals and indicates the rise to prominence of women scholars in counselor education (Johnson et al., 2021; MacInerney et al., 2020; Menzies et al., 2020; Milowski et al., in press; Saks et al., 2020; Sylvester et al., in press).
At the same time the vast majority of lead authors (92.1%) listed primary affiliations in university work settings. Although a non–university-affiliated participation rate of only 7.9% seems low overall, compared to other counseling journals, it actually is comparable with counseling journal leaders in this category like the Journal of Mental Health Counseling (Menzies et al., 2020) and Counseling Outcome Research and Evaluation (Johnson et al., 2021), and higher than most other counseling journals (MacInerney et al., 2020; Milowsky et al., in press; Saks et al., 2020; Sylvester et al., in press). This low level of participation from non–university-affiliated authors across counseling journals is curious given the powerful and necessary voices practitioners can lend to real-world counseling issues and interventions.
But there are certainly barriers and constraints on practitioner motivations to engage in scholarship. First, practitioners are rarely compensated for research, nor are employee evaluations substantively impacted by scholarly contributions. If more incentives like compensation and evaluation were tied to practitioner scholarship efforts, we could expect practitioners to have a larger presence in counseling scholarship and collaborations. Practitioners are also incredibly busy providing counseling services to clients and students, and research and program evaluation becomes a lower priority as time constraints tighten. In contrast, employee scholarship production often is rewarded by universities through salary increases, promotions, and tenure. Likewise, professors are expected to, and often rewarded for, scholarship, including collaboration with graduate students and colleagues in research projects. Graduate students often engage in research to enhance their levels of qualification for doctoral study and future opportunities to join the professoriate. It is also possible that authors who are practitioner-students or scholar-practitioners simply default to a university affiliation for some reason—perhaps believing that university affiliations are more prestigious or may be given greater consideration in a positive disposition. In any case, journal editorial boards should encourage authors to list multiple affiliations to better gauge the prevalence of practitioners among contributing authors.
Counselor scholars should continue to search for opportunities to collaborate with practitioners, both to access rich sources of field-based data and to amplify the valuable voices of experienced clinicians. In just the first 9 years, TPC experienced increased author collaboration, from 2.43 authors per article in 2011–2014 up to 2.83 in 2015–2019. This trend toward more collaboration was seen in all other counseling journals, with many in the same vicinity of average author contributions as TPC, including AdultSpan (Rippeto et al., in press), the Journal of Employment Counseling (Siegler et al., in press), The Journal of Humanistic Counseling (Sylvester et al., in press), and others far higher, exceeding 3.10 authors per article, such as Measurement and Evaluation in Counseling and Development (Saks et al., 2020) and the Journal of College Counseling (Milowsky et al., in press).
Collaboration is essential to the future of counseling research as the profession and our domain of knowledge become larger and at the same time more specialized. This trend toward increased collaboration is very positive, perhaps reflecting a greater focus on mentorship and partnership. It will not be a surprise to note that simultaneous with this rise in collaboration was a proportional rise in publishing research articles. Research ventures are great opportunities for collaboration and building research partnerships with colleagues, graduate students, and practitioners. In particular, partnering with practitioners promotes meaningful field-based studies that enrich practice and document promising evidence-based interventions. Finally, as counselor educator–scholars, we must recommit to training practitioners who can collect, conduct, and collaborate in the publication of field-based research. Field-based studies are critical in counseling research because that is where the overwhelming majority of clients and students are counseled and treated. Conducting studies in research labs must generalize to implementation in the field; studies conducted in the field already have bridged that gap. Melding field-based innovations, counseling research, and practitioner voices will help the counseling profession evolve into a more evidence-based practice accountable to, and valued by, clients and other stakeholders.
Article Characteristics: What Is Published in TPC?
Over the first 9 years of TPC publications, articles were quite well balanced over a broad range of topical content (see Table 1). When combined, over one-third of the articles focused primarily on three topics: counselor education/training (16.4%), multicultural issues (10.3%), and school counseling (10.3%). However, an appropriate and even spread of topic coverage was observed in the other areas, ranging from a low of 3.2% for identity development to 8.4% for health/wellness. Thus, the TPC editorial board is approving a broad swath of important and meaningful topical content for the readership of TPC. It will be important to maintain this balance in the decade ahead as TPC fulfills its goal as a journal of value to all professional counselors, regardless of work setting and counseling sub-discipline.
Research articles are critical components of professional journals. Research articles form the scientific foundation of a profession, and the more we know about the clients we serve, the better prepared we are to serve them. At 58.1%, the proportion of research studies published in TPC is typical when compared with other counseling journals, most of which are in the range of 50%–68%, including Counseling and Values: Spirituality, Ethics, and Religion in Counseling (Alder et al., in press); the Journal of LGBT Issues in Counseling (Gayowsky et al., in press); the Journal of Mental Health Counseling (Menzies et al., 2020); and Adultspan (Rippeto et al., in press). The proportion of research studies in TPC is albeit far lower than the more research-focused counseling journals like Measurement and Evaluation in Counseling and Development (80.7%; Saks et al, 2020), Counseling Outcome Research and Evaluation (75.6%; Johnson et al., 2021), the Journal of Employment Counseling (86.4%; Siegler et al., in press), and Counselor Education & Supervision (90.4%; Johnsen et al., in press) produced during the 2015–2019 time window. Still, TPC has made great inroads in the proportion of research articles published in its first decade, and it will be interesting to see where this trajectory will lead in the next decade.
The research designs used in TPC research studies are heavily weighted toward non-experimental designs, including descriptive or survey (42.4%), qualitative (18.4%), and correlational (18.4%) designs (see Table 2). Descriptive/survey research simply seeks to describe the characteristics of participants and their interactions or performance on variables. True- and quasi-experimental designs appeared in only 4.4% of all TPC research articles, which is a low rate among the family of counseling journals. At the same time, the 12.3% proportion of intervention-focused articles is quite good when compared to other counselor journals (Menzies et al., 2020), as Ray et al. (2011) reported that only about 6% of all research articles published in counseling journals focus on the efficacy of interventions. Intervention research studies tend to be among the most valuable studies published in the counseling profession because intervention studies inform the reader on what efficacy counselors can expect when implementing the intervention with clients or students. Thus, intervention studies help inform us about what we know that works in counseling. In summary, TPC should strive to increase the proportion of intervention articles, as well as true- and quasi-experimental designs, as these approaches help counselors understand what works in counseling related to the effectiveness of counseling practice. True- and quasi-experimental designs also enhance generalizability of sample results to the population, which gives counselors confidence that the more robust experimental results from these studies are more applicable to the broader populations of clients served by counselors.
During its first 4 years of publication, TPC produced one of the highest proportions of qualitative tradition articles seen in the family of counseling journals (53.1%), before declining significantly in 2015–2019 (30.7%). Qualitative research has consistently accounted for 30–45% of research publications in some counseling journals over the last 20 years (Alder et al., in press; Gayowsky et al., in press; MacInerney et al., 2020), but is much lower in other journals like Measurement and Evaluation in Counseling and Development (Saks et al, 2020) and Counseling Outcome Research and Evaluation (Johnson et al., 2021), which produce more quantitative, generalizable research. It will be interesting to see if the significant decline in qualitative articles continues over the next decade or stabilizes in the 30% range.
The significant increases in adults and counselors or other mental health service providers as participants in TPC research studies was interesting, as these two groups comprised more than two-thirds (67.5%) of participant types in the 2015–2019 time window (see Table 3). This was accompanied by a significant decline in the use of undergraduate and graduate students. The use of adult participants in counseling research is a welcome occurrence, as adults comprise the majority of clients seen in counseling agencies and private practice. And the focus on counseling practitioners is very appropriate for a journal whose mission it is to meet the professional needs of all counselors across diverse work settings and disciplines.
Although the median sample sizes did increase from 65 to 107 participants across the two time windows, that observation is expected given the increase in the proportion of quantitative compared to qualitative studies, as quantitative studies generally have higher sample sizes. Still, the overall consistency in the proportions of small, medium, large, and very large sample sizes is a sign of maturation in such a young journal.
Statistical procedures appearing in TPC articles were very well balanced across categories and across the two time windows. Not surprisingly, basic approaches like descriptive analyses and thematic coding comprised about half of all procedures. Descriptive statistics are the most basic type of statistics and are often used to convey results in surveys and nonexperimental studies. MANOVA, ANOVA, and t-tests combined for a very respectable total proportion of 16.8%. TPC should strive to increase the prominence of these more sophisticated statistical tests. Among counseling journals, Counseling Outcome Research and Evaluation (Johnson et al., 2021) leads the way in use of these tests of difference statistics at more than 20%, but TPC is not far behind.
Finally, TPC editors have a great deal of progress to make in improving the proportions of reporting standards. In the first 9 years of publication, TPC authors reported effect size estimates in only 23.5% of articles, sample reliability estimates in only 39.2%, and sample validity estimates in 36.6% of research articles published. Reports of effect size, score reliability, and score validity are indications of study rigor and meaningfulness. For example, authors should always report on the reliability of scores of standardized dependent variables used in a study so readers know how much error variance in measurement occurred. Likewise, statistical significance is important in hypothesis testing, but effect sizes give readers an indication of how important and meaningful the results are in a grander context. These effect size and reliability reports are among the lowest rates of any counseling family journal (MacInerney et al., 2020; Milowsky et al., in press; Rippeto et al., in press; Saks et al., 2020; Siegler, in press; Sylvester et al., in press), so the TPC editorial board is encouraged to add these reporting standard aspects to review protocols and author requirements to insure inclusion in future articles.
Limitations and Conclusion
This synthesis and analysis of the first 9 years of TPC publications has several limitations that should be explicated. First, no causal inference may be derived from these results. This means that one cannot determine the cause of any of the analyses indicated because the design of the study was not experimental; we were able to describe the variables, not determine what caused the results. This meta-study used descriptive and comparative statistical analyses to summarize proportions aggregated across time windows to discern trends occurring over time. However, no inference is offered as to why the proportions and trends were observed.
Second, despite the use of independent coders and robust, standardized coding procedures, the potential for coding errors always exists. Thus, some categorization or classification errors may have occurred. This is a particular risk within categories that are more subjective or when the descriptions provided by TPC authors lacked clarity or essential information. Third, we chose to segment the 9 years of TPC publications into two periods to bolster analytic power, although others might prefer smaller time windows when engaging in trend analysis.
Fourth, while this meta-study combined the quantitative and qualitative designs into a larger analysis and then took a closer look at just the quantitative designs, there is value in conducting a parallel analysis of the methodological rigor of both the quantitative and qualitative studies published in TPC to date. This will help address or at least acknowledge the possible limits of a positivist epistemological lens.
Finally, we were not able to code important author demographics such as race, ethnicity, age, or other attributes. We instead focused on readily available information like lead author domicile and author institutional affiliations and gender. For future analyses, it would be helpful if authors would self-identify a wider variety of demographic descriptors (e.g., self-identified gender, race, nationality) or at least designate all university and non-university affiliations. This would help clarify the degree to which practitioners and authors of diverse backgrounds are represented within author configurations.
In summary, TPC has made great progress across many dimensions over its first 9 years of publication. Also, it appears that TPC is well on its way to fulfilling its mission to provide valuable research and practice information to all professional counselors regardless of work setting or sub-discipline. We look forward to seeing the continued progress of this new counseling journal in the decades ahead and hope this meta-study is of use to the TPC editorial board, authors, and readership as a description of who and what is published in TPC.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Dorrie Williams is a master’s candidate at Vanderbilt University. Marcella Melanson is a master’s candidate at Vanderbilt University. Bradley T. Erford, PhD, NCC, LPC, LCPC, is a professor in the Peabody College at Vanderbilt University. Correspondence may be addressed to Bradley T. Erford, PMB 90, Vanderbilt University, Nashville, TN 37202-5721, Bradley.t.erford@vanderbilt.edu.
Feb 26, 2021 | Volume 11 - Issue 1
Christian D. Chan, Stacey Diane Arañez Litam
The emergence and global spread of COVID-19 precipitated a massive public health crisis combined with multiple incidents of racial discrimination and violence toward Asian American and Pacific Islander (AAPI) communities. Although East Asian communities are more frequently targeted for instances of pandemic-related racial discrimination, multiple disparities converge upon Filipino communities that affect their access to mental health care in light of COVID-19. This article empowers professional counselors to support the Filipino community by addressing three main areas: (a) describing how COVID-19 contributes to racial microaggressions and institutional racism toward Filipino communities; (b) underscoring how COVID-19 exacerbates exposure to stressors and disparities that influence help-seeking behaviors and utilization of counseling among Filipinos; and (c) outlining how professional counselors can promote racial socialization, outreach, and mental health equity with Filipino communities to mitigate the effects of COVID-19.
Keywords: Asian American, Filipino, mental health equity, COVID-19, discrimination
Asian Americans represent the fastest-growing ethnic group in the United States (Budiman et al., 2019). Following the global outbreak of COVID-19, many Asian Americans and Pacific Islanders (AAPIs) have experienced a substantial increase in race-based hate incidents. These incidents of racial discrimination have included verbal harassment, physical attacks, and discrimination against Asian-owned businesses (Jeung & Nham, 2020), which multiply the harmful effects on psychological well-being and life satisfaction among AAPIs (Litam & Oh, 2020). According to Pew Research Center trends (Ruiz et al., 2020), about three in 10 Asian adults reported they experienced racial discrimination since the outbreak began. Proliferation of anti-Chinese and xenophobic hate speech from political leaders, news outlets, and social media, which touted COVID-19 as the “Chinese virus,” further exacerbate instances of race-based discrimination (U.S. Department of Justice, 2020) and echo the Yellow Peril discourse from the late 19th century (Litam, 2020; Poon, 2020).
Although the community is often aggregated, Asian Americans are not a monolithic entity (Choi et al., 2017; Jones-Smith, 2019; Sue et al., 2019). The term Asian American encompasses over 40 distinct subgroups, each with distinct languages, cultures, beliefs, and migration histories (Pew Research Center, 2013; Sue et al., 2019). It is no surprise, therefore, that specific ethnic subgroups would be more affected by the pandemic than others. For example, instances of COVID-19–related racial discrimination disproportionately affect East Asian communities, specifically Chinese migrants and Chinese Americans. An analysis of nearly 1,500 reports of anti-Asian hate incidents indicated approximately 40% of Chinese individuals reported experiences of discrimination as compared to 16% of Korean individuals and 5.5% of Filipinos (Jeung & Nham, 2020). Although Chinese individuals disproportionately experience overt forms of COVID-19–related discrimination, Filipino migrants and Filipino Americans are not immune to the deleterious effects of the pandemic.
With over 4 million people of Filipino descent residing in the United States (Asian Journal Press, 2018), it is of paramount importance for professional counselors to recognize how the Filipino American experience may compound with additional COVID-19 exposure and related stressors in unique ways that distinctively impact their experiences of stress and mental health. The current article identifies how the racialized climate of COVID-19 influences Filipino-specific microaggressions and the presence of systemic and institutional racism toward Filipino communities. The ways in which COVID-19 exacerbates existing racial disparities across social determinants of health, help-seeking behaviors, and utilization of counseling services are described. Finally, the implications for counseling practice and advocacy are presented in ways that can embolden professional counselors to promote racial socialization, outreach, and health equity with Filipino communities to mitigate the effects of COVID-19.
Health Disparities Among Filipino Americans
The unprecedented emergence of COVID-19 has affected the global community. As of January 5, 2021, a total of 21,382,296 cases were confirmed and 362,972 deaths had been reported in the United States (Worldometer, n.d.). Although information about how racial and ethnic groups are affected by the pandemic is forthcoming, emerging data suggests that specific groups are disproportionately affected. Professional counselors must be prepared to support communities that may be more vulnerable to pandemic-related stress and face challenges related to medical and mental health care access because of intersecting marginalized identities, such as age, race, ethnicity, gender identity, sexual identity, social class, and migration history (Chan & Henesy, 2018; Chan et al., 2019; Litam & Hipolito-Delgado, 2021). For example, the AAPI population may be especially in need of mental health support because of ongoing xenophobic sentiments from political leaders that combine with intergenerational trauma, racial discrimination, and racial trauma (Litam, 2020).
Underutilization of Mental Health Services
Compared to other Asian American subgroups, Filipinos are the least likely to seek professional mental health services. In a study of 2,230 Filipinos, approximately 73% had never used any type of mental health service and only 17% sought help from friends, community members, peers, and religious or spiritual leaders (Gong et al., 2003). Since the Gong et al. (2003) study, a multitude of researchers have documented the persistent disparity of mental health usage and unfavorable attitudes toward professional help-seeking among Filipinos (David & Nadal, 2013; David et al., 2019; Nadal, 2021; Tuazon et al., 2019), despite high rates of psychological distress (Martinez et al., 2020).
The experiences of Filipino communities uniquely influence aspects of mental health and wellness. Compared to other subgroups of Asian Americans, Filipino Americans with post-traumatic stress experiences tend to exhibit poorer health (Kim et al., 2012; Klest et al., 2013), and report higher rates of racial discrimination (Li, 2014). As a subgroup, Filipino Americans present to mental health counseling settings with high rates of depression, suicide, HIV, unintended pregnancy, eating disorders, and drug use (David et al., 2017; Klest et al., 2013; Nadal, 2000, 2021). Compared to other Asian subgroups, Filipinos may experience lower social class and employment statuses, which may increase the prevalence of mental health issues (Araneta, 1993). Among Filipinos, intergenerational cultural conflicts and experiences of racial discrimination were identified as significant contributors to depression and suicidal ideation (Choi et al., 2020). The underutilization of professional mental health services and help-seeking among Filipino communities is unusual because of their familiarity with Western notions, systems, and institutions, which surface as traits that are typically associated with mental health help-seeking within the broader AAPI community (Abe-Kim et al., 2002, 2004; Shea & Yeh, 2008).
Distinct Experiences of Oppression
Aspects of Filipino history are characterized by colonization, oppression, and intergenerational racial trauma (David & Nadal, 2013) and have been rewritten by White voices in ways that communicate how America saved the Philippines from Spanish rule through colonization (Ocampo, 2016). These sentiments remain deeply entrenched within the mindset of many Filipinos in the form of colonial mentality (David & Nadal, 2013; Tuazon et al., 2019). Colonial mentality refers to the socialized and oppressive mindset characterized by beliefs about the superiority of American values and denigration of Filipino culture and self (David & Okazaki, 2006a, 2006b). Colonial mentality is the insidious aftermath galvanized through years of intergenerational trauma, U.S. occupation, and socialization under White supremacy (David et al., 2017). Professional counselors must recognize the interplay between colonial mentality and the mental health and well-being of Filipino clients to best support this unique population.
The internalized experiences of oppression perpetuate the denigration of Filipinos by Filipinos as a result of the internalized anti-Black sentiments and notions of White supremacy that remain at the forefront of American history (Ocampo, 2016). The Filipino experience is one that is characterized by forms of discrimination by individuals who reside both within and outside of the Filipino community (Nadal, 2021). For example, Filipinos who espouse a colonial mentality disparage those with Indigenous Filipino traits (i.e., dark skin and textured hair) as unattractive, undesirable, and worthy of shame (Angan, 2013; David, 2020; Mendoza, 2014). Filipinos also experience a sense of otherness within the AAPI community and from other communities of color because their history, culture, and phenotype combine in ways that “break the rules of race” (Ocampo, 2016, p. 13). Although Filipinos are sometimes confused with individuals from Chinese communities, they are not typically perceived as Asian or East Asian (Lee, 2020) and are often mistaken for Black or Latinx (Ocampo, 2016; Sanchez & Gaw, 2007). These pervasive experiences render the Filipino identity invisible (Nadal, 2021). Ultimately, Filipinos remain among the most mislabeled and culturally marginalized of Asian Americans (Sanchez & Gaw, 2007). Professional counselors who work with Filipino clients must obtain a deeper understanding of how these unique experiences of invisibility and colonial mentality continue to affect the minds and the worldviews of Filipinos and Filipino Americans.
Risk Factors for COVID-19 Exposure
The burgeoning rate of COVID-19 cases has devastated hospitals and medical settings. The overwhelming strain faced by medical communities uniquely affects Filipino migrants and Filipino Americans who are overrepresented in health care and disproportionately at risk of COVID-19 exposure (National Nurses United, 2020). The overrepresentation of Filipinos in health care, particularly within the nursing profession, is directly tied to the history of U.S. colonization. Following the U.S. occupation of the Philippines from 1899 to 1946, the Filipino zeitgeist became imbued with profound cultural notions of American superiority and affinity for Westernized attitudes, behaviors, and values (David et al., 2017). For example, the introduction of the American nursing curricula by U.S. Army personnel during the Spanish-American war (McFarling, 2020) instilled pervasive cultural influences that positioned the nursing profession as a viable strategy to escape political and economic instability in pursuit of a better life in the United States (Choy, 2003). These cultural notions have culminated to make the Philippines the leading exporter of nurses in the world (Choy, 2003; Espiritu, 2016). Of the immigrant health care workers across the United States, an estimated 28% of registered nurses, 4% of physicians and surgeons, and 12% of home health aides are Filipinos (Batalova, 2020). About 150,000 registered nurses in the United States are Filipino, equating to about 4% of the overall nursing population (McFarling, 2020; National Nurses United, 2020). According to the National Nurses United (2020) report, 31.5% of deaths among registered nurses and 54% of deaths among registered nurses of color were Filipinos. Based on these statistics, Filipinos face disproportionate exposure to pandemic-related stressors and death that may increase the risk for mental health issues.
Individuals of Filipino descent may also face significant COVID-19–related challenges, as they are predisposed to several health conditions that have been linked with poorer treatment prognosis and outcomes (Ghimire et al., 2018; Maxwell et al., 2012). Compared to other racial and ethnic subgroups, Filipinos residing in California had higher rates of type II diabetes, asthma, and cardiovascular disease (Adia et al., 2020). High rates of hypertension, cholesterol, and diabetes were also noted in studies of Filipino Americans residing in the greater Philadelphia region (Bhimla et al., 2017) and in Las Vegas, Nevada (Ghimire et al., 2018). One study of Filipinos residing in the New York metropolitan area indicated rates of obesity significantly increased the longer Filipino immigrants resided in the United States (Afable et al., 2016). The Centers for Disease Control and Prevention (2021) associated each of these underlying medical conditions with a greater likelihood for hospitalization, intensive care, use of a ventilator, and increased mortality. Filipino Americans also tend to report lower social class and employment statuses as compared to other Asian Americans, which may contribute to higher rates of mental health issues and create barriers to health care access (Adia et al., 2020; Sue et al., 2019).
Cultural Barriers to Professional Mental Health Services
Filipinos face culturally rooted barriers to seeking professional mental health services that may include fears related to reputation, endorsement of fatalistic attitudes, religiousness, communication barriers, and lack of culturally competent services (Gong et al., 2003; Nadal, 2021; Pacquiao, 2004). The presence of mental illness stigma is also deeply entrenched within Filipino communities (Appel et al., 2011; Augsberger et al., 2015; Tuazon et al., 2019). In many traditional Filipino families, mental illness is mitigated by addressing personal and emotional problems with family and close friends, and through faith in God (David & Nadal, 2013). Rejection of mental illness is based on the belief that individuals who receive counseling or therapy are crazy, dangerous, and unpredictable (de Torres, 2002; Nadal, 2021).
Connection and Kinship
Given the central prominence of family, it is no surprise that Filipino individuals’ mental health begins to suffer when their connection to community and kinship is compromised. Although relatively few studies on Filipino mental health exist, Filipinos and Filipino Americans consistently report family-related issues as among the most stressful. In one study of Filipino and Korean families in the Midwest (N = 1,574), the presence of intergenerational family conflict significantly contributed to an increase in depressive symptoms and suicidal ideation (Choi et al., 2020). In another study of Filipino Americans, quality time with family, friends, and community was identified as an important factor in mitigating the effects of depression (Edman & Johnson, 1999). The centralized role of Filipino families uniquely combines with a group mentality in ways that may additionally hinder rates of professional help-seeking.
Hiya and Amor Propio
Notions of hiya and amor propio each represent culturally specific barriers to seeking mental health care. According to Gong and colleagues (2003), hiya and amor propio are related to the East Asian notions of saving face. While hiya emphasizes the more extensive experience of shame that arises from fear of losing face, amor propio is associated with concepts of self-esteem linked to the desire to maintain social acceptance. A loss of amor propio would result in a loss of face and may compromise the cherished position of community acceptance (Gong et al., 2003). Filipino Americans may thus avoid seeking professional mental health services because of combined feelings of shame (hiya) linked to beliefs that one has failed or is unable to overcome their problems independently, and fears of losing social positioning within one’s community (amor propio). To experience amor propio would put a Filipino—or worse, their family—at risk for tsismis, or gossip. Indeed, avoiding behaviors that may lead others within the Filipino community to engage in tsismis about the client or their family is a significant factor that guides choices and behaviors. Engaging in behaviors that result in one’s family becoming the focus of tsismis is considered highly shameful and reprehensible among Filipino communities.
Bahala Na
The Tagalog term bahala na refers to the sense of optimistic fatalism that characterizes the shared experiences of many Filipinos and Filipino Americans. Bahala na can be evidenced through Filipino cultural expectations to endure emotional problems and avoid discussion of personal issues. This core attitude may have deleterious effects on mental health and help-seeking, as many Filipinos are socialized to deny or minimize stressful experiences or to simply endure emotional problems (Araneta, 1993; Sanchez & Gaw, 2007). A qualitative analysis of 33 interviews and 18 focus groups of Filipino Americans indicated bahala na may combine with religious beliefs to create additional barriers to addressing mental health problems (Javier et al., 2014). For example, virtuous and religious Filipinos and Filipino Americans may endorse bahala na attitudes by believing their higher power has instilled purposeful challenges that can be overcome by sufficient faith and endurance (Javier et al., 2014).
Hindi Ibang Tao
Moreover, many Filipinos and Filipino Americans demonstrate hesitance to trust individuals who are considered outsiders. When interactions with those considered other cannot be avoided, traditional Filipinos tend to be reticent, conceal their real emotions, and avoid disclosure of personal thoughts, needs, and beliefs (Pasco et al., 2004). Filipino community members place a large value on in-group versus out-group members and largely prefer to seek support from helping professionals within the Filipino community, rather than from others outside of the group (Gong et al., 2003). Individuals who are hindi ibang tao (in Tagalog, “one of us”) are differentiated from those who are ibang tao (in Tagalog, “not one of us”), which influences interactions and amount of trust given to health care providers (Sanchez & Gaw, 2007). White counselors may be able to bridge the cultural gap with Filipino clients to become hindi ibang tao by exhibiting respect, approachability, and a willingness to consider the specific influences of Filipino history and the importance of family (Sanchez & Gaw, 2007). Professional counselors who overlook, minimize, or disregard these cultural values risk higher rates of early termination and may experience their Filipino clients as exhibiting little emotion (Nadal, 2021). Filipino clients who are not yet comfortable with professional counselors may interact in a polite, yet superficial manner because culturally responsive relationships and trust have not been developed (Gong et al., 2003; Pasco et al., 2004; Tuazon et al., 2019).
Pakikisama and Kapwa
Another Filipino cultural barrier is pakikisama, or the notion that when one belongs to a group, one should be wholly dedicated to pleasing the group (Bautista, 1999; Nadal, 2021). Filipino core values extend beyond the general notion of collectivism and include kapwa, an Indigenous worldview in which the self is not distinguished from others (David et al., 2017; Enriquez, 2010). Thus, Filipinos do not solely act in ways that benefit the group; they are also expected to make decisions that please other group members, even at the expense of their own desires, needs, or mental health (Nadal, 2021). The cultural notions of pakikisama and kapwa interplay with amor propio in ways that have detrimental effects on Filipinos in dire need of mental health support. For example, a second-generation Filipino American may recognize that their suicidal thoughts and experiences of depression may be worthy of mental health support, but recognition of cultural mistrust toward those deemed other may risk their family’s social acceptance (amor propio). Risking the family’s social acceptance could ultimately violate group wishes (pakikisama) and may subject their family to stigma and gossip (tsismis).
Implications for Practice and Advocacy in Professional Counseling
The COVID-19 pandemic and increased visibility to discrimination against Asian Americans illuminates the importance of addressing the presence of mental health barriers among Filipino communities. Filipino communities face complex barriers rooted in colonialism, racism, and colorism that negatively affect their overall mental health (David & Nadal, 2013; Tuazon et al., 2019; Woo et al., 2020). The combination of educational, health, and welfare disparities culminate in poorer health outcomes for Filipino American communities compared to other ethnic Asian groups (Adia et al., 2020). Many of these identifiable barriers and forces of oppression increase the racial trauma narratives incurred among Filipino communities (David et al., 2017; Klest et al., 2013); deny the impact of microaggressions and discrimination (Nadal et al., 2014); divest resources that support economic, educational, and social well-being (Nadal, 2021; Smith & Weinstock, 2019); and discourage the utilization of needed counseling spaces (Tuazon et al., 2019).
Cultivating cultural sensitivity in health care providers can buffer the psychological toll and emotional consequences of negative health care encounters for historically marginalized communities (Flynn et al., 2020), including Filipinos. Findings associated with health equity and help-seeking behaviors (e.g., Flynn et al., 2020; Ghimire et al., 2018) have significant ramifications for Filipino communities that face a litany of barriers to counseling services (Gong et al., 2003; Tuazon et al., 2019). In light of COVID-19, professional counselors are encouraged to employ culturally responsive interpersonal and systemic interventions that promote the sustainable mental health equity of Filipino communities.
Promoting Racial Socialization and Critical Consciousness
Reducing barriers for mental health access is connected to protective factors, actions, and cultural capital instilled across generations of Filipino communities (David et al., 2017). Filipino communities draw from several generations of colonization, which continues to affect second-generation Filipinos living in the United States (David & Okazaki, 2006a, 2006b). Experiences of historical colonization, forced assimilation into other cultures, and the erasure of Filipino cultural values have resulted in a range of Eurocentrically biased and historically oppressive experiences (Choi et al., 2020; David & Nadal, 2013). These experiences have prepared Filipino communities, intergenerationally and collectively, to respond to experiences of discrimination in ways that preserve their cultural values (David et al., 2017). The preservation of Filipino cultural values across generations has bolstered a type of protective factor through racial socialization, where parents and families teach future generations of children about race and racism (Juang et al., 2017). Ultimately, preparing future generations of Filipinos to respond to racial oppression can protect cultural assets (David et al., 2017). In fact, a study by Woo and colleagues (2020) indicated Filipino parents who prepared their children to respond to racial discrimination prepared them for bias and strengthened their ethnic identity.
One strategy that professional counselors can use to infuse social justice in their work is to help Filipino clients raise their critical consciousness. Critical consciousness is an approach that helps clients to recognize the systemic factors contributing to their barriers with mental health utilization and mental health stressors (David et al., 2019; Diemer et al., 2016; Ratts & Greenleaf, 2018; Seider et al., 2020) and to feel empowered to take part in action (Ratts et al., 2016; Watts & Hipolito-Delgado, 2015). Professional counselors can raise Filipino clients’ critical consciousness by engaging in conversations about how the history of colonization, endorsement of colonial mentality, and systemic factors continue to marginalize Filipinos (David et al., 2019). Connecting critical consciousness to COVID-19, professional counselors can highlight how public anti-Asian discourse echoes centuries of oppression and leads to cultural mistrust of health care providers, particularly professional counselors (Litam, 2020; Ratts & Greenleaf, 2018; Tuazon et al., 2019). Similarly, professional counselors can raise the critical consciousness of Filipino clients by discussing the effects of race-based trauma and racial violence as a result of COVID-19 (Litam, 2020; Nadal, 2021). Including these topics during counseling can be instrumental for detecting the effects of race-based trauma, such as somatic symptoms, while grasping the manifestation of pandemic stress (Taylor et al., 2020). As health care providers focus predominantly on wellness, professional counselors play a significant part in deconstructing the connections and nuances among race-based traumatic stress and pandemic stress (Ratts & Greenleaf, 2018).
Additionally, professional counselors can raise the critical consciousness of Filipino clients by examining the intersection of underlying health disparities, Filipino core values, and overrepresentation of Filipinos working in health care positions during COVID-19 through a trauma-informed lens. Aligned with this perspective, professional counselors can identify and discuss how intergenerational trauma narratives may have persisted across generations of Filipino communities (David & Okazaki, 2006b; David et al., 2019; Nadal, 2021; Tuazon et al., 2019) in ways that have adverse effects on mental health. For example, professional counselors may support Filipino clients to critically reflect on how socialized messages from parents and elders with intergenerational trauma may have contributed to the internalization of colonial mentality. Professional counselors may also broach these cultural factors by promoting discussions within clients’ families and communities about the cultural preservation of Filipino identities (Choi et al., 2017, 2020; David et al., 2017).
Culturally Congruent Coping Responses Among Filipino Clients
Professional counselors can help Filipino clients who seek counseling during COVID-19 by empowering them to engage in coping responses that cultivate their cultural assets and strengthen their ethnic identity (David et al., 2017, 2019; Woo et al., 2020). Before implementing these culturally sensitive strategies, professional counselors must reflect on whether they hold individualistic notions and Western attitudes about which coping responses are deemed helpful or unhelpful to mitigate the effects of racial discrimination (Oh et al., in press; Sue et al., 2019). Following experiences of racial discrimination and stress, Filipinos tend to use disengagement coping responses (Centeno & Fernandez, 2020; Tuason et al., 2007). Following an assessment of coping responses, professional counselors can support Filipino clients by reinforcing culturally responsive disengagement coping strategies, such as tiyaga (Tagalog for “patience and endurance”) and lakas ng loob (Tagalog for “inner strength and hardiness”), to promote resilience and demonstrate flexibility.
Given these central cultural values, professional counselors must be cautioned from solely using emotion-centered counseling strategies that center experiences of stress, racial trauma, or COVID-19–related discrimination (Litam, 2020). Instead, Filipino clients may benefit from interventions that draw from their cultural values of endurance (tiyaga) and inner strength (lakas ng loob) to refocus energy toward cultivating meaningful relationships and roles (David & Nadal, 2013; David et al., 2017). For example, Filipino clients who are concerned about the wellness of their community may experience a heightened sense of purpose and inner strength by reflecting on how their actions have already benefitted their families rather than focusing on their fears. Indeed, when stressful experiences occur, Filipinos have a long history of demonstrating resilience. Empowering Filipino clients to reflect on the historical ways that the Filipino community has evidenced resilience and inner strength may cultivate a strong sense of Filipino pride and strengthen ethnic identity as protective factors to mental health distress (Choi et al., 2020; David et al., 2019; Tuazon et al., 2019).
Filipinos may also benefit from engagement coping strategies, such as prayer, employing religious and spiritual resources, and responding with humor, to promote health and wellness (Nadal, 2021; Sanchez & Gaw, 2007). Counselors can help Filipino clients leverage engagement coping strategies by reflecting on existing responses to stress. Counselors may ask, “How have you intentionally responded to stressful events in the past?” and “How did these ways of coping impact your levels of stress?” Counselors can also demonstrate culturally sensitive strategies and lines of questioning that move from general, shared Filipino values to specific client experiences. For example, counselors can state: “Many Filipinos find peace of mind through prayer, religious practices, and humor. I’m wondering if this is true for you?” Because of the community orientation and collectivism embedded within Filipino culture, it may be helpful for counselors to elaborate on cultural contexts and relationships that inform coping strategies: “I am wondering how you may have seen some of these coping strategies in your home, family, or community. How might you have experienced a coping strategy like humor within your own community?” This statement communicates a familiarity with Filipino cultural values and creates an invitation for clients to explore their coping resources.
Creating Outreach Initiatives and Partnerships
For counselors placed in school and community settings, challenging the systemic effects of COVID-19 among Filipino communities necessitates community partnerships and integrated care settings to achieve health equity (Adia et al., 2019). Health equity initiatives call for two types of overarching efforts to sustain long-term benefits and changes. One aspect of health equity relates to developing community partnerships as a method to intentionally increase health literacy within the community (Guo et al., 2018). Increasing mental health literacy, including education about counseling services and a comprehensive approach to wellness, operates as a direct intervention to cultural and linguistic barriers that precede negative health care experiences (Flynn et al., 2020). Increasing mental health literacy in Filipino communities may also normalize the process of professional mental health services, challenge the cultural notion that those who seek mental health care are crazy, and offer strength-based language related to counseling services (Ghimire et al., 2018; Maxwell et al., 2012; Nadal, 2021). Expanding on recommendations by Tuazon and colleagues (2019), professional counselors can challenge the systemic effects of COVID-19 in Filipino communities by helping community stakeholders understand culturally responsive practices for seeking professional mental health services. Professional counselors employed in community settings can leverage opportunities to liaise with Filipino community organizations and leaders to increase the utilization of counseling services as a preventive method (Graham et al., 2018; Maxwell et al., 2012), especially in response to the increased mental health issues in Filipinos following COVID-19. Professional counselors employed in community settings are therefore uniquely positioned to broach cultural factors of colonialism and systemic racism while addressing the urgency of mental health services for Filipino communities during COVID-19 (Day-Vines et al., 2018, 2020).
Increasing Visibility of Filipino Counselors
The second aspect of health equity initiatives focuses on increasing representation in the pipeline of providers. Although Flynn and colleagues (2020) documented the importance of culturally responsive practices to buffer negative health care experiences, public health scholars have generally identified that the representation of professional counselors is crucial for encouraging historically marginalized communities to seek services (Campbell, 2019; Graham et al., 2018; Griffith, 2018). According to Campbell (2019), historically marginalized clients are more likely to pursue services and demonstrate an openness to speak with professional counselors who are representative of their communities. In addition to increasing Filipino counselors and counselor educators in the pipeline (Tuazon et al., 2019), professional counselors can enact community-based initiatives that position Filipino leaders to support the larger Filipino community (Guo et al., 2018; Maxwell et al., 2012; Nadal, 2021). For example, professional counselors can train Filipino leaders and community members to share information about coping responses (e.g., mindfulness, yoga, and diaphragmatic breathing) that mitigate the deleterious effects of racism, colonialism, and COVID-19–related stress. Professional counselors can also work with community members to establish Filipino-led wellness groups that frame discussions about stress within the broader context of health and wellness. Assessing for previous assumptions about mental health literacy may be helpful to normalize group discussions about stress and mental health. As outreach initiatives and community partnerships are established within the context of COVID-19, professional counselors must consider how they develop marketing materials for counseling services that appropriately reflect the cultural and linguistic diversity of Filipinos and invite input from Filipino community leaders (Campbell, 2019; Graham et al., 2018).
Conclusion
The cumulative effects of colonialism and racism continue to influence the mental health and visibility of Filipino communities within the global crisis of COVID-19. Unlike other AAPI subgroups, experiences of pandemic-related distress in Filipinos are additionally compounded by their distinct history of colonization, cultural values, and low levels of help-seeking behaviors. Specific interventions for culturally responsive counseling and outreach for Filipino communities are critical (Choi et al., 2017; David & Nadal, 2013; David et al., 2017; Tuazon et al., 2019) and were outlined in this article. Professional counselors, especially those in community settings, have numerous opportunities to enact a systematic plan of action that integrates culture, health, and policy (Chan & Henesy, 2018; Nadal, 2021). These interventions illuminate a longstanding and never more urgent call to action for extending efforts and initiatives to increase the visibility of Filipino communities and support individuals of Filipino descent in counseling.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Christian D. Chan, PhD, NCC, is an assistant professor at the University of North Carolina at Greensboro. Stacey Diane Arañez Litam, PhD, NCC, CCMHC, LPCC-S, is an assistant professor at Cleveland State University. Correspondence may be addressed to Christian D. Chan, Department of Counseling and Educational Development, The University of North Carolina at Greensboro, P.O. Box 26170, Greensboro, NC 27402, cdchan@uncg.edu.
Feb 26, 2021 | Volume 11 - Issue 1
Lisbeth A. Leagjeld, Phillip L. Waalkes, Maribeth F. Jorgensen
Researchers have frequently described rural women as invisible, yet at 28 million, they represent over half of the rural population in the United States. We conducted a transcendental phenomenological study using semi-structured interviews and artifacts to explore 12 Midwestern rural-based mental health counselors’ experiences counseling rural women through a feminist lens. Overall, we found eight themes organized under two main categories: (a) perceptions of work with rural women (e.g., counselors’ sense of purpose, a rural heritage, a lack of training for work with rural women, and the need for additional research); and (b) perceptions of rural women and mental health (e.g., challenges, resiliency, protective factors, and barriers to mental health services for rural women). We offer specific implications for counselors to address the unique mental health needs of rural women, including hearing their stories through their personal lenses and offering them opportunities for empowerment at their own pace.
Keywords: rural women, mental health counselors, feminist, perceptions, phenomenological
More than 28 million women, ages 18 and older, live in rural America and represent over half of the rural population in the United States (Bennett et al., 2013; U.S. Census Bureau, 2010). Researchers have discussed women’s issues as a distinct category within counseling for over 50 years, yet few counseling programs offer training specific to counseling women (American Psychological Association [APA], 2018; Broverman et al., 1970; Enns, 2017). Rural women have garnered even less attention within counseling literature and training over time (Bennett et al., 2013; Fifield & Oliver, 2016). In addition, rural mental health researchers have focused on rural populations in general, encapsulating women under the entire family unit (U.S. Department of Agriculture, 2015). However, in all environments, women experience mental health needs in unique ways (Mulder & Lambert, 2006; Wong, 2017). Although government agencies have increased efforts to alleviate mental health disparities in rural areas, there is limited research available on rural women’s mental health to guide these efforts (Carlton & Simmons, 2011; Hill et al., 2016). Thus, more studies focused on rural women can assist in comprehensive data-based decision-making efforts of federal, state, and local policymakers (Van Montfoort & Glasser, 2020). Mental health counselors who work with rural women have a unique perspective in understanding the needs of rural women and the disparities they face.
The Invisibility of Rural Women’s Mental Health
Researchers have described rural women as invisible within the mental health literature. Specifically, they have used words such as “unnoticed,” “lack of recognition,” “overlooked,” and “no voice and no choice,” which may illuminate why rural women have less access to appropriate mental health services and may underlie the noticeable absence of rural women as participants within research (Mulder & Lambert, 2006; Weeks et al., 2016). Members of rural communities have traditionally seen women as an extension of their nuclear and extended families and as responsible for involvement in community and church activities (Mulder & Lambert, 2006). Rural women, as a population with unique mental health needs, may need help (i.e., representation in research) getting their voices heard on a more macro level to promote systemic changes (Van Montfoort & Glasser, 2020). A research approach based in feminist theory may amplify the voices of rural women (Schwarz, 2017).
Feminism is a theoretical approach that evolved following the women’s movement in the 1960s, and grew to effect change in social, political, and cultural beliefs about women’s roles (Evans et al., 2005). Many of the early feminist writers spoke of women as “oppressed” and “having no voice” (Evans et al., 2005). Those words have been similarly found throughout the literature on rural women (Weeks et al., 2016). Feminist theory has traditionally challenged the status quo of the patriarchy by working to reduce the invisibility of women’s experiences (Evans et al., 2005; Schwarz, 2017). Further, feminist theory has evolved to amplify voices of all oppressed and marginalized individuals and to promote recognition of the intersectionality of identity. The feminist perspective can facilitate insight into the context of rural women’s experiences (Wong, 2017).
Challenges Faced by Rural Women
The definition of rural areas has historically been based on population size (U.S. Census Bureau, 2010). Some consider rurality a more accurate term than rural, as it may include population density, economic concerns, travel distances to providers, religion, agricultural heritage, behavioral norms, a shared history, and geographical location (Smalley & Warren, 2014). Rural women face unique needs related to the intersection of gender with race, ethnicity, age, and sexual orientation (Barefoot et al., 2015). Rural women have less access to educational opportunities, are often the head of household, and are more likely to live in poverty than urban women (Watson, 2019). Lesbian and bisexual rural women face challenges of bias, lack of support, and increased victimization (Barefoot et al., 2015). Although urban women also experience mental health issues related to motherhood, rural women often must travel long distances to services and have limited access to postpartum care (Radunovich et al., 2017). Residents in many rural communities experience food insecurity and related disordered eating with less proximity to grocery stores and limited food choices (Doudna et al., 2015). Isolation also creates a greater risk for partner abuse that is complicated by long distances to shelters, lack of anonymity, and a widely held view of traditional gender roles (Weeks et al., 2016). The lack of research regarding rural women and mental health compromises the efforts of rural counselors to provide care that is culturally responsive and efficacious (Imig, 2014). In addition, the recognized barriers of accessibility, availability, and acceptability of mental health services in rural areas disproportionally affect rural women (Radunovich et al., 2017).
Barriers to Mental Health Services
A lack of professionals, limited training for work in rural areas, high rates of turnover of mental health professionals, and limited research about rural demographics can negatively impact the quality of services (Smalley & Warren, 2014). In addition, rural residents may experience barriers such as long distances to services, adverse weather conditions, affordability of services, and a lack of insurance coverage (Smalley & Warren, 2014). Rural women may also feel reluctant to seek out mental health services for fear of loss of anonymity and the stigma attached to seeking mental health services in rural areas (Snell-Rood et al., 2019). Approximately 40% of rural residents with mental health issues opt to seek treatment from primary care physicians (PCPs), as these professionals may represent the only health care provider in the area (Snell-Rood et al., 2017). However, these professionals often have limited expertise in diagnosing and treating mental health issues (Hill et al., 2016).
Currently, the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) does not specify rurality or other cultural identities when referencing cultural competence within required curriculum. This omission may contribute to minimal specialized training, in addition to the limited research for mental health counselors to use as a guide for understanding the unique needs of rural women (Watson, 2019). Additionally, agencies have difficulty recruiting mental health counselors because of isolation from colleagues and supervisors, lower salaries, limited social and cultural opportunities, and few training opportunities specific to rural mental health (Fifield & Oliver, 2016).
Addressing Mental Health Needs of Rural Women
Given the limited research about rural women and their unique mental health needs, rural counselors are left with few evidence-based practices to utilize when working with this population (Imig, 2014). Historically, counseling researchers have equated “mentally healthy adults” with “mentally healthy adult males,” resulting in literature that is focused on best practices more appropriate for men (Broverman et al., 1970), and potentially upholding sex-role stereotypes within the fields of psychology, social work, medicine, and mental health counseling (APA, 2018; Schwarz, 2017). More recent researchers have demonstrated the efficacy of gender-specific counseling approaches (Enns, 2017). However, the approaches often do not consider the additional barriers to services that rural women may face, such as long distances to services, limited availability of mental health professionals, and the stigma of seeking services in a rural area (Hill et al., 2016).
In this transcendental phenomenological study, we sought to explore the lived experiences of licensed professional counselors (LPCs) who work with rural women in terms of their perceptions of rural Midwestern women’s mental health, and the academic training they received to prepare them for working with rural women. The study sought to answer the following research questions: (a) What are the lived experiences of LPCs who work with rural women?; (b) What are the challenges and benefits of working with rural women?; (c) How are mental health services perceived by those working with rural women?; and (d) What training, if any, did the participants receive that was specific to work with rural women?
Method
Qualitative research, by its very nature, validates individuals who may be disempowered (Morrow, 2007; Ponterotto, 2010). Phenomenology is a qualitative method that helps researchers describe the common meaning of participants’ lived experiences specific to a particular phenomenon (Creswell & Poth, 2018). In this study, the phenomenon was the lived experiences of LPCs who worked with rural women. Transcendental phenomenology (Moustakas, 1994) provided a framework for the study that began with epoché, a process of bracketing the researchers’ experiences and biases, and the collection of participant stories (Creswell & Poth, 2018). For this study, postpositivist elements of transcendental phenomenology (e.g., bracketing and data analysis) were utilized to reduce researcher biases (Moustakas, 1994). Specifically, we viewed bracketing as essential because participants might not share the feminist viewpoint of the researchers. The infusion of feminism into the study came from a constructivist/interpretivist standpoint as I (i.e., first author and lead researcher) believed—based on literature—the stories of rural women were not being heard and, thus, designed the study to help illuminate the experiences, mental health needs, and resiliency of rural women (Morrow, 2007).
Participants
For this study, participants were recruited using criterion and snowball sampling. Criterion sampling involved selecting individuals on the basis of their shared experiences and their abilities to articulate those experiences (Heppner et al., 2016). Snowball sampling allowed for selecting participants who previously had a demonstrated interest in this area of research based on their connection to other participants. Criteria for participation included a degree from a CACREP-accredited counseling program, licensure within their jurisdiction, current practice, and clinical work that included rural women. To recruit participants, we collected names and emails from a Midwestern state counseling association; however, this method produced only two responses. So, we utilized snowball sampling by asking participants to refer us to others who met our eligibility criteria (Creswell & Poth, 2018). We determined the number of LPCs needed to describe the phenomena by achieving saturation of the data collected (Heppner et al., 2016). This saturation was reflected by eventual redundancy in participant responses.
Following approval from the appropriate IRB, an invitation to participate was emailed to potential participants and included a link to a demographic form and informed consent for those who met the criteria and wished to participate. Rural areas were defined as those geographic areas containing counties with populations of less than 50,000, a definition that did not include population density but was appropriate for the Midwestern areas included in the study (Smalley & Warren, 2014). Twelve mental health counselors met the eligibility criteria for participation and enrolled in the study.
All participants had graduated from a CACREP-accredited counseling program, were licensed to practice within their jurisdiction, were currently practicing privately or in an agency, and had a clinical caseload that included rural women. The designation of LPC was used throughout the study and included all levels of licensure within the various jurisdictions. All of the LPCs reported working with a wide variety of mental health issues; three of the LPCs had addiction counseling credentials. Eleven participants self-identified as female and one self-identified as non-binary. Eleven participants self-identified as Caucasian, and one self-identified as Native American. Years of experience working as a mental health professional ranged from 4 years to 27 years, with an average of approximately 12 years. All participants reported working with both urban and rural clients, and one participant listed a reservation as the primary location for her work. LPCs’ clients included adult rural women from the upper Midwest. The rural women were single or married with children, working or unemployed, Caucasian or Native American. In addition, all the participants expressed a connection to rural areas, either through personal experience of growing up in a rural area or through connections with extended family. Each participant chose a pseudonym that is referred to throughout the manuscript.
Data Collection
We collected data through individual semi-structured interviews and participant artifacts. The semi-structured interview format allowed for more collaboration and interaction between interviewer and interviewee (Creswell & Poth, 2018). In this way, the interview format aligned with a feminist research approach and helped eliminate a power differential between researcher and participant (Heppner et al., 2016). There were 12 interview questions aimed at exploring participants’ work with rural women, participants’ perceptions of the unique mental health needs of rural women, the influence of participants’ rural heritage on their work with rural women, challenges and benefits of participants’ work with rural women, and participants’ training specific to work with rural women (see Appendix for all 12 interview questions). As lead researcher, I conducted all 12 interviews in order to maximize consistency in employing the interview protocol while allowing participants to elaborate on responses. Interviews ranged from 30–45 minutes. All research documents, such as informed consents, demographic questionnaires, and transcriptions, were securely stored on a password-protected device.
Participants were invited to share artifacts that represented their work with rural women. Artifacts could include personal letters, poems, artwork, and photos (Heppner et al., 2016). The artifacts in this study provided an opportunity for broader expression of the counselors’ experiences as well as understanding their connection to rural life. Seven artifacts were pictures of objects or individuals that inspired participants’ work with rural women, two were stories about experiences of rural women, and one was an original poem entitled “Rural Woman.”
Data Analysis
Brown and Gilligan’s (1992) research of young women and relationships utilized a Listener’s Guide for analyzing data. This guide is feminist and relational and allows researchers to pay attention to unheard voices. The Listening Guide is considered a psychological method that reflects the “social and cultural frameworks that affect what can and cannot be spoken or heard” (Gilligan & Eddy, 2017, p. 76). The method included three successive “listenings”—one for plot, one for “I” statements, and one for the individual in relationship to others (Brown & Gilligan, 1992). Throughout the listening process, I looked for and highlighted significant statements the participants made during the interview process that reflected the experiences of the phenomenon. I organized information via a phenomenological template under the heading “Essence of the Phenomenon” and included personal bracketing (epoché), significant statements, meaning units, and textural and structural descriptions (Creswell & Poth, 2018). Although a transcription service was utilized to transcribe the interviews, I read through the transcripts several times and coded data into categories or themes, which emerged organically from the transcripts. An independent peer reviewer then examined the transcriptions and helped to develop the codes and themes. We developed clusters of meaning from the significant statements into themes, followed by a textural and structural description that encompassed the significant statements and related themes. The rich and thick descriptions became the essence of the phenomenon enhanced by continual review of the interview tapes, journal notes, artifacts, and other data collected (Morrow, 2005).
Epoché
The epoché section was written from my perspective as the primary researcher and first author. I was responsible for designing the study, collecting and analyzing data, and writing the manuscript. My co-authors served as consultants in designing the study and helped to write and edit the manuscript. As the primary researcher, I sought to see the lived experiences of participants from a perspective that was free from my assumptions (Creswell & Poth, 2018). I grew up in a Midwestern rural area, steeped in traditional gender roles, while witnessing significant change for all women in expectations and opportunities. During the process of the study, it became apparent that my perceptions of rural women as stay-at-home farmwives have changed to reflect a population more diverse in ethnicity, family structure, and socioeconomic status; however, the traditional patriarchal expectations have not changed. My work as a mental health professional shaped my desire to explore the perceptions of other LPCs’ experiences of their work with rural women. Prior to the data analysis, I bracketed my personal and professional rural experiences about power differentials within rural areas.
Trustworthiness
To promote trustworthiness, I utilized self-reflective journaling, member checks, the achievement of data saturation, independent peer review, and an external audit. I kept a journal and made notes throughout the data collection process to facilitate an awareness of biases and/or assumptions that emerged during the process (Heppner et al., 2016; Morrow, 2005). I also conducted member checks, asking all participants to review and provide feedback via email on descriptions or themes (Creswell & Poth, 2018; Morrow, 2005). Frequently, participants would elaborate on themes by adding clarification to their responses to the interview questions. The “prolonged interaction” (Ponterotto, 2010, p. 583) with participants was significant for developing an egalitarian and unbiased relationship between researcher and participant. This strategy was congruent with feminist theory because it acknowledged the subjectivity of the researcher within the study and facilitated a collaborative relationship between researcher and participant (Morrow, 2007).
Coding the data into categories or themes helped arrange the large amount of data that was collected. The process was made easier by taking notes, or “memoing,” when reading through the information. The peer reviewer evaluated potential researcher bias by checking the coding against all transcripts, serving as a “mirror” that reflected my responses to the research process (Morrow, 2005, p. 254). Next, we discussed possible themes that emerged from the data (Heppner et al., 2016). I also utilized an external auditor to aid in establishing confirmability of the results rather than objectivity (Morrow, 2005). The auditor examined the entire process and determined whether the data supported my interpretations (Creswell & Poth, 2018). Both individuals had participated in phenomenological research and were not authors of this article.
Results
Analysis of the interview transcripts, the artifacts, and the journal reflections resulted in eight themes, organized into two categories. I further categorized each theme as: 1) textural, a subjective experience of the LPC’s experience with rural women; or 2) structural, the context of the experience. According to Moustakas (1994), the textural themes represent phenomenological reduction, a way of understanding that includes an external and internal experience; the structural themes represent imaginative variation, the context of the experience. One of the themes, counselor experience, fit the description of both textural and structural. The categories represented two distinct dimensions of the phenomenon: (a) LPCs’ perceptions of their work with rural women, and (b) LPCs’ perceptions of rural women and issues related to mental health.
Dimension 1: LPCs’ Perceptions of Their Work With Rural Women
Five textural themes emerged from the coding process; I took the names of three of these verbatim from the interviews. The textural themes included 20 codes that represented the subjective experiences of LPCs’ work with rural women. The participants’ pseudonyms were inserted into the direct quotes included in theme descriptions. Artifacts offered by participants were also included.
Bootstraps
Rooted in the familiar saying of “pull yourself up by your bootstraps,” this theme included codes of resilient, stoic, self-sufficient, and independent. According to LPCs’ perceptions of rural women, bootstraps described an acceptance of the current conditions of rural life and a reliance on past experiences for guidance. Many of the LPCs believed that rural women came to counseling with a skill set that, as Nancy said, “can teach us and others about how to be resilient.” Fave commented that working with rural women also required patience:
It’s this sense of “I can do this.” There are more demands with farming, and rural women still believe they should be able to do it all. When they come into counseling it can be difficult because they have worked hard to sort of protect this thing and keep it close to them because they’re pretty sure they can figure it out themselves.
Courtney shared a story about a ranch woman who was grieving the loss of her husband and was struggling with family issues. She remarked in one session, “Today I decided it was time to put on my red cowboy boots.” For Courtney, this represented her client’s resiliency and stoicism—“I’ve got this, and I’ve got my red boots on to prove it.”
Trailblazer
Trailblazer included pioneer, open-minded, resourceful, educated, and empowered; these words described LPCs’ perceptions of rural women’s abilities to move past accepting the realities of rural living and work toward change for improving themselves, their families, and their communities. According to the LPCs, this theme is distinct from bootstraps in that it is future-oriented rather than past-oriented. Elsie first referred to trailblazer when she told a story about a client who began recycling in the early 1980s: “She had bins and bins of recycling because she said, ‘I’m gonna leave this planet in a different shape than I found it.’ Rural women very much can be trailblazers.” The LPCs’ perceptions represented a new perspective that reflected resourceful change-makers, educated and empowered to challenge the status quo.
As one of her artifacts, Courtney offered a story about one woman’s determination to make Christmas special even though there were no resources for gifts and decorations. The woman found a large tumbleweed, covered it with lights and decorations, and declared it beautiful. Courtney said, “She was not just making do, but making things better.”
Challenges of Rural Women
LPCs observed multiple challenges for rural women including isolation, poverty/financial insecurity, role overload, grief, and generational trauma. Layla talked about the complex grief that was experienced by Native American women. She commented that “the death of a family member can mean losing someone from three or four generations. There is grief from loss of jobs, moving from the reservation, and loss of culture.” LPCs cited role overload as one of the most common experiences among rural women. Many rural women worked full-time jobs in addition to caring for family members while contributing to the farm/ranch operation. Jean observed that rural women “are responsible for everyone’s emotions in the family, sometimes leaving them isolated within the family.” LPCs believed that the isolation contributed to vulnerability. Rural women faced domestic violence, anxiety, depression, and addictions, exacerbated by having no one to talk with and long distances to services. Jean noted that resistance to change was perpetuated by the fear and control inherent in domestic abuse for many of her clients and led to complacency in reporting. The challenges of rural women described by participants defined the issues that LPCs faced when working in rural areas and increased their awareness of the critical needs of rural women.
Protective Factors
Protective factors included a sense of identity and the strong support systems of families and community that gave rural women “a lot of people that you can draw upon to help you through hard times,” according to Nancy. Her clients valued the easy access to nature and the opportunity to “immerse yourself in something bigger than yourself. It’s a way to build resilience and find meaning and joy spending time outside.” Layla found a strong sense of identity evident in rural Native women as central to the ability to teach their children cultural beliefs—a protective factor for future generations.
Nancy shared a picture of a family moving their 100-year-old home to a new location as her artifact. Her description of the house and rural heritage symbolized part of what she believed was important for rural women—the connection to family and heritage along with a sense of purpose in maintaining family culture. She said, “It’s a good way to pass down the family stories and even the family culture.”
Counselor Experience
Counselor experience (textural) included the reasons why participants chose to become LPCs. These included the motivations that sustained their work and advice for new counselors. Assumptions about diversity, a sense of purpose, listening, and connections to resources encapsulated this theme.
Layla became a counselor because she wanted “to give back to my Native people.” Nancy believed that the work with rural women helped her build a rural counselor identity. Woods’ early experience with rural women felt profound because of the chaos she observed in the lives of her clients, many of them impoverished single mothers struggling to survive. She was given a sense of purpose in her work saying, “These women are burned into my head.”
When asked about advice for new counselors who anticipate working with rural women, participants offered the following brief statements:
“Don’t make assumptions.” (Courtney)
“Ask to be taught.” (Marie)
“Hear their story without filtering through your own personal lens.” (Nancy)
“There is a difference in working in rural areas—a conservative mind-set, practicality—and you need to meet people where they are.” (Kay)
“Listen more than you talk.” (Suzie)
“Have respect for their culture.” (Layla)
LPCs’ Perceptions of Rural Women and Issues Related to Mental Health
Three structural themes represented what Moustakas (1994) termed imaginative variation, the acknowledgment of the context of multiple perspectives. The themes were derived from nine codes that provided a vital aspect of further describing the phenomenon. The theme descriptions included participants’ quotes and artifacts.
Perceptions of Rural Heritage
This theme represented LPCs’ view of rural life, including traditional values, heritage, and expectations/perfectionism. According to participants, many of the rural women embraced the traditional values of their rural heritage, and the roles of rural life; this theme honors that perspective. Fave talked about the expectations that rural women often have of themselves: “It’s a perfectionist perspective, meaning they can do it all.” Even in light of the increased demands on rural women’s time and energy, Marie found that rural women were often hesitant to seek outside professional mental health counseling, choosing instead to rely on family and community.
Barriers to Mental Health Services
The barriers included codes of lack of resources, stigma, and invisibility. All LPCs felt concerned about the lack of resources for rural women. Suzie talked about the dearth of women’s shelters on the reservation and resources for women who are victims of domestic violence. Suzie said, “They often stay because there are no resources for them to leave, and they can’t afford it.” Woods noted the lack of daycare providers and the fact that many rural women cannot afford these services and depend on family members for childcare. According to several LPCs, rural women do not prioritize their mental health needs, possibly because of the many demands on them.
Kay and Marie practiced in an urban area but saw many rural women who chose to travel long distances for mental health services because it gave them a sense of anonymity. Kay said, “They know if their car is parked at the counselor’s office, it won’t be recognized by everyone in town.” Rural women also feared exposing family secrets if they disclosed something to a counselor who lived in the same area.
Poignantly, LPCs acknowledged the invisibility and minimization of rural women’s mental health needs. The following comments by participants exemplified the rural woman’s experiences of being unnoticed or dismissed. Elsie stated, “Even if rural women are speaking, they don’t have the platform like urban women do, and they feel like nobody gets this life.” Kay stated, “Everything is fine, everything’s great and we’re not going to talk about the fact that Grandma is crying all the time and wearing sunglasses.”
The statements of the participants provided powerful examples of the ramifications of the silencing imposed on rural women through traditional or cultural norms. The stigma of accessing mental health services created a loss of connection between the rural women who needed the services and their community. In addition, rural women often felt selfish in seeking services just for themselves. The consensus among LPCs was that rural women suffer to a greater extent than other rural populations because their needs are minimized or not recognized. Elsie remarked that rural women do not often see their stories in mainstream media, leading them to believe “I’m living this experience that nobody else lives.”
The description of the artifact contributed for this theme may further elucidate the invisibility of rural women. Woods’ artifact was a picture of two locally designed sculptures of women. Woods said, “They are so rooted and earthy.” One sculpture had no arms or legs and, for Woods, that “speaks to the limited access to needed supports and the lack of voice.”
Counselor Experience
Counselor experience (structural) described how LPCs provide mental health services to rural women and included connection to rural life, distances and dual relationships, and lack of academic training/postgraduate training. Although not all the participants grew up in rural areas, many had rural ties through extended family. Marie’s upbringing on a ranch influenced her understanding of rural women: “There is a more intense work ethic; women are very strong and independent and hardworking.”
The LPCs seemed to feel a strong sense of purpose in their work; some of them chose to become counselors and returned to their home communities to work. They discovered that the connections of shared experiences fostered trust in the counseling relationship and process. Most felt that they were helping to make positive change. Although all participants believed the connection to a rural heritage was critical in their work with rural women, some LPCs did not live and work in the same location, saying it helped to reduce the possibility of multiple relationships. Nancy commuted almost an hour to her work “because you really want to have the counseling relationship be through your therapeutic lens and not through the community lens.”
None of the participants recalled receiving academic training specific to rural areas; however, all participants agreed on the need for academic training focused on rural areas and rural women. Elsie believed that textbooks should “include women’s voices and rural voices.” Jean expressed her concern that “We don’t necessarily address rural women or what they need from the communities around them or even what their typical experience is. I think that’s a disservice to our counseling students.”
Two artifacts aligned with this theme: Marie’s picture of a young girl, dressed in overalls, pitching hay, and Mae’s great-grandmother’s writing desk (see Figure 1). Marie’s artifact exemplified the family’s connection to rural life and the physical strength of rural women that she observed in her work. Mae now uses the writing desk in her practice and feels it gives her a strong connection to her rural heritage.
Figure 1
Mae’s Great-Grandmother’s Writing Desk
Note. Mae presented this picture of her great-grandma’s writing desk when asked to provide
an artifact that demonstrated her work with rural women.
Discussion
LPCs described rural women as strong, independent, resourceful, and resilient. However, this image of rural women was not corroborated within the research literature. An APA report on the behavioral health care needs of rural women (Mulder et al., 2000) did not mention resiliency as a coping strategy; however, in 2006, the report’s lead author recognized the need for additional research about resiliency in rural women, saying it would offer “significant potential benefit to rural women” (Mulder & Lambert, 2006, p. 15). In the present study, LPCs’ perceptions of rural women as resilient called attention to the innate strengths of rural women that developed out of necessity, cultivated by connections with family, community, and earth.
Rural heritage represented a dichotomy of rural tradition. From a positive perspective, participants believed the traditional roles of rural women provided a sense of identity and belonging. From a negative perspective, the traditional patriarchy evident in many rural areas dictated social and cultural norms, leaving rural women with the expectation that they should be able to “do it all.” Both perspectives defined a critical aspect of LPCs’ understanding of rural women. Even though many of the rural women participants described worked full-time to contribute to household income and health insurance (in addition to caretaker responsibilities), they faced gender inequities in income, employment, and educational opportunities (Watson, 2019). In addition, rural women have had little political power to effect needed policy changes for better access to care (Van Montfoort & Glasser, 2020).
LPCs highlighted multiple challenges that rural women experience: isolation, poverty, grief, role overload, and generational trauma. Barriers to obtaining services included stigma of mental health issues, loss of anonymity, a lack of resources, invisibility, and minimization of mental health issues. The general population also faces barriers of accessibility, acceptability, and availability of counseling services (Smalley & Warren, 2014); however, there were fewer references to the mental health barriers and challenges specific to rural women (Van Montfoort & Glasser, 2020). This is surprising given that the population of rural women exceeds that of any other population group in rural areas (Bennett et al., 2013). Rural women experience higher risks of depression, domestic violence, and poverty (Snell-Rood et al., 2019). The mental health services available in rural areas, often described as “loosely organized, of uneven quality, and low in resources” (Snell-Rood et al., 2019, p. 63), compound the challenges for rural women.
As evident in the themes of assumptions and diversity, rural women represent a unique population who deserve mental health services that reflect their specific needs. Rural communities and rural women are more diverse than once believed. LPCs’ observations are corroborated by research that acknowledged differences among rural women in socioeconomic status, family structure, age, sexual identity, ethnicity, education, and geographical location (Barefoot et al., 2015). In addition, there remains a misconception that the mental health needs of urban and rural women are the same; in fact, much of the literature about women and mental health is based on an urban context (Weaver & Gjesfjeld, 2014). The findings of the current study support the lack of recognition of the context of rural women’s issues and their status as an invisible population (Bender, 2016). Two LPCs’ observations of the isolation felt by rural women reinforced previous research of the invisibility of rural women. Elsie said, “Rural women don’t see their story a lot,” and Fave shared that “a lot of the women I work with don’t feel like they’re heard.”
None of the participants recalled academic training or postgraduate opportunities specific to work in rural areas or with rural women. Even though rural areas represent the largest population subgroup in the United States (Smalley & Warren, 2014), this study suggests that new counselors may not feel prepared to meet the needs of this underserved population. The shortage of mental health professionals working in rural areas and the lack of counselors who have training specific to rural mental health care suggest a need for rural-based training that might include an elective course in rural mental health and rural internships (Fifield & Oliver, 2016).
Implications
The recognition of the challenges and benefits of working with rural women may validate rural LPCs’ experiences, promote their professional identity as rural counselors, and potentially decrease the isolation felt when working in rural areas. Protective factors, including connections to family, community, and nature, may be critical for building resiliency in both rural women and rural LPCs. The increasing diversity of rural women is often contrary to the traditional stereotype of a stay-at-home farmwife (Carpenter-Song & Snell-Rood, 2017); diverse rural women may face unique barriers to accessing culturally relevant mental health services. In addition, many rural women experience role overload from working full-time and caring for families while contributing to the farm/ranch operation. Counselors should avoid interacting with rural women clients in ways that limit their identities based on stereotypes and work to make their services accessible for all women.
The study results also have implications for counselor educators. Rural-based counselors in this study did not report being taught how to work with rural women. A review of the 2016 CACREP programs found few gender-based counseling courses and none that addressed rural mental health. Programs could offer electives on counseling in rural areas, incorporate the context of gender and rural mental health into current curricula, and encourage rural internships. Collaborating with other rural health professionals may provide more informed approaches to working in rural areas. Rural residents may see their PCPs for mental health–related treatment, as PCPs may be the only health care provider in rural areas (Snell-Rood et al., 2017). Lloyd-Hazlett et al. (2020) suggested creating additional training for LPCs who choose to work in settings offering integrated care. Incorporating LPCs who have the appropriate training and skills into rural medical settings may offer mental health services in a familiar clinical context and one that does not broadcast engagement in mental health care. The collaboration may also provide more awareness of the mental health needs of rural women.
Limitations
The study has several limitations. Although I took measures to reduce any personal bias as a non-traditional rural woman, I do not believe it is possible to eliminate all biases. Many of the participants talked about empowering rural women and working toward making their clients’ voices heard, both tenets of feminist theory (Evans et al., 2005); however, participants rarely used the language of feminism. Several of the participants related personal stories of their connections with rurality and, often, their stories of rural women were from decades ago. Their stories may not have represented the current generation of rural women. Another limitation relates to the demographics of LPCs because a majority of participants self-identified as Caucasian and female and represented rural areas in the Midwest. LPCs working in other areas of the United States may encounter different demographics of rural women, mental health challenges specific to region, and unique intersections of their clients’ identities. Finally, the experiences of rural women were heard through LPCs and not from rural women clients themselves.
Directions for Future Research
This study included a sample of rural LPCs who were primarily Caucasian females from the Midwestern United States; future researchers may seek professional perspectives from participants who represent a blend of race, ethnicities, gender identities, and geographical locations. Research with rural women as participants themselves is also an important opportunity. Based on findings from this study, future researchers might also explore training needs related to work with rural women and rural populations. Studying counselor educators who teach in counseling programs based in rural areas could also offer unique insights. This may reveal information about ways educators currently infuse rural culture and work with rural women into the curriculum. Future researchers may study counselors, health care providers, and rural women in finding ways to integrate health care services in rural areas to provide better access to services and reduce the stigma often associated with mental health. Finally, additional studies about working with rural PCPs may highlight issues (e.g., intimate partner violence) that could benefit from early screening of symptoms.
Conclusion
Gilligan offers these words: “To have something to say is to be a person. But speaking depends on listening and being heard; it is an intensely relational act” (1982/1993, p. xvi). As indicated in our findings, rural women are too often invisible and unheard. This study represents a first step in amplifying the voices of rural women regarding their specific mental health needs. The experiences of the LPCs in this study have illuminated ways to connect with rural women, listen to their stories, and validate unique aspects of their cultural identities that seem to be well illustrated in one participant’s poem:
Rural Women
Resilient; stubborn; motivated
frightened; broken; courageous
Struggling; down-trodden; strong
Relentless in self-expectation
Armed with determination.
A common thread unites us
The heart gently calls, and the
soul asks only—please—listen to me.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Appendix
Twelve Interview Questions
- Tell me about what comes to mind when you think about working with rural women.
- Tell me about where you grew up and how that has influenced your work with rural women.
- Tell me about how you began your work with rural women.
- What have you learned about rural women through your work with them?
- What are the unique mental health needs of rural women that you have seen in your work?
- Tell me about some of the benefits and rewards, if any, you have experienced working with rural women.
- Tell me about some of the challenges, if any, you have experienced working with rural women.
- How have your experiences working with rural women changed you as a mental health counselor?
- Tell me about any academic/classroom experiences in your graduate program that involved the mental health issues of rural women (e.g., class discussions, special projects, conversations with colleagues, internship experiences).
- Tell me about any training experience post-graduation that have involved the mental health issues of rural women (e.g., workshops, conference presentations, webinars, conversations with colleagues).
- What would you like other counselors to know about working with rural women?
- Please describe how the artifact that you have chosen relates to your work with rural women.
Lisbeth A. Leagjeld, PhD, NCC, LCPC, LPC-MH, is a program liaison and faculty member at South Dakota State University – Rapid City. Phillip L. Waalkes, PhD, NCC, ACS, is an assistant professor and doctoral program coordinator at the University of Missouri – St. Louis. Maribeth F. Jorgensen, PhD, NCC, LPC, LMHC, LIMHP, is an assistant professor at Central Washington University. Correspondence may be addressed to Lisbeth A. Leagjeld, 4300 Cheyenne Blvd., Rapid City, SD 57709, Lisbeth.leagjeld@sdstate.edu.
