Dec 22, 2025 | Volume 15 - Issue 4
Ne’Shaun J. Borden, Natalie A. Indelicato, Jamie F. Root, Lanni Brown
In this secondary qualitative data analysis, we examined data collected between 2018 and 2023 from See the Girl: In Elementary (formerly Girls Matter: It’s Elementary), a program model grounded in Relational–Cultural Theory that intervenes early in elementary school to improve school success and relational connection, decrease suspension and expulsion, and mitigate system involvement. African American girls ages 8 to 9 comprise 79% of the participants in this study. A reflexive thematic analysis focused on two open-ended questions from a larger program assessment tool: how the girls knew that their counselor listened and how the program was helpful to them. The analysis yielded three major themes for each research question. Girls knew counselors were listening to them through active listening, therapeutic support, and authenticity. Girls stated that the program helped them develop coping and relationship-building skills and provided them with a supportive environment. Given these findings, mental health professionals and supervisors are encouraged to prioritize culturally responsive models.
Keywords: girls, elementary, intervention, relational–cultural theory, culturally responsive
School disciplinary reforms following the 1994 Gun-Free Schools Act brought about zero tolerance policies, calling for mandatory punitive measures for students who violate codes of school conduct (Kang-Brown et al., 2013). Though evidence for the efficacy of such practices is lacking (American Psychological Association Zero Tolerance Task Force, 2008; Lamont et al., 2013; LiCalsi et al., 2021), these policies have since become widespread; as of the 2021–2022 school year, 62% of schools in the United States had a zero tolerance policy in effect. Of these, 76% allowed for students to be suspended for minor or nonviolent offenses such as talking back to a teacher or being inattentive in class (The Brookings Institution, 2023). Troublingly, these policies are applied disproportionately to students of color, children from low socioeconomic backgrounds, and those with disabilities (Anderson & Ritter, 2017; Anyon et al., 2014; Brobbey, 2017; Ryberg et al., 2021; Welsh & Little, 2018). According to recent Department of Education data, while Black boys are overrepresented among students who are suspended or expelled, Black girls are almost twice as likely as White girls to face expulsion or suspension (U.S. Department of Education, Office for Civil Rights, 2023). Research has shown that students who are suspended or expelled in earlier grades are more likely to face suspension or expulsion in high school, to subsequently leave school, and to enter the juvenile justice system (Anyon et al., 2014; Novak, 2018; Skiba et al., 2014; Vanderhaar et al., 2014).
In response to these harsh disciplinary measures and in line with current recommendations from the Department of Education (U.S. Department of Education, Office for Civil Rights, 2023), several experimental school-based positive intervention programs have been implemented and studied as alternatives. The Positive Behavioral Interventions and Supports (PBIS) framework evolved in the late 1990s into School-Wide Positive Behavioral Support (SWPBS), a comprehensive system of behavioral support for the entire population of students across the school. This approach emphasizes a multitiered system of support utilizing evidence-based practices, focusing on implementing interventions that have proven effective in other packaged or manualized formats rather than relying on a standardized set of interventions (California Positive Behavioral Interventions and Supports, 2023; Sugai et al., 2000). SWPBS has been found to be a positive alternative to exclusionary discipline practices, as studies have demonstrated that schools that implement SWPBS programs with fidelity show marked decreases in disciplinary referrals and suspensions (Bradshaw et al., 2009; Gage et al., 2018). SWPBS is the most widely used school-based positive intervention program, with over 25,000 schools currently utilizing some form of this approach (Center on Positive Behavioral Interventions & Supports, 2024). Additional school-based positive intervention programs showing positive student outcomes include the Building Bridges program (Hernandez-Melis et al., 2016; Rappaport, 2014) and the Monarch Room, a trauma-informed alternative to suspension, utilized over a span of 3 years in an urban public charter school (Baroni et al., 2016).
Although exclusionary disciplinary practices have been widely adopted in U.S. schools over the past 30 years, their efficacy is not supported by the evidence, and the unequal application of such measures has raised significant concerns about equity and long-term student outcomes. Alternative interventions show promise in reducing disciplinary referrals and suspensions, particularly when implemented with fidelity and cultural sensitivity (Gage et al., 2018; Hernandez-Melis et al., 2016). Continued research and adaptation of such approaches is essential to create more equitable and effective disciplinary practices in schools.
See the Girl: In Elementary Program
Our study examines data from the Delores Barr Weaver Policy Center, conceptualized in 2007 and opened in 2013. The mission of the Policy Center is to “advance the rights of girls and elevate justice reform, gender equity, and system accountability through research-based community solutions, and bold policy—all with a girl-centered approach.” (See the Girl, n.d.). The Policy Center focuses on research, advocacy, training, and programming for girls. The See the Girl: In Elementary program (SGIE; formerly Girl Matters®: It’s Elementary) is one of the model programs developed by the Policy Center to help mitigate the impact of the school-to-prison pipeline for girls in Florida during the early 2000s. SGIE focuses on school-level interventions, one-on-one skill building, referrals for services in the community, crisis intervention, and home visits (Patino Lydia et al., 2014). Program staff oversee the delivery of these interventions and train graduate and undergraduate counseling interns to provide one-on-one support for girls. The aims of the SGIE programming model are to “1) improve school success, 2) interrupt the suspension and expulsion of girls, and 3) prevent the spiraling effect of girls entering the juvenile justice system” (Patino Lydia et al., 2014, p. 2).
In order to meet these goals, the developers of SGIE created a program underpinned by tenets of Relational–Cultural Theory (RCT; Jordan, 2017). RCT exists within a feminist framework, one that assesses beyond individual factors and recognizes the broader impact that the environment has on girls, girls’ behavior, and crimes committed by girls (Patino Lydia & Moore, 2015). At its foundation, RCT is about relationships and growth, espousing the idea that we are born to create and maintain relational connections (Miller, 1976). Noting that individualistic, Western approaches of isolation and maladaptive independence can stunt developmental growth, RCT emphasizes culture, community, and the innate desire for interconnectedness (Jordan, 2017; Lenz, 2014). Healthy developmental growth is conceptualized through the perspective of RCT as active participation in growth-fostering relationships and genuine connections with others (Lenz, 2014). Relationships defined as growth-fostering are ones that empower both members to dually affect and be affected via the “five good things” (i.e., sense of zest, worth, productivity/creativity, clarity, desire for more connection; Jordan, 2017; Lenz, 2014).
Women and girls internalize numerous identities (e.g., sister, daughter, mother) that hold the power to shape the way they interact with the world around them (Patino Lydia & Moore, 2015). Grounded in RCT, the SGIE programming model seeks to move away from “blame and pathologize” to highlighting the distinct relational features that criminal justice systems, schools, and society have overlooked in understanding girls’ development (Patino Lydia & Moore, 2015).
Purpose of the Present Study
A pilot evaluation of the program examined data collected between 2011 and 2014 and showed positive and promising results at the girl, school, and community levels, including an 84% decrease in suspensions during the 2013–2014 school year (Patino Lydia et al., 2014). Similarly, 85% of girls reported that skill building with the assistance of the counseling intern was the most helpful aspect of the program. Although the initial evaluation showed positive results, with girls reporting that they felt more confident after learning skills, research did not indicate which aspects of the girls’ interactions with their counselors were most helpful. Thus, we sought to explore what aspects of the SGIE program were most impactful for the participants.
Positive, relationally based interventions show promise in reducing disciplinary referrals and suspensions, particularly when implemented with fidelity and cultural sensitivity (Gage et al., 2018; Hernandez-Melis et al., 2016). Continued research and replication of such approaches are essential to create more equitable and effective disciplinary practices in schools. Additionally, calls for research that include perspectives from the youth utilizing programming have been made to determine efficacious, culturally responsive interventions that improve academic and social outcomes (Goodman-Scott et al., 2024; Wymer et al., 2024). Researchers conducted a secondary analysis of two qualitative, open-ended questions from 2018–2023 assessment data with girls in the SGIE program to better understand which aspects of the program and interactions with their counselors were most helpful. This study focused on two open-ended questions from a broader assessment used by the Policy Center to collect data on the girls’ experiences in the program: 1) How do you know your counselor listens to you? and 2) How has SGIE been helpful to you?
Method
Prior to accessing the data, we worked in collaboration with the Delores Barr Weaver Policy Center to learn about the SGIE program, identify the program’s assessment process, and develop appropriate research questions, after which we obtained IRB approval. The secondary data used for this study are part of a larger assessment interview of girls participating in the SGIE program. Every aspect of the Policy Center’s work is girl-centered with the aim to inform the work based on girls’ lived experiences and voices. The girl-centered approach led us to focus on analysis of two open-ended questions from the assessment across a 5-year time frame to better understand how the girls knew when their counselor was listening and how the SGIE program was helpful. Open-ended questions in research can generate responses that are meaningful to the participant, unanticipated by the interviewer, and often descriptive and contextual in nature (Goodman-Scott et al., 2024; Mack et al., 2005).
Participants
From 2018–2023, 407 girls were referred to SGIE. At the time of referral, girls were between the ages of 5 and 13 years old (M = 8.60) and ranged from kindergarten to sixth grade (M = 3.18). Girls who shared their race at the time of referral (N = 228) identified as American Indian/Native American (.88%, n = 2), Black (79.39%, n = 181), Hispanic (5.7%, n = 13), White (7.89%, n = 18), and multiracial (6.14%, n = 14).
While 407 girls were referred to SGIE, there were fewer qualitative responses included in the data analysis because of variation in assessment administration by the Policy Center, girls’ school attendance rates or changing schools, and missing qualitative data at assessment. Once we accessed the de-identified data and deleted missing qualitative data entries for the two questions analyzed, a total of 107 qualitative responses were recorded for the first research question, “How do you know your counselor listens to you?” and 109 qualitative responses were recorded for the second research question, “How has SGIE been helpful to you?”
Research Team
Prior to engaging in the study, the research team discussed our personal beliefs about effective counseling skills; how clients know whether counselors are listening; and what makes a school-based positive intervention program effective, particularly for girls. Ne’Shaun Borden is a cisgender African American woman from the Southeastern United States. She has been a counselor educator for 5 years and licensed mental health counselor for 10 years with prior professional experience as an elementary school teacher and a school-based mental health professional (SBMHP). Natalie Indelicato is a cisgender multiracial counselor educator and licensed mental health counselor from the Southeastern United States. She has been in the mental health field for 20 years; her research and clinical work have focused on women and girls’ mental health. She has worked closely with the Delores Barr Weaver Policy Center for the past 10 years as a research collaborator and clinical supervisor for student interns. Jamie Root is a White cisgender female second-year student in a Master’s in Clinical Mental Health Counseling program who has a personal and professional interest in adolescent mental health. She has resided in the Southeastern United States for the past 25 years. Lanni Brown is an African American cisgender female second-year student in a Master’s in Clinical Mental Health Counseling program with an interest in counseling justice-involved youth. Throughout the research process, we discussed how our sociocultural positions and experiences in counseling informed our understanding of the analysis. These identities and beliefs about counseling skills and effective program components were referenced in peer discussion during data analysis.
Data Analysis
Girls’ responses to each open-ended question were transcribed and analyzed following Braun and Clarke’s (2006) approach to reflexive thematic analysis. Thematic analysis is a method of analyzing qualitative data that is transtheoretical and flexible and allows researchers to identify and interpret patterns or themes found within the data using minimally structured organization (Braun & Clarke, 2006). We chose thematic analysis because it allowed us to capture themes based on quality, appropriateness of the information to the research question, and frequency of topics across the 5-year span of data collection. This approach was appropriate given the structure of the data sources and its emphasis on the active involvement of the researcher in the analytic process (Braun & Clarke, 2019).
We conducted a detailed review of all de-identified assessment data, including transcribed responses, for the two qualitative questions, using line-by-line coding to identify significant phrases. To facilitate organization and code tracking, we created a coding platform in Microsoft Excel, allowing researchers to record initial codes, note exemplar quotes, and maintain authentic, developmentally accurate, child-specific language. We interpreted meaning in context, prioritizing the participant’s intent while retaining the authenticity of developmental expression. When girls are referred to the SGIE program, parents provide consent to the assessment along with counseling services, and participants provide assent. Assessment items were administered by trained program staff, separate from counselors directly providing services, whenever possible to minimize social desirability or power influences; however, due to limited staff resources, counselors did administer assessments if other SGIE staff were not available. Additional safeguards included emphasizing confidentiality, administering surveys in private settings within the schools, and clarifying that responses would not affect program participation. Although social desirability may have influenced responses, these procedures enhanced authenticity and strengthened the credibility and trustworthiness of findings.
Independent coding further ensured interpretive rigor, centering girls’ own descriptions. Within the reflexive paradigm, consensus was conceptualized as achieving a shared understanding of patterns and meanings across the data. We collaboratively reviewed transcripts and initial codes, iteratively discussing and refining interpretations until a coherent set of themes and subthemes emerged for each question. These methods align with key standards for reporting qualitative research (O’Brien et al., 2014), including purpose, approach, description of the research team and their roles, data collection context, coding and theme development processes, strategies to enhance trustworthiness and reflexivity, and limitations.
Trustworthiness
Trustworthiness was established by emphasizing transparency in coding decisions, iterative theme development, and critical reflexivity; potential researcher bias was identified through ongoing self-reflection and addressed by maintaining reflexive individual and group note-taking, engaging in peer debriefing, and explicitly acknowledging the researchers’ positionalities in relation to the data. We recognized that our own therapeutic experiences and theoretical orientations could influence our interpretations of participants’ narratives. To mitigate this potential bias, we engaged in reflexivity by discussing our assumptions together, as well as with the Policy Center staff, and how these might shape our understanding of the data. This process involved critically examining our roles as both researchers and clinicians, acknowledging the interplay between our professional identities and the research process. By incorporating reflexive practices, such as individual and group note-taking, peer discussions, and frequent interaction with the Policy Center staff, we aimed to enhance the validity of our interpretations and ensure that the participants’ voices were authentically represented.
Findings
A total of 107 qualitative responses were recorded for the first research question, “How do you know your counselor listens to you?” Girls described how they knew their counselor listened to them in developmentally typical language indicating that they knew counselors were listening by providing eye contact, responding to what they said, answering their questions, helping them problem-solve, being respectful, and paying attention to them. RCT is the theoretical framework of the SGIE program, and girls’ focus on their relationship with their counselor and growth-fostering connections was evident. We identified three major themes: Active Listening, Therapeutic Support, and Authenticity. Major themes, subthemes, and examples from the participants are provided in Table 1.
Table 1
Research Question 1 Themes, Subthemes, and Examples
| Research Question: How Do You Know Your Counselor Listens to You? |
| Theme 1. Active Listening
Fully engaging with the girls through verbal and nonverbal cues and thoughtful responses |
| Subtheme: Nonverbal Encouragers/Body Language |
| “She had her ears on. . . . She would listen to me when I had problems with other girls.”
“She would always look in my eyes.”
“She had her eyes on me, and we had so much fun.”
“She listened to me, it was fun, and we drew pictures together.” |
| Subtheme: Open-Ended Questions |
| “She asks me questions and pays attention to me.”
“She asks what I like about myself.”
“Because she asks how I am doing.” |
| Subtheme: Minimal Encourager |
| “By looking in my eyes or shaking her head.”
“She allows me time to talk.”
“She would say something like ‘okay’ or ‘I get it’ and I knew she was listening to me.”
“When we talk, she would laugh.” |
| Theme 2. Therapeutic Support
A counseling alliance grounded in consistency, reliability, advocacy, and compassionate presence |
| Subtheme: Reliability and Consistency |
| “When I ask her something, she always answers.”
“She is there when I need help.” |
| Subtheme: Advocacy and Problem-Solving |
| “She helps me solve the problems that I have, like when I have a conflict with someone.”
“She would talk to my teacher to help me.” |
| Subtheme: Kindness and Caring |
| “She is friendly and nice.” “I can tell them how I feel in school.”
“When I told her about my problems, she would relate to them.”
“Because if I’m going through something, they’d ask me how I’m doing and care for me.” |
| Theme 3. Authenticity
Building a personal connection to create a counseling experience tailored to each girl’s unique needs |
| “Because they are curious about my life.” “When I cry, she tells me to breathe.”
“Whenever I asked a question, she replied to me.” “She responds to things I say.”
“I listen to her, and she listens to me.” “She has activities just for me.”
“When playing together, she would know stuff about me.”
“Because they respond back when I am telling my story and get more information about it and they comfort.” |
Note. Quotes included are as verbatim as possible from the child participants with light edits as appropriate.
Active Listening
Girls emphasized that they knew their counselor was listening to them when they received eye contact; open-ended questions; and encouragement to share what they were going through at school, at home, and with friends. We identified three subthemes of Active Listening, including nonverbal encouragers and body language (e.g., “She had her ears on . . . ”; “She would always look in my eyes.”); open-ended questions (e.g., “She asks me questions and pays attention to me.”); and minimal encouragers (e.g., “She would say something like ‘okay’ or ‘I get it’ and I knew she was listening to me.”). Girls paid attention to the counselors’ active listening skills to determine whether they were listening, which in turn helped the girls determine whether they could trust them and thus increase their engagement in the relationship.
Therapeutic Support
The girls identified counselors’ investment in building a therapeutic alliance and providing support as indicators of whether their counselors were listening. Three subthemes included Reliability and Consistency, Advocacy and Problem-Solving, and Kindness and Caring. Girls stated that counselors who listened were reliably available when the girls sought them out and consistent in their ability to provide support (e.g., feeling like the counselor “always answers” or “is there when I need help”). Girls shared that part of the listening process included engaging back and forth in problem-solving or determining how to advocate for themselves when they perceived unfair treatment by a friend or teacher (e.g., assisting “when I have a conflict with someone” or “talk[ing] to my teacher to help me”). Finally, girls shared that they felt supported and listened to because of the kindness and caring they received from counselors as well as when counselors were friendly in their interactions (e.g., “Because if I’m going through something, they’d ask me how I’m doing and care for me.”). Girls perceived listening as caring, which deepened trust and relational growth with counselors. They discussed knowing that their counselor was listening because of the caring follow-up questions about how the girl is doing and the counselor’s attunement and responsiveness to the girl’s emotions.
Authenticity
Girls described knowing their counselor was listening to them by the way they responded with genuine interest and authenticity (e.g., the counselor showing signs of “curiosity”). Additionally, girls indicated that they felt listened to when the counselor came to the counseling space with interventions that were individually tailored to their interests and their counselor’s knowledge of them (e.g., “When playing together she would know stuff about me.”). This included playful interventions that were fun for the girl. Girls identified play as a way for the counselor to demonstrate authenticity within the relationship. Girls knew that their counselors were listening to them when there was genuine interest within their exchange (e.g., sincere responsivity, mutual respect).
For the second research question, “How has SGIE been helpful to you?”, we recorded 109 qualitative responses. Overall, girls indicated that the program was helpful and provided a safe, supportive space for participants to express emotions, talk about problems, build coping skills, and receive support. Girls reported that the program helped improve behavior, confidence, focus, and relationships. We identified three major themes: Coping Skill Development; Relationship Building; and having a Supportive and Safe Environment. Major themes, subthemes, and examples from the participants are provided in Table 2 .
Table 2
Research Question 2 Themes, Subthemes, and Examples
| Research Question: What Helps? |
| Theme 1. Coping Skill Development
Building strategies to express emotions, manage academic challenges, and solve problems effectively |
| Subtheme: Emotional Regulation and Expression Skills |
| “It would get all my bad thoughts away, and it would make me happy.”
“Because she taught me a lot of stuff and I use that stuff at home.”
“I used to be bad and now I communicate with others.”
“I’ve learned about saying how I feel.”
“I know it helps me because my mom used to say I was like a robot, but now I’m not.”
“It teaches how to have self-control, and you can talk about stuff that I can’t say to my parents and help me calm down. They care about my issues.”
“Whenever I was going through my dad passing away, coming here and doing fun stuff helped.”
“Helps me keep calm.” |
| Subtheme: Problem-Solving Skills |
| “We get to work stuff out here.”
“If something’s wrong, I have somebody to talk to.”
“They taught me not to get into drama, like when girls are about to fight.” |
| Subtheme: Academic Skills |
| “Made a planner, did more homework, and tried new things.”
“It helps me concentrate on how to work, and it helps me understand if I’m stuck and what I should be doing.”
“We had fun and read books.” |
| Theme 2. Relationship Building
Creating connections that help girls feel seen, valued, and confident in their own strengths |
| Subtheme: Trust |
| “I trust my counselor.” |
| Subtheme: Increased Confidence and Self-Awareness |
| “Helps me feel good about myself and makes me confident.”
“Helped me see myself in a positive light.”
“I have been feeling more confident and comfortable in school.”
“Made new friends and learned things about myself.” |
| Theme 3. Supportive and Safe Environment
Providing a consistent space where girls feel safe to express themselves freely and openly |
| “Helps you with things and helps you calm down.”
“I can talk about my emotions and it’s a safe place where I can work on things.”
“It is calming because I can have a bad day at school but when I go there it’s more calming and relaxing.”
“When I’m angry, I have somewhere to go.”
“I like having girls’ conversation and you get to do a lot of fun things. Helpful because I normally don’t get to do a lot of things with girls.” |
Note. Quotes included are as verbatim as possible from the child participants with light edits as appropriate.
Coping Skill Development
Girls emphasized learning coping skills as one of the primary ways that the program was helpful. We identified three subthemes related to coping skill development: Emotional Regulation and Expression Skills, Problem-Solving Skills, and Academic Support. Girls discussed the value of learning how to better understand their emotions, communicate about how they were feeling, increase strategies for calming themselves, and reframe negative thinking (e.g., “I’ve learned about saying how I feel.”; “It teaches how to have self-control . . . ”). Girls discussed increased emotional expression at school and at home. They associated increased emotional expression and ability to regulate emotions with an improvement in communicating with peers and family members. Girls also disclosed learning how to navigate problems through utilizing school, peers, and home support (e.g., “If something’s wrong, I have somebody to talk to.”). Girls identified learning how to access academic support as a coping skill. They acknowledged that problem-solving and implementing academic and organizational skills improved their overall emotional coping (e.g., success strategies such as “[making] a planner, [doing] more homework,” and “read[ing] books.”).
Relationship Building
Girls described relationship building as a significant benefit of the SGIE program. Subthemes within this theme include Trust and Increased Confidence and Self-Awareness. Girls emphasized cultivating a trusting relationship with their counselor and gaining confidence through the relationship. Girls described the program as helping them feel more positively about themselves, more comfortable at school, and better equipped to handle conflicts. Girls attributed the program to making new friends, discovering more about their interests, and having fun.
Supportive and Safe Environment
The last theme regarding what participants found helpful about the program is the idea that it provides a place that is safe, calm, relaxing, and fun. Overall, the girls felt secure in knowing they had a safe, consistent place to go during the school day to talk about emotions and receive support (e.g., “I can talk about my emotions, and it’s a safe place where I can work on things.”). The data indicate that the program provides a calming and relaxing environment, particularly during or following stressful experiences within the school environment (e.g., relaxing after a “bad day at school” or “when I’m angry”). Additionally, fun activities were mentioned as contributing to positive experiences and feeling a connection with their counselor.
Discussion
Our study results indicate that the SGIE program was well received by program participants. Overall, girls felt that the program was helpful, that their counselors listened to them, and that they could trust their counselors. These findings support the RCT underpinnings of the program design, which emphasize the importance of connection, authenticity, and growth-fostering relationships (Miller, 1976). Active listening reflects mutuality and attunement—core competencies in culturally responsive practice. By providing consistent eye contact, nonverbal encouragers, open-ended questions, and minimal verbal prompts, counselors communicate genuine attention and respect for girls. These behaviors allow girls to feel heard and foster relational trust. In practical terms, counselors demonstrate mutuality by engaging in reciprocal dialogue, attunement by noticing and responding to both verbal and nonverbal cues, and agency by encouraging girls to guide the conversation and share concerns that matter most to them.
Therapeutic support operationalizes culturally responsive behaviors through reliability, advocacy, and caring responsiveness, which are critical for promoting agency and relational safety. Girls recognized listening when counselors consistently made themselves available; assisted with problem-solving; and advocated for girls in contexts where they experienced unfair treatment, such as conflicts with peers or teachers. These actions reflect culturally responsive competencies by attending to systemic inequities while centering the girls’ perspectives. Counselors’ kindness, follow-up inquiries, and emotional responsiveness exemplify attunement, which signals to girls that their emotional experiences are acknowledged and respected. Such behaviors strengthen growth-fostering relationships and enable girls to participate more fully in interventions, reinforcing both empowerment and trust.
Authenticity further underscores culturally responsive practice by highlighting genuine curiosity, individualized interventions, and playful engagement. Counselors who demonstrate authentic interest in each girl’s unique experiences and tailor activities to her preferences convey respect for individuality and support the development of agency. For example, incorporating play or personalized activities not only fosters engagement but also models culturally responsive competencies by creating a safe space where girls can express themselves freely. Together, these three listening themes reflect an integrated approach, ensuring that relational connections are both growth-fostering and equity-centered in under-resourced school contexts.
Implications
Counselor Education
Counselor educators in clinical mental health counseling programs provide counseling trainees with the knowledge and skills to work with individuals across the lifespan. Utilization of traditional, often monocultural, pedagogy may restrict counselor educators in their ability to train counseling students to tackle complex, culture-bound topics (Lertora et al., 2020). Though there now exists increased accountability for clinical mental health counseling programs to teach cultural competence and relational approaches within multicultural foundation courses, limited research exists regarding the implementation of culturally tailored relational processes within technique and skills courses (Lertora et al., 2020). To address this issue, we recommend that counselor educators revise the traditional transcription and recording assignment, which is a hallmark of many counselor training courses. In courses such as Counseling Children and Adolescents or Skills Training, educators could guide students to identify authenticity and mutuality as microskills, integrating these concepts into their practice and reflection.
Current findings highlight the need for educators to go beyond simple definitions toward increasingly practice-based instruction on how to best apply culturally bound relational skills within the counseling relationship. Future exploration of the continued examination of effective skills for counselors-in-training is warranted. For example, broaching grants the counselor the ability to intentionally address the cultural impact on well-being and demonstrates a holistic relational skill (Day-Vines et al., 2007). Additional efforts to attract and retain counseling students from diverse backgrounds have become a growing interest within clinical mental health counseling programs (Purgason et al., 2016) and may assist in an increasingly culturally responsive counseling profession.
Supervision
Often, novice counselors, especially when working cross-culturally with individuals from diverse backgrounds, may unintentionally overuse interventions at the expense of developing rapport with clients. This can also be seen when working with girls who have been labeled as defiant and disrespectful. A potential recommendation for overcoming this barrier is to use modeling within the supervisory relationship. Parallel processes (i.e., the replication of client–counselor dynamics brought into the supervisory relationship) can occur during supervision and are often deemed as important aspects of the process (Tracey et al., 2012). Specifically, supervisors can model RCT tenets in individual and group supervision with counselor trainees. In accordance with current findings, we propose that supervisors utilize RCT concepts while engaging in counselor supervision. A practical approach would be to incorporate an active listening self-assessment, enabling counselors-in-training to become more aware of their own listening skills. Following this, an active listening checklist could be integrated into supervision sessions. Because supervisees who struggle to listen and remain engaged in the supervisory relationship are likely to exhibit similar behaviors with clients, this checklist would provide a targeted way to identify, address, and strengthen those essential skills.
Emphasizing a relational approach, the integration of RCT components into the supervisory environment assists in the creation of a creative, open-minded space, allowing for a transformative experience and acknowledgement of the relationship between client, therapist, and supervisor (Lasinsky, 2020; Lenz, 2014). Lenz (2014) offered a relational–cultural supervision (RCS) model dually promoting the professional growth of both supervisor and supervisee as a two-dimensional approach: essential practices (i.e., RCT skill acquisition) and essential processes (i.e., relational development of supervisee). Through consistent development of RCT skills and practices identified by Lenz (2014) alongside recognition of personal and cultural influences of relationships, via the innate parallel process, the modeling interactions promote the development of competence and growth. Limited research exists applying this specific RCS model, but research supports the overall use of relational models within the supervisory relationship. In their exploration of developmental relational counseling (an integrated model founded on RCT), Duffey et al. (2016) noticed clear disparities between growth-fostering and disconnected supervisory relationships. These findings suggest an increased ability by those in healthy supervisory relationships to approach the client–counselor relationship with empathy and mutuality. Though increased research is needed within supervision literature, it is evident that supervision creates a unique opportunity for supervisors to model and incorporate underpinnings of RCT by focusing on the relationship between the supervisor and trainee through modeling mutual empathy, empowerment, and relational authenticity (Duffey et al., 2016; Lasinsky, 2020; Lenz, 2014).
School-Based Mental Health Professionals
SBMHPs such as mental health counselors, social workers, school psychologists, and school counselors are all tasked with supporting aspects of girls’ wellness within the school setting through counseling, resource sharing, staffing, testing, classroom lessons, and group counseling (Zabek et al., 2023). With limited resources and the often overwhelming responsibilities that come with these roles, various barriers to effective practice may emerge, including feelings of uncertainty on when to begin implementing programming due to time constraints, staff shortages, lack of multidisciplinary communication, and insufficient budgeting (Frey et al., 2022; Zabek et al., 2023). If SBMHPs are unable to implement a curriculum as outlined in this study, they can instead utilize relational, culturally based interventions that have been shown to positively impact adolescent girls. In a review of RCT interventions, Evans and O’Donnell (2024) identified four key characteristics that effective approaches share: mutual empathy, authenticity, empowerment, and opportunities to strengthen and deepen relational connections. The interventions reviewed included psychoeducation groups, expressive arts groups, individual counseling, and equine-assisted therapy, which could be implemented by SBMHPs as appropriate in their settings.
Further, to increase quality of care and reduce barriers, potential connections between school districts and SBMHPs with girl-serving agencies could open access to curriculum like the SGIE, which requires minimum training to implement and relies mostly on the counseling training that professionals have already received. Furthermore, SBMHPs can evaluate the effectiveness of their programs from the girls’ perspectives by utilizing the questions explored in this study as part of their ongoing assessment of services.
Future Directions
Women and girls experience unique, gender-specific realities; therefore, culturally responsive interventions and approaches are needed. Utilizing a qualitative framework allows for a richer understanding of why certain factors (e.g., active listening, therapeutic support, authenticity, coping skill development, relationship building, a supportive and safe environment) elicit a positive, beneficial experience for girls. Our study supplements existing literature by offering insights into effective, culturally responsive program delivery and client outcomes by examining which aspects of counselor interactions were most helpful. Considering the commitment for counselor education programs to continually evolve by adapting to the ever-changing needs of students, clients, and the counseling profession, current findings can be used to inform counselor education training moving forward.
Future research related to counselor training and longitudinal outcome data on girls is warranted. Patino Lydia and colleagues (2014) called for research that examines the effectiveness of the training of graduate- and undergraduate-level counselors. Given that the SGIE program relies heavily on undergraduate and graduate counselor interns to provide program interventions and that these interventions are helpful from the girls’ perspectives, future research should focus on their training to identify which aspects were most helpful for their development in order to replicate this model program in other schools. Also, longitudinal outcome data on the girls participating in the SGIE program would help determine the long-term impact of participating in girl-centered programming.
Limitations
Although this study contributes to the literature on girl-centered programs by adding qualitative data on girls’ perspectives, several limitations should be noted. The use of secondary data posed challenges, as the researchers did not design the original assessment tools, oversee implementation, or participate in data collection. The data were cleaned, organized, and anonymized prior to analysis, which may have introduced gaps affecting representation of all participant perspectives. For instance, although 407 girls were referred to the program between 2018 and 2023, only 107 and 109 qualitative responses were available for analysis for each research question, respectively. Nonresponse and missing data may have introduced bias, as participants who did not respond could differ systematically from those who provided complete data, potentially resulting in differing thematic patterns in girls’ perceptions of counselor listening and program helpfulness. Additionally, opportunities to mitigate nonresponse prospectively (e.g., participant follow-up or additional data collection) were not available. As a result, researchers relied on post hoc approaches, including examining patterns of missing data, utilizing demographics of the number of girls referred to SGIE, and considering the potential limitations when interpreting results. Finally, because the data were collected from a limited number of public schools in one large Southeastern city, the generalizability of findings to other geographic or cultural contexts is limited. Future research should employ strategies to minimize missing data during primary data collection and use analytic techniques such as weighting, multiple imputation, or sensitivity analyses to better account for possible nonresponse bias.
Conclusion
This study directly advances equity and culturally competent care for underserved girls by offering relationally based programs as an effective alternative to exclusionary discipline practices. Additionally, the study offers specific counselor behaviors that foster trust and growth in RCT-informed settings. The authors sought to explore girls’ perspectives on two specific aspects of the SGIE program: how the girls knew their counselors listened to them and which aspects of the program the girls found most helpful. Though the average age of the girls in our study was eight years old, from their developmental perspective, girls were able to identify the importance of active listening, therapeutic alliance and support, trust, and authenticity in the counseling relationship. Further, the girls identified that skill building was one of the most helpful aspects of the program, specifying the value of learning relationships and coping skills in a safe and supportive environment.
Assessing and examining girls’ perspectives on the efficacy of girl-centered programming is critical for improving program delivery and client outcomes. Gathering feedback directly from girls, almost 80% of whom were Black, provides invaluable insights into their experiences and helps identify which aspects of the counseling services are working well and which areas need improvement. Understanding their perspectives ensures that the services are culturally responsive, leading to more effective and relevant interventions. By analyzing girls’ perceptions of progress, outcomes, and overall benefit, researchers can gauge whether the programs are achieving their intended goals. This information is essential for determining the actual efficacy of interventions beyond standardized outcome measures. Girls who feel that their perspectives are valued and acted upon are more likely to remain engaged with the counseling process. By incorporating girls’ feedback into program design and implementation, programs foster a girl-centered, collaborative, and supportive environment, which can improve client retention and engagement. Finally, examining girls’ perspectives can influence policy decisions and funding allocations. Demonstrating that counseling services are valued by girls and are effective can support arguments for continued or increased funding, helping to sustain and expand beneficial programs. This approach enhances the quality of the services provided and promotes a more ethical and responsive practice in counseling. Including girls’ perspectives and prioritizing the development and maintenance of growth-fostering relationships through connection and coping skills is critical to the efficacy of girl-centered programming.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
American Psychological Association Zero Tolerance Task Force. (2008). Are zero tolerance policies effective in the schools?: An evidentiary review and recommendations. American Psychologist, 63(9), 852–862.
Anderson, K. P., & Ritter, G. W. (2017). Disparate use of exclusionary discipline: Evidence on inequities in school discipline from a U.S. state. Education Policy Analysis Archives, 25(49). https://doi.org/10.14507/epaa.25.2787
Anyon, Y., Jenson, J. M., Altschul, I., Farrar, J., McQueen, J., Greer, E., Downing, B., & Simmons, J. (2014). The persistent effect of race and the promise of alternatives to suspension in school discipline outcomes. Children and Youth Services Review, 44, 379–386. https://doi.org/10.1016/j.childyouth.2014.06.025
Baroni, B., Day, A., Somers, C., Crosby, S., & Pennefather, M. (2016). Use of the Monarch Room as an alternative to suspension in addressing school discipline issues among court-involved youth. Urban Education, 55(1), 153–173. https://doi.org/10.1177/0042085916651321
Bradshaw, C. P., Mitchell, M. M., & Leaf, P. J. (2009). Examining the effects of schoolwide positive behavioral interventions and supports on student outcomes: Results from a randomized controlled effectiveness trial in elementary schools. Journal of Positive Behavior Interventions, 12(3), 133–148.
https://doi.org/10.1177/1098300709334798
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa
Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589–597. https://doi.org/10.1080/2159676X.2019.1628806
Brobbey, G. (2017). Punishing the vulnerable: Exploring suspension rates for students with learning disabilities. Intervention in School and Clinic, 53(4), 216–219. https://doi.org/10.1177/1053451217712953
The Brookings Institution. (2023). School discipline in America. https://www.brookings.edu/tags/school-discipline-in-america/
California Positive Behavioral Interventions and Supports. (2023). https://pbisca.org
Center on Positive Behavioral Interventions & Supports. (2024). https://www.pbis.org
Day-Vines, N. L., Wood, S. M., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K., & Douglass, M. J. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85(4), 401–409. https://doi.org/10.1002/j.1556-6678.2007.tb00608.x
Delores Barr Weaver Policy Center: See the Girl. Mission, vision, values. https://www.seethegirl.org/about-us/mission/
Duffey, T., Haberstroh, S., Ciepcielinski, E., & Gonzales, C. (2016). Relational-cultural theory and supervision: Evaluating developmental relational counseling. Journal of Counseling & Development, 94(4), 405–414. https://doi.org/10.1002/jcad.12099
Evans, K., & O’Donnell, K. (2024). Relational cultural theory and intervention approaches with adolescent girls: An integrative review. Affilia, 40(1), 83–102. https://doi.org/10.1177/08861099241271296
Frey, A. J., Mitchell, B. D., Kelly, M. S., McNally, S., & Tillett, K. (2022). School-based mental health practitioners: A resource guide for educational leaders. School Mental Health, 14, 789–801. https://doi.org/10.1007/s12310-022-09530-5
Gage, N. A., Grasley-Boy, N., Peshak George, H., Childs, K., & Kincaid, D. (2018). A quasi-experimental design analysis of the effects of school-wide positive behavior interventions and supports on discipline in Florida. Journal of Positive Behavior Interventions, 21(1), 50–61. https://doi.org/10.1177/1098300718768208
Goodman-Scott, E., Perez, B. M., Dillman Taylor, D., & Belser, C. T. (2024). Youth-centered qualitative research: Strategies and recommendations. Journal of Child and Adolescent Counseling, 10(2), 66–84.
https://doi.org/10.1080/23727810.2024.2360681
Hernandez-Melis, C., Fenning, P., & Lawrence, E. (2016). Effects of an alternative to suspension intervention in a therapeutic high school. Preventing School Failure: Alternative Education for Children and Youth, 60(3), 252–258. https://doi.org/10.1080/1045988X.2015.1111189
Jordan, J. V. (2017). Relational–cultural theory: The power of connection to transform our lives. The Journal of Humanistic Counseling, 56(3), 228–243. https://doi.org/10.1002/johc.12055
Kang-Brown, J., Trone, J., Fratello, J., & Daftary-Kapur, T. (2013). A generation later: What we’ve learned about zero tolerance in schools. Vera Institute of Justice. https://www.vera.org/downloads/publications/zero-tolerance-in-schools-policy-brief.pdf
Lamont, J. H., Devore, C. D., Allison, M., Ancona, R., Barnett, S. E., Gunther, R., Holmes, B., Lamont, J. H., Minier, M., Okamoto, J. K., Wheeler, L. S. M., & Young, T. (2013). Out-of-school suspension and expulsion. Pediatrics, 131(3), e1000–e1007. https://doi.org/10.1542/peds.2012-3932
Lasinsky, E. E. (2020). Integrating relational-cultural theory concepts and mask-making in group supervision. Journal of Creativity in Mental Health, 15(1), 117–127. https://doi.org/10.1080/15401383.2019.1640153
Lenz, A. S. (2014). Integrating relational-cultural theory concepts into supervision. Journal of Creativity in Mental Health, 9(1), 3–18. https://doi.org/10.1080/15401383.2013.864960
Lertora, I. M., Croffie, A., Dorn-Medeiros, C., & Christensen, J. (2020). Using relational cultural theory as a pedagogical approach for counselor education. Journal of Creativity in Mental Health, 15(2), 265–276. https://doi.org/10.1080/15401383.2019.1687059
LiCalsi, C., Osher, D., & Bailey, P. (2021). An empirical examination of the effects of suspension and suspension severity on behavioral and academic outcomes. American Institutes for Research. https://www.air.org/sites/default/files/2021-08/NYC-Suspension-Effects-Behavioral-Academic-Outcomes-August-2021.pdf
Mack, N., Woodsong, C., MacQueen, K. M., Guest, G., & Namey, E. (2005). Qualitative research methods: A data collector’s field guide. Family Health International. https://www.fhi360.org/wp-content/uploads/2024/01/Qualitative-Research-Methods-A-Data-Collectors-Field-Guide.pdf
Miller, J. B. (1976). Toward a new psychology of women. Beacon Press.
Novak, A. (2018). The association between experiences of exclusionary discipline and justice system contact: A systematic review. Aggression and Violent Behavior, 40, 73–82. https://doi.org/10.1016/j.avb.2018.04.002
O’Brien, B. C., Harris, I. B., Beckman, T. J., Reed, D. A., & Cook, D. A. (2014). Standards for reporting qualitative research: A synthesis of recommendations. Academic Medicine, 89(9), 1245–1251. https://doi.org/10.1097/ACM.0000000000000388
Patino Lydia, V., Baker, P., Jenkins, E., & Moore, A. (2014). Girl matters: It’s elementary evaluation report. Delores Barr Weaver Policy Center. https://www.seethegirl.org/wp-content/uploads/2019/05/GMIE-Pilot-Evaluation-Report.pdf
Patino Lydia, V., & Moore, A. (2015). Breaking new ground on the first coast: Examining girls’ pathways into the juvenile justice system. Delores Barr Weaver Policy Center. https://www.seethegirl.org/wp-content/uploads/2019/05/Girls-Pathways.pdf
Purgason, L. L., Avent, J. R., Cashwell, C. S., Jordan, M. E., & Reese, R. F. (2016). Culturally relevant advising: Applying relational-cultural theory in counselor education. Journal of Counseling & Development, 94(4), 429–436. https://doi.org/10.1002/jcad.12101
Rappaport, M. (2014). Building bridges: An alternative to school suspension. Bridges.
Ryberg, R., Her, S., Temkin Cahill, D., & Harper, K. (2021). Despite reductions since 2011-12, Black students and students with disabilities remain more likely to experience suspension. https://www.childtrends.org/publications/despite-reductions-black-students-and-students-with-disabilities-remain-more-likely-to-experience-suspension
Skiba, R. J. (2008). Are zero tolerance policies effective in the schools?: An evidentiary review and recommendations. American Psychologist, 63(9), 852–862. https://doi.org/10.1037/0003-066X.63.9.852
Skiba, R. J., Arredondo, M. I., & Williams, N. T. (2014). More than a metaphor: The contribution of exclusionary discipline to a school-to-prison pipeline. Equity & Excellence in Education, 47(4), 546–564. https://doi.org/10.1080/10665684.2014.958965
Sugai, G., Horner, R. H., Dunlap, G., Hieneman, M., Lewis, T. J., Nelson, C. M., Scott, T., Liaupsin, C., Sailor, W., Turnbull, A. P., Turnbull, H. R., III, Wickham, D., Wilcox, B., & Ruef, M. (2000). Applying positive behavior support and functional behavioral assessment in schools. Journal of Positive Behavior Interventions, 2(3), 131–143. https://doi.org/10.1177/109830070000200302
Tracey, T. J. G., Bludworth, J., & Glidden-Tracey, C. E. (2012). Are there parallel processes in psychotherapy supervision? An empirical examination. Psychotherapy, 49(3), 330–343. https://doi.org/10.1037/a0026246
U.S. Department of Education, Office for Civil Rights. (2023). Student discipline and school climate in U.S. public schools: 2020–21 Civil Rights Data Collection. https://www.ed.gov/sites/ed/files/about/offices/list/ocr/docs/crdc-discipline-school-climate-report.pdf
Vanderhaar, J., Munoz, M., & Petrosko, J. (2014). Reconsidering the alternatives: The relationship between suspension, disciplinary alternative school placement, subsequent juvenile detention, and the salience of race. Journal of Applied Research on Children, 5(2). https://doi.org/10.58464/2155-5834.1218
Welsh, R. O., & Little, S. (2018). The school discipline dilemma: A comprehensive review of disparities and alternative approaches. Review of Educational Research, 88(5), 752–794. https://doi.org/10.3102/0034654318791582
Wymer, B., Guest, J. D., & Barnes, J. (2024). A content analysis of recent qualitative child and adolescent counseling research and recommendations for innovative approaches. Journal of Child and Adolescent Counseling, 10(2), 85–98. https://doi.org/10.1080/23727810.2024.2357520
Zabek, F., Lyons, M. D., Alwani, N., Taylor, J. V., Brown-Meredith, E., Cruz, M. A., & Southall, V. H. (2023). Roles and functions of school mental health professionals within comprehensive school mental health systems. School Mental Health, 15, 1–18. https://doi.org/10.1007/s12310-022-09535-0
Ne’Shaun J. Borden, PhD, LMHC (FL), is an assistant professor and program director at Jacksonville University and was a 2019 Doctoral Fellow in Mental Health Counseling with the NBCCF Minority Fellowship Program. Natalie A. Indelicato, PhD, LMHC, is a professor at Jacksonville University. Jamie F. Root, BSc, RMCHI, is a registered mental health counseling intern in Florida. Lanni Brown, BS, is a counseling student at Jacksonville University. The authors would like to acknowledge the Delores Barr Weaver Policy Center for partnering to conceptualize this project and provide the de-identified program data used for analysis. Correspondence may be addressed to Ne’Shaun J. Borden, 2800 University Blvd. N., Jacksonville, FL 32211, nborden@ju.edu.
Dec 22, 2025 | Volume 15 - Issue 4
Jacob Perkins, Harley Locklear
This study employs narrative inquiry to explore the experiences of LGBTQ+ individuals in Appalachia as they navigate addiction and recovery. From in-depth, semi-structured interviews, five central themes emerged: becoming in Appalachia, seeking refuge, reaching a breaking point, recovery in the margins, and visions of wellness. These themes illuminate the complex interplay between LGBTQ+ identity development, structural marginalization, and lack of access to affirming recovery supports in the Appalachian region. Participants’ stories reveal how isolation, stigma, and cultural expectations shape both substance use and recovery trajectories. Themes also highlight resilience, chosen family, and the reimagining of wellness beyond dominant treatment models. This work contributes to the limited scholarship on LGBTQ+ recovery in rural regions and underscores the importance of culturally responsive, community-rooted approaches to care in Appalachia.
Keywords: LGBTQ+, Appalachia, addiction, recovery, narrative inquiry
LGBTQ+ individuals stand a significant chance of experiencing social stressors due to their sexual, affectional, and gender-expansive identities (Fernandez et al., 2021; Frey et al., 2021; Krasnova et al., 2021; Lee et al., 2016; Meyer, 2003; Moon et al., 2024; Nieder et al., 2025; Shelton, 2021). The Substance Abuse and Mental Health Services Administration reports that repeated exposure to societal stigma, discrimination, and harassment can cause LGBTQ+ people to face an increased risk of mental health conditions including major depressive episodes, suicidal ideation, and substance use disorders (SUDs; HC DrugFree, 2023). If LGBTQ+ individuals do not receive emotional support from caregivers or mental health providers during moments of distress, maladaptive coping strategies including SUDs can develop as a result (Allan & Johnson, 2017; Paschen-Wolff et al., 2024; Shelton, 2021; Zuccarini & Karos, 2011). Therefore, when working with LGBTQ+ clients navigating recovery from SUDs, counseling practitioners must conceptualize the individual’s symptomatology within the larger sociocultural factors that contribute to each person’s sense of relational disconnection (Allan & Johnson, 2017; Zuccarini & Karos, 2011).
Although the correlation between environmental stressors and substance use within LGBTQ+ communities has been extensively documented (Chaney & Mason, 2024; Fernandez et al., 2021; Lee et al., 2016; Meyer, 2003; Moon et al., 2024; Nieder et al., 2025; Shelton, 2021), there remains a critical need for qualitative inquiry that centers the voices of LGBTQ+ individuals pursuing recovery from SUDs (Chaney, 2019; Paschen-Wolff et al., 2024). Furthermore, most of the existing research on substance use treatment tailored to LGBTQ+ individuals consists of data sourced from highly populated urban areas where LGBTQ+–affirming resources are more readily available (Frey et al, 2021; Lavender-Stott et al., 2018; Nieder et al., 2025; Pachankis et al., 2020; Paschen-Wolff et al., 2024; Senreich, 2010; Ware et al., 2023), highlighting the need for firsthand accounts of recovering LGBTQ+ individuals residing in rural locations. Although the American South contains the highest concentration of substance use disorder treatment facilities nationwide (Ware et al., 2023), programs tailored to LGBTQ+ populations are disproportionately located in the Northeast and West (Qeadan et al., 2022). Given this gap, the present study utilized qualitative interviews and Meyer’s (2003) minority stress theory to explore the following research question: What are the lived experiences of Appalachian LGBTQ+ individuals pursuing recovery from substance use disorders? Our primary aims were to examine the complex issues contributing to SUDs in Appalachian LGBTQ+ communities, identify factors that sustain recovery for these individuals, and inform culturally responsive treatment interventions for mental health providers working with this population.
Literature Review
Minority Stress and Substance Use Disorders
Meyer (2003) created the minority stress theory to illustrate the link between LGBTQ+ individuals’ experiences of their social context and their sense of well-being in the world. Meyer (2003) views the “social environment as providing people with meaning to their world and organization to their experiences . . . interactions with others are therefore crucial for the development of a sense of self” (p. 675). LGBTQ+ people often encounter adversity ranging from microaggressions to acts of violence, interactions with the dominant heterosexual/cisgender culture that can negatively shape their self-perception. Meyer (2003) defines two types of minority stressors: distal (e.g., discrimination, sexual and physical victimization) and proximal (e.g., internalized homophobia/transphobia). Within the LGBTQ+ population, social stigma has historically led to isolation, lack of integration with one’s community, and subsequent issues with identity development (Allan & Johnson, 2017; Meyer, 2003). Additionally, Meyer (2003) reports that “internalized homophobia, or the gay person’s direction of negative social attitudes toward the self, can further lead to a devaluation of the self and resultant internal conflicts and poor self-regard” (p. 682). Meyer (2003) takes care to note that it is the process of marginalization that contributes to poorer mental health outcomes, not the holding of an LGBTQ+ identity itself.
One of the ways LGBTQ+ individuals cope with minority stress and negative self-image is through substance use (Chaney & Mason, 2024; HC DrugFree, 2023; Meyer, 2003; Moon et al., 2024; Nieder et al., 2025; Paschen-Wolff et al., 2024; Shelton, 2021). Shelton (2021) notes that LGBTQ+ individuals who report at least one SUD were significantly more likely to have experienced internalized homophobia than those who did not report an SUD. LGBTQ+ individuals may also use substances to soothe anxiety that comes from having to disclose one’s sexual, affectional, or gender-expansive identity (Frey et al., 2021; Shelton, 2021); to lessen the burden of concealing one’s identity to avoid potential discrimination (Allan & Johnson, 2017; Frey et al., 2021); or to alleviate the deleterious symptoms of post-traumatic stress disorder (Johnson, 2019; Meyer, 2003). In each of these examples, social isolation from the dominant heterosexual/cisgender culture underpins the LGBTQ+ person’s need for substances to mitigate the mental health symptoms stemming from minority stress.
LGBTQ+–Affirming Substance Use Treatment
Although LGBTQ+–affirming treatment for SUDs has shown to be effective in reduced reliance on or sustained abstinence from substances (Krasnova et al., 2021; Nieder et al., 2025; Paschen-Wolff et al., 2024), scholars have noted a lack of research, treatment protocols, and facilities catering to the specific needs of this population (Chaney, 2019; Chaney & Mason, 2024; Guy et al., 2023; Ware et al., 2023). When pursuing recovery in residential or outpatient health care facilities, many LGBTQ+ patients have noted stigma, harassment, and alienation from providers or fellow patients that mirrored their experiences of minority stress in the outside world (Gorritz FitzSimons & Byrd, 2025; Micale et al., 2025; Paschen-Wolff et al., 2024; Senreich, 2010). These unfavorable conditions have been associated with elevated rates of relapse, leaving treatment prematurely, and dismissal of treatment as a viable option altogether (Chaney & Mason, 2024; Paschen-Wolff et al., 2024).
Conversely, when LGBTQ+ individuals have engaged in treatment tailored to their population, patients reported higher rates of sustained abstinence and satisfaction with recovery (Chaney & Mason, 2024; Guy et al., 2023; Nieder et al., 2025; Paschen-Wolff et al., 2024; Senreich, 2010). Paschen-Wolff et al. (2024) emphasize that in settings often marked by stigma, the presence of even one staff member advocating for LGBTQ+ inclusion offered participants a sense of safety and belonging, helping to ease experiences of fear and isolation. In addition to LGBTQ+–affirming staff members, building community with other LGBTQ+ people while pursuing recovery can mitigate the ramifications of minority stress that may contribute to substance use relapse (Kidd et al., 2018; Nieder et al., 2025; Paschen-Wolff et al., 2024). As Gorritz FitzSimons and Byrd (2025) state, companionship, opportunities to discuss trauma related to LGBTQ+ identity, and diversity within substance use counseling are three considerable benefits that arise from LGBTQ+–affirming treatment programs, especially if the program welcomes discussion of intersecting sexual and racial/ethnic identities (e.g., LGBTQ+ Black, Indigenous, or people of color).
LGBTQ+ Recovery in Appalachia
If empirical and qualitative data supports that LGBTQ+–affirming treatment increases the likelihood of LGBTQ+ individuals achieving and sustaining recovery, what are the experiences of this population in rural areas with less access to culturally responsive substance use treatment? Although the American South has the greatest number of substance use disorder treatment facilities when compared to the West, Northeast, and Midwest regions (Ware et al., 2023), LGBTQ+–tailored programs were more likely to be found in the Northeast and West (Qeadan et al., 2022). These findings suggest geographic sociocultural views may contribute to the availability of culturally responsive interventions for this population (Frey et al., 2021; Ware et al., 2023). Frey et al. (2021) found that 100% of their North Carolina–based study participants had experienced stigma because of their sexual identity; many of them inferred that politically conservative and faith-based views contributed to the discrimination they had faced. For example, the implementation of legislation such as House Bill 574 and Senate Bill 49 in North Carolina supports these participants’ concerns about their sociopolitical climate impacting their ability to safely express their LGBTQ+ identities (McClellan, 2023). These pieces of legislation force transgender athletes to play on teams associated with their “reproductive biology and genetics at birth” and limit discussions of gender identity in K–4 classrooms, respectively (McClellan, 2023). Additionally, the lack of LGBTQ+–specific treatment in the Southern region has been attributed to fewer LGBTQ+ individuals living in sparsely populated areas (Ware et al., 2023). For these rural LGBTQ+ individuals pursuing affirming recovery options, the closest option may be many hours or states away (Nieder et al., 2025; Senreich, 2010).
When considering Meyer’s (2003) minority stress theory, negative societal views toward LGBTQ+ people can produce distal and proximal stressors, which, as stated previously, have been shown to increase the likelihood of SUDs. If geographic barriers further limit access to LGBTQ+–affirming treatment, these SUDs are more likely to remain untreated (Senreich, 2010). To that end, scholars have called for further qualitative research to ascertain LGBTQ+ experiences of stigma and mental health treatment in rural regions (Frey et al., 2021; Nieder et al., 2025; Senreich, 2010; Ware et al., 2023).
Method
Narrative Inquiry
Narrative inquiry, rooted in interpretivist and constructivist paradigms, is centered on the belief that humans make meaning of their lives through stories (Clandinin, 2022). It is particularly well-suited for research involving marginalized populations, as it prioritizes their lived experiences and resists reducing individuals to overly simplified categories or variables (Bruner, 1991; Hendry, 2007). Within this methodology, the researcher’s positionality is acknowledged as integral to both the co-construction and interpretation of participants’ stories, as meaning emerges relationally between storyteller and listener (Clandinin, 2022). We chose to utilize this particular methodology because it allowed for the centering of the voices contributing their stories (Clandinin, 2022).
This study aimed to explore the recovery stories of LGBTQ+ individuals living in the Appalachian United States. Our inquiry was driven by the following research question: What are the experiences of LGBTQ+ Appalachians who have been able to sustain recovery? This approach focusing on personal narratives allowed for the exploration of how LGBTQ+ participants construct and make sense of their identities in traditionally conservative rural contexts and how those identities intersect with substance use, recovery, and access to care. Stories offered nuanced insight into not only individual recovery trajectories but also the broader sociocultural and geographic landscapes that shape them.
Participants
Participants in this study were individuals who identified as LGBTQ+, had lived experiences with addiction, had been in an active state of recovery for at least 90 days, were currently residing in the Appalachian United States, were 18 years of age or older, and had access to Zoom. We engaged in purposive and snowball sampling strategies, which were particularly appropriate given the close-knit, often private nature of the LGBTQ+ Appalachian community. These methods facilitated access to participants who might otherwise be difficult to reach due to concerns about stigma and confidentiality. A digital research flyer containing an invitation and link to our informed consent document and eligibility screening demographic survey was distributed through LGBTQ+ social media groups and professional networks within the Appalachian addiction recovery community.
Six individuals responded and were admitted to the study. Their demographic information is presented in Table 1. Although our sample was diverse in terms of sexual, affectional, and gender identity, all participants identified racially as White. Additionally, the age distribution of participants ranged from 30–45, not representative of younger and older adults.
Data Collection
Participants who responded to the research call completed a demographic questionnaire via QuestionPro as a prescreening mechanism. Here, they also denoted their preferred pseudonyms, which were used to protect their privacy and confidentiality. For respondents who met the inclusion criteria, we scheduled 60–90-minute interviews that were conducted via Zoom and transcribed verbatim using Otter.ai. We developed a semi-structured interview protocol informed by minority stress theory (Meyer, 2003) and existing literature centered at the intersection of LGBTQ+ identity and substance use (Chaney & Mason, 2024; HC DrugFree, 2023; Meyer, 2003; Moon et al., 2024; Nieder et al., 2025; Paschen-Wolff et al., 2024; Shelton, 2021; see Appendix). Interview questions sought to capture the narratives of our participants, placing emphasis on storytelling. We debriefed after each interview to discuss emerging themes and to engage in reflexive dialogue about how our own experiences impacted our perception of the participant interviews. Both researchers kept a reflexivity journal for trustworthiness and bias-checking purposes.
Table 1
Participant Demographics
| Pseudonym |
Gender Identity |
Sexual/Affectional Identity |
Pronouns |
Racial Identity |
Age |
| AvP |
Cisgender Female |
Lesbian |
she/her |
White |
42 |
| Michael |
Nonbinary |
Trixic |
they/them |
White |
45 |
| Alan |
Cisgender Male |
Gay |
he/him |
White |
30 |
| Avery |
Cisgender Male |
Gay |
he/him |
White |
31 |
| Em |
Nonbinary |
Queer |
they/them |
White |
32 |
| Beans |
Genderqueer |
Pansexual |
he/they |
White |
44 |
Data Analysis
Upon completion of data collection, we reviewed all transcripts for accuracy and to familiarize ourselves with the data, noting points of convergence and divergence across participants’ accounts. Transcripts were then uploaded into Atlas.ti, a qualitative coding software, for the purpose of facilitating data analysis. In alignment with paradigmatic narrative analysis (Polkinghorne, 1995), we sought to identify themes across participant stories that revealed shared meaning, recurring challenges, and sites of hope. We began with a round of open and in-vivo coding, allowing the participants’ language to inform initial codes. Although we did not use a code book, we did engage in consensus coding to ensure that both researchers were in alignment with primary codes. We met after coding each transcript to discuss divergences in our codes and to provide transcript-based rationale to come to consensus and to minimize researcher bias. In the second round, we generated axial codes to begin organizing patterns across the data. These coding strategies primarily served to group participants’ stories for narrative analysis, with particular attention paid to how meaning was constructed within each narrative and how that meaning varied or aligned across participants. Through this iterative process, we identified five overarching themes that illustrate the participants’ experiences.
Trustworthiness
To ensure ethical rigor and transparency, several strategies were employed to enhance the study’s credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Institutional Review Board approval was obtained prior to recruitment and data collection. Credibility was strengthened through meaningful engagement with participants, iterative data analysis, and participant member checking. Regarding member checking specifically, participants were provided copies of their transcripts and associated codes and were offered the opportunity to provide feedback, make edits, or provide additional context to their interviews. Transferability was addressed by providing thick, contextualized descriptions of participants’ experiences, settings, and sociocultural climate within Appalachia.
To promote dependability, the research team maintained a detailed audit trail that documented methodological decisions and changes made throughout the research process. Research reflexivity was supported through individual and team reflexivity journaling, memoranda, and positionality discussions conducted before, during, and after data collection. This was essential considering the positionality of the researchers to the research topic. Regular research meetings were used to bracket assumptions and collaboratively interrogate emerging interpretations. During the data analysis process, we considered the participant transcripts, research memos, and research positionality statements provided below to engage in triangulation. This enhanced confirmability and ensured that findings were grounded in participants’ narratives rather than researcher preconceptions. Finally, participant voices were centered in the findings through rich description and extensive use of direct quotations.
Research Positionality Statements
Jacob Perkins
As a gay cisgender White male in recovery from chemical addiction and a current graduate student in clinical mental health counseling, my personal and professional identities inform this research. I got sober in New York City, where LGBTQ+–centered recovery spaces were more accessible. Since relocating to Appalachia, I’ve experienced firsthand the scarcity of culturally affirming support systems for LGBTQ+ individuals in recovery, particularly within Appalachian contexts. This gap has influenced my decision to explore LGBTQ+ Appalachian recovery narratives.
My recovery journey has been shaped by the intersection of my sexual identity and substance use, and this lens influences how I approach both the topic and the participants. I occupy a dual position as both insider and outsider: I share lived experience with many of the individuals whose stories I seek to understand, yet I also recognize the diversity within LGBTQ+ communities and the unique cultural dynamics of Appalachia. My aim is to amplify voices that are often marginalized in recovery discourse and to contribute to the development of services that are both culturally competent and personally resonant—services I would have benefited from in my own early recovery.
Harley Locklear
As an Indigiqueer person and counselor educator who has been impacted by the prevalence of substance misuse in my communities—rural, LGBTQ+, and Indigenous—I approach this research with both lived experience and a deep professional and communal commitment to improving substance use treatment and recovery outcomes. My positionality informs how I understand healing, resilience, and systemic inequity, as well as how I interpret participants’ narratives of recovery. I recognize that my insider perspectives afford unique insight into the cultural and relational dynamics shaping addiction and recovery in these contexts yet also require continuous reflexivity to ensure that my interpretations do not overshadow participants’ distinct experiences.
Findings
Five overarching narrative themes emerged that encapsulate the reconstructed stories of our participants. These themes are presented both chronologically and thematically, tracing a journey from growing up LGBTQ+ in Appalachia, through experiences of addiction and recovery, and culminating in a reimagined vision of LGBTQ+ sober joy in the region.
Becoming in Appalachia: Formative Experiences of LGBTQ+ Identity Development
Each participant detailed experiences of nonaffirming messaging regarding their LGBTQ+ identity during childhood and adolescence. In Appalachia—where each person in our study came of age—religious, familial, and sociocultural ideologies about sexual/gender minorities contributed to a sense of alienation, shame, and identity confusion. Michael (45, nonbinary, they/them, trixic) recalled a sentiment expressed by many of the participants: “I was told by my church when I was 12 that I was going to hell.” Beans (44, genderqueer, he/they, pansexual) echoed this statement when they said: “[The church] always told me that I was going to die if I left . . . and that I was going to go to hell.”
Alongside these faith-based doctrines, participants’ families of origin often impacted identity development. Alan (30, cis male, he/him, gay) stated:
I come from a very conservative background . . . I didn’t really receive a lot of education on acceptance of different people or differences within myself, so I didn’t really understand . . . the feelings that I was experiencing, or attractions that I tended towards.
Regarding culture, AvP (42, cis female, she/her, lesbian) expressed that Appalachian norms informed her reservations about disclosing her sexual identity: “Growing up here . . . [an LGBTQ+ identity] just wasn’t acknowledged. It was sort of like pushed down. . . . I was afraid to discuss my same-sex attraction.”
As a result of these early encounters with discrimination and stigma, all participants noted that identity concealment became a crucial way to lessen the possibility of social rejection and/or violence. Avery (31, cis male, he/him, gay) described masking as a learned ability:
I’d mastered this skill of duality. I was able to present one image to the public . . . while withholding what was really going on, or how I really felt . . . and that was a skill that I had really honed during my adolescence, when I was hiding who I was as a homosexual.
Others sought to hide their LGBTQ+ identity by entering and sustaining heterosexual partnerships. Michael explained an early “lavender relationship” as an attempt to “make my parents happy by marrying,” which turned out to be “a very miserable experience for me and unfortunately for my husband. I had to almost put on a mask and become somebody else.”
Although all participants encountered forms of marginalization related to their minoritized sexual/gender identities in Appalachia, many of them also detailed moments of acceptance and affirmation in their communities. AvP discussed coming out to her godmother:
I was like, “I just kind of have to tell you something. . . . Maybe I’m not going to have a boyfriend.” And she was like, “Are you trying to tell me that you’re gay?” And I was like, “Probably.” And she was like, “You think I didn’t already know that?” So, she was much more accepting than I imagined.
Similarly, Avery “never really struggled . . . with [his] parents when it came to coming out as homosexual.”
While some participants received support for their LGBTQ+ identities from their families of origin, others found it through chosen family. Em (32, nonbinary, they/them, queer) said, “I was engaged in a lot of environmental justice work in the area. . . . What community I did have, queer community, were generally people from other areas who had come to Appalachia to fight the pipeline.” This support from participants’ immediate environments—familial or peer-to-peer—proved even more important amidst the anti-LGBTQ+ rhetoric many of them witnessed in the larger cultural atmosphere. Michael said:
I would go to school auditorium functions, and they would have not necessarily blatantly anti-LGBTQ stuff, but it would be kind of obvious that they were hinting at the fact that good people don’t do these things, and that was just the way proper society was. So that’s the kind of shorthand that I grew up with. I grew up with the knowledge that certain people were not safe, like Jerry Falwell or Jim Bakker. And [the queer community], we would tell each other who was safe and who was not.
These formative experiences of identity suppression, religious trauma, and social marginalization shaped the conditions under which substance use became a meaningful, if often dangerous, response. For each participant, the initiation into drugs or alcohol was not merely recreational; it reflected a deeper negotiation with an LGBTQ+ identity in environments that denied its legitimacy. Substance use functioned as self-medication, camouflage, relational currency, or even rebellion against the roles they were forced to inhabit.
Seeking Refuge: Precipitating Factors With Substance Use
As identity concealment pervaded participants’ formative social interactions, substances provided many of them with momentary bouts of courage to explore salient parts of self that they hid out of necessity. Michael stated, “I was more queer when I was drinking than I was when I was sober. It freed me up to express who I really was, and it was like taking the mask off. It was liberation.” Michael also conveyed that substances provided a safeguard if others questioned their sexual identity: “[Substances] gave me an excuse. Because if something were to have happened and my parents caught me, ‘Oh no . . . I’m not gay. I was just drunk.’” Alternatively, Avery stated that substances “helped [him] combat some of the feelings and emotions that [he] was having . . . that [he] didn’t know how to express” or wasn’t comfortable feeling. Drugs and alcohol could either inhibit or inspire a participant’s identity expression, depending on their circumstantial need.
Because social alienation often dominated participants’ daily lives, substances sometimes offered the comfort of connection. Alan explained: “The group that I started to get to know while using drugs, there was much more acceptance. . . . [There was] no judgment in those circles.” Similarly, AvP discussed how her early drug use was entangled with romantic validation in her first same-sex partnership:
I met this girl. . . . She’s the one who introduced me to drugs. . . . I really was in love with this chick, and I was, like, willing to do whatever to do that relationship. I would have done anything to have [my LGBTQ+ identity] be normalized . . . the substances were like an afterthought. I don’t know that I would have actually participated in [drug use] if it wasn’t for, like, the desire to feel normal and to feel validated in those feelings.
When this connection was not achieved, however, some participants used substances as a coping strategy. Em discussed the escalation of substance use that came with being the only LGBTQ+ person in most spaces: “Whenever I came back [to Appalachia] . . . there was never a place I could go where . . . I wasn’t one of the only queer folks, if I wasn’t the only one. . . . The environment that I [used substances] in was very lonely.”
Lastly, some participants felt empowered by their substance use as a form of rebellion. As a response to the anti-LGBTQ+ messaging they received through their church, Beans said:
I figured that if I was going to sin and I was going to die, I was going to do it in a fun way. So my ass took off to New Orleans, and I didn’t sober up for the month that I was in New Orleans, and then I hitchhiked across the U.S. and spent 18 months on the road. . . . And there was always weed. And then there were people with [cocaine]. And [cocaine] was amazing. . . . It slowed my brain down. Because I went from like all of this confusion and everything in the church and always being told that if I just prayed hard enough, all of the shit in my head would go away, and then suddenly I’m like, “Oh my god. . . . Maybe this is what normal people sort of feel like.”
Together, these narratives illustrate how substance use served as a complex mechanism for survival and self-exploration. For many participants, substances were not merely a form of escape—they were a means of negotiating visibility, accessing belonging, and reclaiming autonomy. While this experimentation with drugs and alcohol introduced varying degrees of risk and harm, it also provided an entryway into LGBTQ+ identity exploration.
Reaching a Breaking Point: Pivotal Moments in the Recovery Journey
For all participants, the initiation of substance use arose not only from impulsivity or peer influence, but as a response to chronic marginalization. After developing a reliance on substances, each of the participants described distinct turning points when their relationships with drugs or alcohol shifted from coping mechanisms to sources of harm. These revelations regarding physical dependence, interpersonal strain, and emotional rupture led to participants’ initial attempts at recovery.
Physical dependence and withdrawal symptoms were many participants’ first hints at their problematic relationship with substances. Michael recalled, “I started shaking really bad in the morning, and I didn’t ever know if it was nerves or the alcohol or what, but I did know that if I drank, it would stop.” Avery detailed the reckoning with his dependence:
When you’re in jail, you have all these thoughts, “I’m going to change. My life is going to be different.” I said everything I needed to say to get out of jail. My boyfriend picked me up . . . and within 30 minutes, I was high . . . using drugs again. It took about 2 weeks for me to get re-arrested on felony possession charges. . . . I had come to a realization . . . the second time I was in jail, that, like, I’m not cut out for this. . . . I’m not going to do well in jail, and I had to take . . . some responsibility.
Secondly, each participant remembered how substances impacted their close relationships. Michael stated, “When I was 21, I got drunk and slept with my husband’s roommate. . . . I said, ‘No, I can’t do this anymore, I’m hurting way too many people.’” Em said, “I was living with two friends. My substance use was getting to the point where it was impacting our relationship, and they finally decided that they needed to move out and . . . de-escalate our friendship.”
In addition to physiological ramifications and interpersonal strain, all participants noted moments of emotional rupture and clarity related to their substance use. AvP stated:
I had burnt all my bridges at this point. When I got out of jail . . . I was sitting outside, and I remember looking up at the sky, and I was like, “Wow. The sky is so pretty.” That sounds, like, so wild, but I never looked up. And I was sitting there, and I was like, “Okay, maybe you should really . . . do what these people want you to do, and that way, if you try it for a year, when you do go back on the street, you’ll know you did everything you could.”
Beans recognized that their substance use was impeding their treatment for nonsuicidal self-injury:
My cutting became really extreme. . . . I ended up contacting a friend of mine when I was kind of in the depths of despair, and I disassociated so much that I woke up, and it was a horrific scene of self-injury, and I was like, I just can’t do this anymore. And he picked me up and took me home. . . . And I realized that I had to stop . . . because I knew that I needed to take meds to help with my self-injury and my depression. And if I drank with that, then it could really fuck with the rest of my world.
Em detailed their critical breaking point:
I had a night where I drove, I think, very much intending to end my life, and at one point something changed. Instead, I drove to my mom’s house . . . where she basically said, “I buried my younger brother when I was 12 years old. I had to become . . . the person holding my family together and . . . that’s made it hard for me to always hear you and see you. I don’t know how to fix [your reliance on substances] . . . but I don’t want to bury my child the way I buried my brother.” And I think that full vulnerability . . . from my mom . . . that was maybe the biggest moment where I was like, “I’ve got to make a change.”
Each participant’s journey toward recovery began not with a singular decision but through cumulative contemplation. These moments catalyzed a recognition that substance use was no longer a refuge but a source of harm. What followed was a complex process of seeking support—not simply entering treatment but infusing their recovery with personal meaning.
Recovery in the Margins: Turning to Chosen Supports
Although many of our participants pursued traditional recovery routes, it was consistently emphasized that there was a devastating lack of LGBTQ+–affirming recovery services within Appalachian communities. These barriers to care resulted in experiences where participants felt alienated, unsafe, or discontent, forcing them to turn inward and focus on the strength of their personal networks.
Participants’ experiences with 12-step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) were mixed. Some found resonance and stability through structure and sponsor relationships. For example, AvP described a turning point:
I rode my bike to an AA meeting, and I got a sponsor, and I began the process, and I just dove in. . . . They really reached a nerve in me. . . . I went through the 12 steps, and I really never looked back.
Michael similarly recalled feeling immediate rapport: “Something about the way they talked about drinking clicked with me, and I knew I fit with these people.”
However, for others, the culture and rigidity of these programs was discomfiting, particularly when compounded by heteronormative or religious undertones. Alan recounted the judgment he experienced: “I’ve been told, while clean and sober from somebody who just relapsed, that my recovery is bullshit because I didn’t work 12 steps. I got a really bad taste of NA in my mouth.” Michael also noted that although they found affirmation in certain spaces, the lack of turnout for LGBTQ+–specific meetings reflected ongoing stigma: “There used to be an LGBTQ AA meeting, and it folded because nobody showed up. . . . People are willing to go to AA meetings and admit they’re alcoholics but not show up to an AA meeting specifically for queer people.” These accounts were consistent among participants, denoting a lack of LGBTQ+–centric addiction and recovery programs and interventions.
Participants also spoke to the emotional toll of navigating recovery in the absence of visible LGBTQ+ exemplars. Avery said, “I didn’t have any role models within my community to look up to that had gotten sober and maintained that sobriety.” Alan confirmed that “all [he] saw were the gay drug addicts . . . that were described to [him] by family and friends.”
Even after achieving a state of recovery, LGBTQ+–specific resources remained scarce. Avery reflected that since he’s “gotten sober and really started the journey of recovery, [he’s] not really found anything super productive or helpful locally for the gay recovery community.” Michael expressed the need for sober LGBTQ+ spaces: “We’ve had several discussions where we’ve talked about starting a coffee club for the gay community . . . because there aren’t enough places, queer or not, where you can hang out that aren’t bars.”
In place of formal support systems, many participants sought emotional safety and trust through chosen family and peer-based strategies. Beans described how their friends intuitively practiced harm reduction:
I was like, “I haven’t had a drink in months, but I’m gonna go out and lose myself in it.” And they’re like, “Hey, why don’t we get a tattoo or a piercing?” And that moved into, oh, that’s the same feeling I get when I self-harm or drink. So why don’t I body mod [instead]?
Beans emphasized “that mutuality and community support 100% keeps [them] sober and level.” Similarly, Alan credited his recovery to interpersonal accountability: “The expectations of somebody else . . . is what keeps me sober.” Michael summed it up simply: “To be able to laugh . . . and to have a safe space where everyone can talk freely . . . that’s what I would like to find.”
These narratives point to the resilience fostered by LGBTQ+ communities without formal supports. When culturally responsive infrastructures were limited, participants carved out recovery on their own terms, often in the margins of systems not built for them. These chapters in the participants’ lives were pivotal in their recovery journey and ultimately shaped their present and future perceptions of wellness.
Visions of Wellness: LGBTQ+ Recovery and Reimagined Support in Appalachia
Participants described a present marked by hard-won wholeness: stable recovery; authentic LGBTQ+ visibility; and a sense of belonging woven through family, partners, and chosen community. Yet their narratives did not stop at personal wellness. Each speaker pivoted toward an expansive future vision, imagining recovery supports that are culturally rooted in Appalachia. Their recommendations included staff trained in LGBTQ+ competencies, meeting spaces free from religious persecution, and peer-led groups that feel like home. In their eyes, true recovery captures a movement from personal success to collective advocacy for the next generation of LGBTQ+ Appalachians seeking recovery.
Several participants framed their recovery as an intentional disruption of intergenerational trauma and addiction. For Avery, recovery meant building a new kind of family legacy:
[My husband and I] want to establish a family unit which breaks the cycle of addiction. We want to have children. We want to be an outlet for those children to feel safe, included, and part of a bigger community, regardless of how they choose to identify.
For some, sobriety created space not only for personal healing but also for service to others. Participants described their recovery as a catalyst for becoming counselors, facilitators, or peer mentors. Beans shared:
I’m out of that . . . Maslow’s hierarchy of needs . . . and I’m now at the place where I want to help bring people to that level. . . . Keeping folks alive if they’re not ready to stop—being able to provide harm reduction resources for them to stay alive long enough to get that help. I want to keep them alive long enough that they can hopefully inspire and help other people.
Em described how one trauma recovery center became a turning point—not just for healing, but for becoming a leader within recovery communities:
[X] Trauma Recovery Center was the space that I came into in recovery. . . . I joined as a participant seeking care, and then a year later was empowered to start facilitating my own groups. They supported me in getting certified as a peer recovery specialist. . . . So absolutely, that was a space that . . . my story could be a force of positivity for other people.
Both Alan and Avery turned lived experience into professional work in peer support and housing services, embodying recovery structures they wished had existed for them.
Across interviews, participants emphasized the importance of meaningful relationships in sustaining wellness. For many, especially those estranged from biological kin, these connections were formed within chosen LGBTQ+ families. Em reflected on the power of intimate, affirming community:
Now I feel a lot more grounded in my few core relationships. . . . All of them are [with] trans people. That’s not necessarily the qualifier in my mind, but it works out that way. They’re the ones I can feel present with . . . who are doing the same kind of work.
Others spoke to the power of finding LGBTQ+ recovery networks online, particularly in rural or isolated communities. Beans noted, “Being able to find the Appalachian queer groups . . . queer folks on Facebook . . . having that kind of community and support in staying sober, and in connecting with people, is huge.”
Participants called for reimagined recovery spaces that honor both LGBTQ+ identity and Appalachian culture. Avery envisioned “some kind of community center. . . . A place people in recovery can go to and identify as safe.” Em suggested programming grounded in local traditions: “Recovery folks going on hikes together, sitting around the fire, playing music, doing art . . . being in our bodies in a way that helps us feel present.” Additionally, visibility and early intervention were central to participants’ recovery visions. Avery shared:
I think it would have definitely decreased the negative impacts . . . if you had some kind of programming in schools that was affirming—that included, “It’s okay to be gay. . . . It’s okay to have these feelings.” . . . It just wasn’t talked about when I was young.
Digital platforms, social media, and informal events like cookouts were seen as powerful, culturally congruent ways to nurture LGBTQ+ recovery communities. As Alan expressed, “I think if we really want that community, it needs to be in people’s homes. Events like cookouts or birthday parties. . . . It’s not as loud, which is important to me, but it’s effective, creating a family, essentially.”
Collectively, these visions point to a future in which recovery is community-led, culturally grounded, and unapologetically LGBTQ+. For participants, recovery was not the end of their stories; it was a springboard for advocacy, care, and collective joy in the face of systemic erasure.
Discussion
The lived experiences of Appalachian LGBTQ+ individuals in this study offer vivid accounts of Meyer’s (2003) minority stress theory. Participants’ early exposure to religious condemnation, familial rejection, and cultural dismissal created conditions of chronic ostracism. For many, these distal stressors became compounded with proximal stressors like shame and internalized homophobia/transphobia. Avery’s “mastery of duality” and Michael’s “lavender relationship” reflect how participants developed survival strategies to navigate hostile environments, often at the cost of authenticity and mental health.
Substance use emerged as a complex response to these stressors. Participants described using drugs and alcohol as tools for LGBTQ+ identity exploration and emotional regulation. Michael’s assertion that alcohol “freed [them] up to express who [they] really [were]” exemplifies Shelton’s (2021) findings that LGBTQ+ individuals often use substances to manage the anxiety of choosing identity disclosure or concealment.
The Appalachian context intensified the effects of minority stress through geographic and cultural isolation. Participants like Em described being “the only queer person in most spaces,” underscoring the lack of LGBTQ+–affirming community. As previously noted, LGBTQ+–specific treatment programs are disproportionately located in urban centers, leaving rural individuals with limited access to culturally responsive care (Qeadan et al., 2022; Ware et al., 2023). This geographic barrier heightened the effects of minority stress for many participants, making recovery more difficult and substance use more likely to persist.
Even when participants sought formal recovery services, they encountered heteronormative and religious undertones that mirrored the very stigma they were trying to escape. Alan’s experience of having his recovery dismissed for not following the 12-step model and Michael’s account of the dissolution of an LGBTQ+ AA meeting due to low turnout suggest ongoing stigma within recovery spaces. These findings echo Gorritz FitzSimons and Byrd (2025), who emphasize the need for LGBTQ+–affirming treatment environments that welcome intersectional identities and trauma narratives.
In the absence of affirming clinical care, participants turned to chosen family and peer-based strategies to sustain recovery. Beans’s friends practicing harm reduction by suggesting body modification instead of drinking illustrates the healing power of relational safety. Our participants’ narratives align with Paschen-Wolff et al. (2024), who found that even one affirming provider or peer can mitigate feelings of isolation and foster recovery.
Participants also described joy, humor, and emotional openness as key aspects of LGBTQ+ recovery culture. Michael’s desire for “a safe space where everyone can talk freely” and not be afraid of judgment reflects a longing for community-based recovery models rooted in mutual aid and authenticity. Em’s grounding in trans friendships and Beans’s connection to Appalachian LGBTQ+ groups online demonstrate how peer networks can bridge geographic isolation and nurture belonging.
Our findings call for a reimagining of recovery supports in rural Appalachia—ones that are culturally rooted yet explicitly LGBTQ+–affirming. Participants envisioned meeting spaces free from religious judgment, staff trained in LGBTQ+ competencies, telehealth to bridge rural distance, and peer-led recovery groups. Em’s vision of recovery through land-based practices—hiking, music, and storytelling—suggests that Appalachian cultural traditions can be powerful tools for healing when integrated with LGBTQ+-affirming care.
Visibility and early intervention were also central to participants’ recovery visions. Avery’s call for affirming school programming and Alan’s emphasis on informal events like cookouts reflect a desire for culturally congruent, grassroots approaches to wellness. These aspirations align with the literature’s call for inclusive treatment models that honor regional specificity while addressing the structural conditions that make substance use a survival strategy (Frey et al., 2021; Senreich, 2010).
Importantly, participants did not merely survive their substance use; they used recovery as a pathway to reclaim autonomy and serve others. Em’s facilitation of peer recovery groups and Beans’s commitment to harm reduction reflect a shift from personal healing to community leadership. Avery’s goal of building a family that “breaks the cycle of addiction” exemplifies how recovery can turn individual liberation into greater communal gain.
These narratives of Appalachian LGBTQ+ individuals pursuing recovery from SUDs reflect a journey from survival to flourishing. Their stories underscore the urgent need for culturally responsive care (Paschen-Wolff et al., 2024), the transformative power of chosen community (Gorritz FitzSimons & Byrd, 2025), and the potential for recovery to become a site of LGBTQ+ possibility, resilience, and advocacy.
Implications
The findings from this study have important implications for both clinical practice and community interventions in Appalachia. Foremost, the noted lack of LGBTQ+–affirming recovery services within the region illuminates the need for more programs that support these individuals in active addiction and recovery. It is imperative that practitioners take necessary steps to improve their capacity for care while also increasing the volume of LGBTQ+ services. Given the reverence shown to chosen family and peer support by the participants, it is essential that practitioners are intentional about integrating these networks into their clients’ treatment plans. Additionally, practitioners should place emphasis on ensuring that peer-led models are accessible to community members within formal treatment. We encourage practitioners to familiarize themselves with and have an expansive referral list of peer support specialists within their communities. Many of the participants noted that these models proved paramount to their recovery journey, establishing strong evidence of efficacy.
Beyond clinical settings, we noted that Appalachian community hubs (e.g., schools, faith communities, etc.) can serve as access points for early intervention. Counselors should cultivate relationships with stakeholders within these spaces to promote LGBTQ+ visibility, foster a culture of acceptance, and raise mental health awareness for both youth and adults. These advocacy initiatives are imperative for Appalachian counselors considering the close, tight-knit nature of these communities. Lastly, incorporating Appalachian cultural values and traditions into recovery interventions should be prioritized, as they can serve as powerful tools for healing. Em noted that “Appalachian culture involves getting your hands into things,” so “connecting folks to art, or woodworking, or maker spaces” along with music and hiking is culturally responsive.
Limitations
Although this study has yielded rich narratives detailing the nuances of addiction and recovery for Appalachian LGBTQ+ individuals, it must be noted that our participant pool was limited. Participants were primarily recruited through snowball sampling and community-based networks, which may have limited the diversity of narratives that we were able to collect. The sample was relatively homogeneous, consisting entirely of White participants between the ages of 30 and 45. As such, the findings may not fully capture the heterogeneity of racial, ethnic, or age-related experiences within the broader LGBTQ+ Appalachian community.
Additionally, all interviews were conducted via Zoom at a single point in time, which may have constrained the depth of relational engagement and limited our ability to observe changes in participants’ perspectives or recovery processes over time. Given the sensitivity of the topic and the close-knit nature of many Appalachian communities, social desirability and recall bias may also have influenced participants’ willingness to disclose certain experiences or to recall them in ways that aligned with community or researcher expectations.
Lastly, although our analysis attends to regional context, it is important to recognize that Appalachia itself is not a monolithic space. Cultural, economic, and social conditions vary widely across subregions, and these differences shape how individuals experience their LGBTQ+ identities, addiction, and recovery. Our sample was drawn primarily from Central and Southern Appalachian communities, and thus the findings should be interpreted with that regional specificity in mind.
Recommendations for Future Research
Considering the limited scope of the current literature base, future research should build on this study, with the imperative to investigate the experiences of community members who are in active addiction and early recovery. This would offer a more in-vivo assessment of how traditional and nontraditional treatment options are experienced by LGBTQ+ individuals in Appalachia. Focusing future research on community members with other marginalized identities (e.g. ethnicity, race, disability) could also offer a new richness in terms of understanding recovery in Appalachia. Moving forward, we hope that findings from this study will prove insightful in the development of LGBTQ+–affirming interventions for individuals who are both in active addiction and recovery. A multi-methodological approach to assess the efficacy of these interventions is warranted. Additionally, community-engaged and culturally responsive approaches such as community-based participatory research, participatory action research, and creative methods like photovoice and digital storytelling can meaningfully involve Appalachian LGBTQ+ people as partners in shaping the research process. Finally, future scholarship should further explore the role and utility of recovery supports referenced within the findings of this study: mutual aid, peer support, and Appalachian-based interventions.
Conclusion
This study explored the intersections of identity, geography, trauma, and resilience as they shape the recovery journeys of LGBTQ+ individuals in Appalachia, revealing that recovery is both a process of healing and an act of resistance. Participants’ narratives illuminate how affirming relationships, community belonging, and self-determined resilience sustain recovery amid religious condemnation, sociopolitical isolation, and systemic neglect. For practitioners, these findings underscore the importance of peer-led and affirming care models, place-based and community-embedded supports, and accessible telehealth and hybrid services that honor the geographic realities of the region. Collectively, these approaches move toward care that is locally grounded, culturally responsive, and unapologetically affirming of LGBTQ+ Appalachian lives.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Allan, R., & Johnson, S. M. (2017). Conceptual and application issues: Emotionally focused therapy with gay male couples. Journal of Couple & Relationship Therapy, 16(4), 286– 305. https://doi.org/10.1080/15332691.2016.1238800
Bruner, J. (1991). The narrative construction of reality. Critical Inquiry, 18, 1–21. https://www.sas.upenn.edu/~cavitch/pdf-library/Bruner_Narrative.pdf
Chaney, M. P. (2019). LGBTQ+ addiction research: An analysis of the Journal of Addictions & Offender Counseling. Journal of Addictions & Offender Counseling, 40(1), 2–16. https://doi.org/10.1002/jaoc.12053
Chaney, M. P., & Mason, N. (2024). Queering recovery: A proposed model for LGBTQ+-affirmative relapse prevention. Journal of Addictions & Offender Counseling, 45(1), 98–110. https://doi.org/10.1002/jaoc.12128
Clandinin, D. J. (2022). Engaging in narrative inquiry (2nd ed.). Routledge.
Fernandez, J., Gonzalez, R., Oves, J. C., Jr., Rodriguez, P., Castro, G., & Barengo, N. C. (2021). Illicit substance use disparities among lesbian, gay, and bisexual high school students in the U.S. in 2017. Journal of Adolescent Health, 68(6), 1170–1175. https://doi.org/10.1016/j.jadohealth.2021.02.004
Frey, J. J., Hall, W. J., Goldbach, J. T., & Lanier, P. (2021). “Here in the Bible belt, it’s predominantly negative”: Sexual identity stigma in the American South, 50 years after Stonewall. Frontiers in Psychology, 12, 804064. https://doi.org/10.3389/fpsyg.2021.804064
Gorritz FitzSimons, F. B., & Byrd, J. J. (2025). Queer, transgender, Black, and/or Indigenous people of color experiences in substance use disorder counseling: Enhancing QTBIPOC counseling care. Journal of Addictions & Offender Counseling, 46(1), 18–38. https://doi.org/10.1002/jaoc.12144
Guy, A. A., Surace, A., Zelaya, D. G., Flynn, R., Opalo, C., Keuroghlian, A. S., Mayer, K. H., Monti, P. M., & Kahler, C. W. (2023). Transgender and gender diverse adults’ reflections on alcohol counseling and recommendations for providers. American Journal of Orthopsychiatry, 93(2), 166–175. https://doi.org/10.1037/ort0000663
HC DrugFree. (2023, June 13). SAMHSA releases new data on lesbian, gay and bisexual behavioral health. https://hcdrugfree.org/2023/06/samhsa-releases-new-data-on-lesbian- gay-and-bisexual-behavioral-health
Hendry, P. M. (2007). The future of narrative. Qualitative Inquiry, 13(4), 487–498. https://doi.org/10.1177/1077800406297673
Johnson, S. M. (2019). Attachment theory in practice: Emotionally focused therapy (EFT) with individuals, couples, and families. Guilford.
Kidd, J. D., Jackman, K. B., Wolff, M., Veldhuis, C. B., & Hughes, T. L. (2018). Risk and protective factors for substance use among sexual and gender minority youth: A scoping review. Current Addiction Reports, 5, 158–173. https://doi.org/10.1007/s40429-018-0196-9
Krasnova, A., Diaz, J. E., Philbin, M. M., & Mauro, P. M. (2021). Disparities in substance use disorder treatment use and perceived need by sexual identity and gender among adults in the United States. Drug and Alcohol Dependence, 226, 108828. https://doi.org/10.1016/j.drugalcdep.2021.108828
Lavender-Stott, E. S., Grafsky, E. L., Nguyen, H. N., Wacker, E., & Steelman, S. M. (2018). Challenges and strategies of sexual minority youth research in southwest Virginia. Journal of Homosexuality, 65(6), 691–704. https://doi.org/10.1080/00918369.2017.1364104
Lee, J. H., Gamarel, K. E., Bryant, K. J., Zaller, N. D., & Operario, D. (2016). Discrimination, mental health, and substance use disorders among sexual minority populations. LGBT Health, 3(4), 258–265. https://doi.org/10.1089/lgbt.2015.0135
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. SAGE.
McClellan, H. V. (2023, August 23). What to know about the new legislation impacting LGBTQ+ youth in North Carolina. EducationNC. https://www.ednc.org/what-to-know-about-the-new-legislation-impacting-lgbtq-youth-in-north-carolina
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
Micale, A. M., Brubaker, M. D., Richardson, G. B., & Acquavita, S. P. (2025). Examining alcohol use disorder treatment utilization in lesbian, gay, and bisexual populations through the Behavioral Model for Vulnerable Populations. Journal of Addictions & Offender Counseling, 46(1), 69–88. https://doi.org/10.1002/jaoc.12143
Moon, S. S., Timbers, V. L., Boddie, S. C., Ryan-Pettes, S. R., & Anderson, L. (2024). Multiple risk factors of substance use among lesbian, gay, bisexual (LGB) adults: A comparison study. Journal of Human Behavior in the Social Environment, 34(6), 926–937. https://doi.org/10.1080/10911359.2024.2323007
Nieder, A., Schachter, J., & Ajayi, A. A. (2025). Minority stress, substance use, and resilience: Examining long-term sobriety in the LGBTQ community. Alcoholism Treatment Quarterly, 43(2), 290–305. https://doi.org/10.1080/07347324.2024.2432337
Pachankis, J. E., Williams, S. L., Behari, K., Job, S., McConocha, E. M., & Chaudoir, S. R. (2020). Brief online interventions for LGBTQ young adult mental and behavioral health: A randomized controlled trial in a high-stigma, low-resource context. Journal of Consulting and Clinical Psychology, 88(5), 429–444. https://doi.org/10.1037/ccp0000497
Paschen-Wolff, M. M., DeSousa, A., Paine, E. A., Hughes, T. L., & Campbell, A. N. C. (2024). Experiences of and recommendations for LGBTQ+-affirming substance use services: An exploratory qualitative descriptive study with LGBTQ+ people who use opioids and other drugs. Substance Abuse Treatment, Prevention, and Policy, 19, Article 2. https://doi.org/10.1186/s13011-023-00581-8
Polkinghorne, D. E. (1995). Narrative configuration in qualitative analysis. International Journal of Qualitative Studies in Education, 8(1), 5–23. https://doi.org/10.1080/0951839950080103
Qeadan, F., Akofua Mensah, N., Gu, L. Y., Barbeau, W. A., Madden, E. F., Porucznik, C. A., & English, K. (2022). Factors associated with the availability of tailored programs for LGBT clients in substance use disorder treatment facilities in the U.S. from 2008 to 2018. Journal of Gay & Lesbian Social Services, 34(2), 247–268. https://doi.org/10.1080/10538720.2021.1954125
Senreich, E. (2010). Are specialized LGBT program components helpful for gay and bisexual men in substance abuse treatment? Substance Use & Misuse, 45(7–8), 1077–1096. https://doi.org/10.3109/10826080903483855
Shelton, M. (2021). Treating LGBT couples experiencing substance use disorders: Trauma-informed and affirmative therapy approaches. In R. Harvey, M. J. Murphy, J. J. Bigner, & J. L. Wetchler (Eds.), Handbook of LGBTQ-affirmative couple and family therapy (2nd ed., pp. 381–400). Routledge. https://doi.org/10.4324/9780429274626-26
Ware, O. D., Austin, A. E., Srivastava, A., Dawes, H. C., Baruah, D., & Hall, W. J. (2023). Characteristics of outpatient and residential substance use disorder treatment facilities with a tailored LGBT program. Substance Abuse: Research and Treatment, 17, 1–7. https://doi.org/10.1177/11782218231181274
Zuccarini, D., & Karos, L. (2011). Emotionally focused therapy for gay and lesbian couples: Strong identities, strong bonds. In J. L. Furrow, B. A. Bradley, & S. M. Johnson (Eds.), The emotionally focused casebook: New directions for treating couples (1st ed., pp. 317–342). Routledge.
Appendix
Semi-Structured Zoom Interview Protocol
Participant’s Pseudonym:
Researcher/Interviewer:
Date:
Scheduled Time:
Start Time: End Time:
Researcher: Thank you for taking the time to talk with me today. As you know, the purpose of this study is to explore the experiences of LGBTQ+ Appalachian Individuals in recovery from substance use, and to uncover what factors have sustained their sobriety. The researchers’ primary aim is that insights generated from the study will inform counselors who serve members of this population and aid in generating more positive outcomes for clients in treatment. It is also hoped that the findings will prove decisive in the curation of interventions/approaches to working with the population. This study will provide participants with the opportunity to share their individual narratives through the use of semi-structured interviews. These narratives will then be reconstructed in an authentic way to share the collective story of all participants involved.
Throughout this interview, I will ask you questions about your experiences in recovery from substance use/addiction with centrality placed on your identity as an LGBTQ+ person living in Appalachia. Please refrain from sharing names or other identifying information about others. I may ask you to elaborate or clarify responses to questions. Please feel free to ask me for clarification at any point during the interview process if questions are unclear.
Do you have any questions regarding the informed consent form that you previously signed or in general?
Do you still consent to participating in the Zoom interview and having this interview recorded?
Semi-Structured Interview Questions
- Can you tell me a little bit about your background? Where did you grow up, and what was it like for you being LGBTQ+ in your community?
- Can you tell me about your first experience(s) with using substances?
- How did your identity as an LGBTQ+ individual shape or influence your experiences with substances?
- When did you first recognize that your relationship with substances was becoming problematic? What led to that realization?
- Can you share with me the story of your journey toward sobriety? What were some of the key turning points for you?
- On your path toward sobriety, what kind of support did you seek out and what did you find to be most helpful?
- Were there specific people, communities, or resources that you found particularly affirming of both your LGBTQ+ identity and your recovery journey?
- Throughout your journey what has aided you in remaining sober?
- Looking forward, what does a healthy, sober life look like for you?
- How does your LGBTQ+ identity influence your vision of recovery and your future?
- If you could design a support system or intervention specifically for LGBTQ+ Appalachian individuals in recovery, what would it look like?
- How would that support system or intervention have changed your experience in seeking recovery?
- Is there anything else you’d like to share about your experiences in recovery that we haven’t touched on yet?
Researcher: Thank you again for taking the time to participate in this interview. During the data analysis process, you will be provided the opportunity to review your transcript and any codes generated from it to ensure accuracy. Please don’t hesitate to contact me if you have any questions at any time.
Jacob Perkins is an MAEd candidate at Virginia Tech University and was a 2024 Master’s Fellow in Addictions Counseling with the NBCCF Minority Fellowship Program. Harley Locklear, PhD, NCC, LCMHCA, LSC, is an assistant professor at Virginia Tech University and was a 2022 Doctoral Fellow in Mental Health Counseling with the NBCCF Minority Fellowship Program. Correspondence may be addressed to Jacob Perkins, 1750 Kraft Dr., Blacksburg, VA 24061, jacobperkins988@vt.edu.
Dec 22, 2025 | Volume 15 - Issue 4
Shadin Atiyeh
This study explored the challenges and strategies employed by counselor educators in training students to work effectively with refugee populations. Utilizing a qualitative descriptive analysis, a qualitative open-ended survey was conducted with 11 counselor educators and a focus group meeting with four counselor educators from various CACREP-accredited master’s programs across the United States. The analysis revealed several barriers to effective training, including the perceived limited relevance of the topic, time constraints within courses, and the complexity of addressing refugee issues. Participants emphasized the pressing need for comprehensive curricula that integrate refugee concerns and enhance multicultural competence. Findings suggest that diverse teaching strategies, such as case studies and experiential learning, are essential for preparing students to meet the unique mental health needs of refugees. This study underscores the importance of equipping future counselors with the skills and knowledge required to support this underserved population effectively and to advocate for the integration of refugee topics across counseling courses to promote social justice.
Keywords: refugees, barriers, multicultural competence, curricula, counselor educators
According to the American Counseling Association (ACA; 2014) Code of Ethics, counselors must gain multicultural competence to work with diverse populations and to advocate for equitable access to mental health care among underserved populations. Refugee populations represent a diverse group who face barriers to accessing mental health care in many societies (Satinsky et al., 2019). The UN Refugee Agency (formerly the United Nations High Commissioner for Refugees; 2025) defined a refugee as a person who flees their home country because of persecution based on race, religion, nationality, political opinion, or membership in a social group. The number of forcibly displaced people globally was 123.2 million people at the end of 2024, including 42.7 million refugees (The UN Refugee Agency, 2025). Despite the growing global need for counseling services among refugees, counselor training programs often do not include orientation to refugee issues in their counseling courses. The Council for the Accreditation of Counseling and Related Educational Programs (CACREP; 2023) addresses migration in its standards within the definitions of cultural identity, diversity, and marginalized populations. However, the topic of migration is included explicitly within the standards when relevant to the impact of migration on family functioning for the marriage, couple, and family counseling specialization (CACREP, 2023). Counselors are currently facing a global humanitarian call to support refugee populations (Snow et al., 2021). The goal of this study was to explore approaches to counselor education that teach counseling students about refugee concerns and the barriers counselor educators face in training counseling students to develop this competence. The findings offer diverse strategies to facilitate multicultural competence among counseling students and illuminate the barriers to access, which the profession must address in order to respond to the current mental health crisis among the growing number of refugees globally.
Refugee Resettlement in the United States
The United States has admitted more than 3.1 million refugees since the passage of the Refugee Act in 1980 (U.S. Department of State, 2018). To address the unprecedented global refugee crisis, the United States raised its admissions ceiling to 125,000 for fiscal years 2023 and 2024. In the fiscal year 2023, the United States also launched a private sponsorship pathway for refugee arrivals called Welcome Corps. This allowed groups of citizens to sponsor and resettle refugees in their communities. The United States also established a pathway for migration to those fleeing the Ukrainian and Afghan crises and allowed eligibility for refugee services for those individuals in addition to a streamlined application process for Cubans, Haitians, Nicaraguans, and Venezuelans to seek refuge. These actions yielded more opportunities for migrants to seek refuge and more communities across the country welcoming refugees outside of the traditional refugee resettlement structure. Traditionally, refugees are resettled in 48 states, with Washington, California, Texas, Ohio, and New York being the top resettlement areas (U.S. Department of State, 2018). The top 10 native languages that refugees living in the United States speak include Arabic, Nepali, Somali, Karen, Spanish, Swahili, Chaldean, Burmese, Armenian, and Farsi (U.S. Department of State, 2018). In fiscal year 2024, 100,034 refugees were admitted, with the top five countries of origin being the Democratic Republic of Congo, Afghanistan, Venezuela, Syria, and Burma. Although this was a record number for the traditional refugee resettlement program in the 21st century, it did fall short of the 125,000 ceiling set by the federal administration (Refugee Council USA, 2024). In January 2025, the federal administration closed both the traditional pathway for refugee resettlement and the parole application processes, as well as removing legal status for previously approved groups (Church World Service, 2025).
Mental Health Needs
Refugees are ethnically diverse and have varied experiences and backgrounds; however, they all share an increased risk for trauma-related distress and underuse of services (Bemak & Chung, 2021). One distinction between refugees and other migrants is that while immigrants tend to arrive in the United States healthier than the native-born population and then develop illnesses over time, refugees tend to enter the country less healthy than the native-born population (Pampati et al., 2018). Refugees have higher prevalence rates of post-traumatic stress disorder and depressive disorders (Bartholomew et al., 2021), and compared to other immigrants, refugees have the additional difficulties of pre-migratory traumatic experiences, grief, and loss of self-determination (Rometsch et al., 2020). Immigrants who choose to migrate and prepare for that transition face barriers such as culture shock and acculturation difficulties. However, refugees flee for their safety, without a choice and often without time to prepare, often leaving behind valuables and important documents. This loss of self-determination compounds in migration, as host countries often do not offer refugees the right to work, establish a lawful presence, or study. Much of the current literature related to the resettlement of refugees focuses on traumatic experiences before migration and leaves out the stressors involved after resettlement to a third country (Interiano-Shiverdecker et al., 2020). However, the daily stressors post-migration can be more distressing than war-related trauma and necessitate a social justice perspective to counseling (Kondili et al., 2022). These daily stressors may include acclimating to a new culture, language, and socioeconomic status, as well as navigating new social systems to access public benefits and health care. The focus of refugee services toward self-sufficiency as quickly as possible contrasts the policy of referring the most vulnerable refugees to resettlement, and the refugees’ years of experience having to depend on others for survival. Discrimination and prejudice are risks to overall well-being, affecting self-esteem, belonging, and self-determination (Interiano-Shiverdecker et al., 2020). The need for counseling services among refugee populations, particularly in resettlement to the United States, is well established.
Barriers to Counseling for Refugee Populations
Despite the need, refugees face various barriers to access for counseling services. Regardless of cultural background, refugees commonly experience barriers related to transportation, language, loss of social networks, financial difficulties, and limited access to resources (Tribe et al., 2019). Cultural barriers to seeking mental health counseling include shame about sharing personal or family concerns with those outside the family, a need to maintain a positive reputation within the community, and disbelief that talking about an issue could make it better (Hosseini et al., 2023). Refugees, who often have experienced oppression that breeds mistrust of people in power, may have concerns related to privacy and safety in counseling (Duden & Martins-Borges, 2021). With varying educational levels and interrupted education due to conflict, refugees may also lack knowledge about the availability and utility of counseling services (Duden & Martins-Borges, 2021).
Systemic issues also play a role, such as a misalignment between the mental health care system’s offerings and the specific needs of refugee communities (Bartholomew et al., 2021). Individualized Western conceptualizations of mental illness and its treatment are limited in being able to address the mental health needs of refugee groups (Bartholomew et al., 2021). Psychosocial distress presents itself with somatic symptoms such as headaches, backaches, and stomach pains among refugee groups, complicating identification and treatment of psychosocial disorders (O’Brien & Charura, 2023). Effective support requires a holistic and culturally sensitive approach that addresses not only specific psychiatric conditions but also the practical, social, and cultural contexts of their lives (Salami et al., 2019). In summary, refugees face a complex web of interconnected barriers to accessing mental health care. These include practical issues like cost and language, cultural factors such as stigma and differing illness beliefs, and systemic problems where the services offered do not match clients’ perceived needs. Overcoming these barriers requires a multifaceted approach that includes providing practical support, fostering cultural humility among clinicians, and adapting therapeutic models to be more responsive to the unique circumstances of refugee populations.
Multicultural Competence in Counseling Refugees
Ratts et al. (2016) created a multicultural counseling model that includes attitudes and beliefs, knowledge, skills, and action across the domains of interventions, relationships, client worldviews, and counselor self-awareness. Ratts et al. (2016) approached multicultural competence with an awareness of the need to include a broader concept of diversity, intersectionality of identities, and the role of counselors as social justice advocates. Cultural competence requires flexibility in accepting individual conceptualizations and needs rather than knowledge of a set of generalized facts about a cultural group (Cabell et al., 2024). To work with refugees effectively, counselors must have a range of skills, including navigating boundaries, advocating, responding to trauma, facilitating acculturation, and working with interpreters (Atiyeh & Gray, 2022). Training and preparation of counselors in their master’s-level courses are key to laying the foundation for multicultural competence development to work with refugee clients. This training also extends toward multicultural competence with other populations (Atiyeh & Gray, 2022). Although it is understood that counselors need to be culturally competent social justice advocates, knowing how to support trainees in learning and demonstrating those skills in real-world contexts is less understood (Kuo et al.,2020). Professional development training on specific cultures is important to further develop multicultural competence beyond master’s-level training (Cabell et al., 2024). Much of the training provided in master’s counseling programs relies on a traditional model of counseling utilizing Western-based theories, and promoting refugee mental health requires incorporating a collaborative and social justice approach (Kondili et al., 2022). Counseling programs may be deficient in preparing counselors who are knowledgeable about their clients’ worldviews (Damra & Qa’aymeh, 2024). The intersection of the high need for counseling services, the systemic barriers preventing effective and culturally responsive counseling, and the limited competence among counselors poses a serious health equity issue that the profession must address.
Method
The purpose of the study was to explore the ways that counselor educators address refugee concerns in counseling courses in order to highlight barriers and resources for counselor education. The research question was: What are the experiences of counselor educators who address refugee concerns in master’s-level counseling courses? I conducted a qualitative descriptive analysis study utilizing an open-ended qualitative online survey and a focus group session. This approach is appropriate when exploring participants’ experiences and perceptions from a naturalistic orientation (Sandelowski, 2010). As the current literature demonstrates a need for competent mental health counseling for refugee populations, further investigation into the barriers that counselor educators experience in training students to work with this population and how they navigate these barriers is important. Qualitative description offers a starting point to explore how counselor educators incorporate refugee concerns in the classroom at the master’s level. The survey included questions related to which courses cover refugee concerns, what strategies they use, what barriers they face in doing so, and the training they have had related to refugee concerns. The study design followed a descriptive content analysis with the intent of describing how counselor educators may be teaching students in the classroom how to work with refugee clients, the resources they utilize, and the challenges they face in doing so. This qualitative approach can be useful in identifying and sharing data in a way that is relevant to a specific audience (Sandelowski, 2000).
Study Design
I shared an online survey with open-ended questions utilizing Qualtrics on listservs and social media groups for counselor educators. These outlets for recruitment were appropriate to seek out counselor educators who self-identified as incorporating refugee concerns into their master’s-level counseling courses. After an initial analysis of the survey data, I posted a focus group meeting opportunity on the same listservs. In the focus group meeting, initial themes were shared, and participants were asked to react to and expand on the results. The transcript for the focus group meeting was coded using in-vivo coding. Individual codes were grouped into categories and those were grouped under major themes.
Participants
Participant inclusion criteria included counselor educators who teach master’s-level counseling courses and address refugee concerns in those courses. I recruited participants online through emails to a listserv of counselor educators and social media groups of counselor educators. These included CESNET and social media groups for the NBCC Foundation Minority Fellowship Program recipients and alumni. An invitation to participate in the focus group meeting was sent to the same groups. Eleven participants completed the open-ended survey and four counselor educators participated in the focus group meeting. Demographic data were not collected as part of the survey or focus group questions in order to preserve anonymity, as the community of counselor educators with experience incorporating refugee topics in their courses may be quite small, and demographic data may reduce their openness to provide in-depth responses.
Procedure
This study received ethical approval from the host institution’s IRB. The emailed recruitment message included a research information sheet explaining the research and participation expectations. It also included a link to complete the survey using Qualtrics. There were no planned follow-up procedures after the survey. Eleven participants completed the open-ended survey, which included the following questions:
- In what classes and during which topic areas do you include refugee concerns in your counseling courses?
- What activities or resources do you use to teach counseling students about refugee concerns?
- What barriers or challenges do you face when teaching counseling students about refugee concerns?
- How have you received training or education regarding refugee concerns, if any?
These questions were developed to respond to the research question of: What are the experiences of counselor educators who address refugee concerns in master’s-level counseling courses? The questions were also framed to lead to practical resources and techniques for counselor educators to utilize within their courses. I grouped responses to these questions into descriptive categories. I submitted and obtained approval for an amendment to the initial IRB approval to obtain focus group data to expand on emerging themes from the survey. I emailed a recruitment message with an edited research information sheet detailing focus group procedures and an invitation to a virtual meeting on Microsoft Teams, which four participants attended. Participants had the choice to be off-camera during the meeting. The meeting was recorded for transcription, and the recording was deleted after the transcription was created. I presented these to the focus group participants for elaboration and description of the emerging themes. I shared the initial results from the survey data and asked participants to share what stood out to them about these findings. I also asked the focus group participants the same questions from the survey. The focus group meeting was semi-structured with an in-depth discussion following the participants’ responses to allow for a deeper discussion of the research question that the open-ended questionnaire could not offer (Bengtsson, 2016). The transcript of the focus group meeting was analyzed and coded in vivo. Those codes were grouped into categories and then organized into themes.
Data Analysis
I downloaded Qualtrics responses in an Excel spreadsheet and reviewed them several times following a content analysis approach (Sandelowski, 2000). I then read through the data two times before conducting in-vivo coding. A code was written next to the relevant data on the Excel spreadsheet. Similar codes were then grouped together in Microsoft Word. While staying close to the data, it was organized into categories (Prasad, 2019). I organized the data into categories so that the description could lead to meaningful implications to which the focus group participants could react. After the focus group, the meeting was transcribed automatically using Microsoft Teams and analyzed separately from the survey data. This analysis included the same process of reading through the transcript twice initially, then a round of initial in-vivo coding within an Excel spreadsheet, then grouping similar codes into a table on Microsoft Word, and finally grouping those categories into larger themes.
Researcher Positionality and Reflexivity
A key element of rigor in qualitative research is researcher reflexivity (Olmos-Vega et al., 2023). While inherent biases, subjectivities, and power imbalance inevitably inform data analysis and influence the research process, sharing the positionalities of the researcher is an important first step in trustworthiness (Olmos-Vega et al., 2023). Olmos-Vega et al. (2023) defined reflexivity as a dynamic and collaborative process that involves self-critique and context evaluation by first making positionality explicit. I am an assistant professor in the counselor education department at a public urban university offering CACREP-accredited master’s-level programs in clinical mental health, school counseling, and clinical rehabilitation counseling. I also have over 10 years of experience providing counseling and employment services with refugee populations and supervising such programming. I approach my clinical and academic work from a constructivist and existential perspective in which knowledge and experiences are co-constructed through meaning-making and perspective-taking. I have not personally experienced migration, forced or otherwise, but have grown up around immigrant communities as the child of an immigrant. I conducted this study to bring attention to the need for counseling services for refugee communities and the struggles faced and strategies employed by educators when training counseling students to do so. This is the perspective with which I approached study design and data interpretation. I also developed reflexivity throughout the process by checking initial interpretations from survey data with the focus group participants and connecting themes with the quotes from the data.
Results
The initial survey results are outlined in Table 1. Focus group participants discussed their reactions to these responses and expanded on them in their own answers to the same questions. The analysis of the transcript yielded 89 codes that were grouped into 11 categories and three themes.
Table 1
Survey Results
| Courses |
Strategies |
Barriers |
Training for Educators |
| Diversity |
Guest Speakers |
Lack of student interest |
Conferences |
| Ethics |
Videos |
Not relevant |
Articles |
| Family |
Articles |
Limited time |
Lived experience |
| Trauma |
Poems |
Not covered in textbooks |
Consultation |
| Group |
Case Studies |
Political reasons |
Workshops |
| Career |
Student Presentations |
Too complex |
None |
| School |
Textbook |
|
|
| Internship |
|
|
|
| Advocacy |
|
|
|
Description of Courses
The survey results indicated that refugee concerns may be addressed in courses throughout the master’s program, not just in a singular course focused on multicultural diversity. These courses included an introductory course on diversity topics in addition to ethical practice, family counseling, treating trauma, groupwork, career counseling, school counseling, clinical courses, and a course on advocacy strategies. This is in line with guidance within the counseling literature on facilitating multicultural competence across the curriculum. Multicultural competence is too complex and important to be limited to only one class. Doing so may allow students to grasp some of the complexity involved in working with refugees and develop their counseling skills to work with intersectional identities. However, focus group participants were struck by the lack of standardization to how counselor educators address refugee concerns in their courses, highlighting the variability in responses to which courses include the topic. This variability also comes up in the ways that counselor educators approach training students to work with refugee clients.
Description of Strategies
Counselor educators also broach the topic in various ways: allowing students to bring it up, inviting a guest speaker, or having a discussion led by the educator. Participants shared that it comes up in courses because students bring up the topic through their papers, presentations, or case presentations, if they happen to be working with a refugee client. Participants might bring refugee concerns into the classroom as they discuss current news stories or events.
The content presented by counselor educators included peer-reviewed articles, student presentations, case studies, and textbooks. Participants also utilize creative approaches that highlight the lived experiences of refugees, such as poetry or film. Guest speakers share their own clinical experiences working with refugees in the field. Focus group participants shared specific examples, such as incorporating case studies in various classes. One focus group participant described a paper assignment given to students in which they needed to analyze an ethical issue relevant to a population facing racism or oppression; some students selected a concern facing refugees. Another participant led an internship experience at a local shelter for migrants and trained students to work specifically with this population through experiential training and weekly supervision. Although this participant described requiring students to have a traditional counseling experience before participating in this internship and the importance of having balance in skills for both conventional in-office counseling and nontraditional counseling conducted in shelters, they stated, “It can be very, very difficult to get them to understand that counseling does not have to happen in an office in 50 minutes.” This participant identified that in practice, “These are not the skills that they are taught in the classes . . . there’s a lot of retraining . . . unteaching and untraining can be a barrier and a challenge.” This discussion of strategies utilizing experiential learning quickly turned into a discussion of challenges and barriers in attempting to fit work with refugee clients into the current paradigm of training counselors, which often relies on Western theories of counseling. Another participant in the focus group reflected on how difficult it was to adapt to working with refugee clients after graduating from a master’s program, even while sharing a language and cultural background with clients. They stated, “When I graduated as a master’s student, I went into an agency to work with refugees, and at first, just implementing everything we learned was sometimes damaging.” Allowing for supportive opportunities to practice throughout the master’s curriculum allows students to have safe opportunities to practice before graduation. One participant offered that they “do a lot of shadowing” throughout their practicum experience. Another participant agreed: “I think that that’s where that immersion experience is going to be critical, and immersion doesn’t have to be going to a refugee camp. It could be through different means.”
Description of Barriers
Participants also identified challenges they may face while trying to educate counseling students in the classroom on how to work with refugee clients. These challenges included a perception of the lack of relevance of refugee concerns, limited opportunities to teach students how to work with refugee clients, and the complexity involved in refugee concerns. Some of the quotes from participants illuminated the challenges in teaching counseling students to work with refugees. The direct quotes that support these themes are listed in Table 2.
Table 2
Challenges to Incorporating Refugee Concerns
| Theme |
Quotes |
| Lack of Relevance |
“Some students don’t seem interested or think that they don’t want to work with that population.”
“Students don’t see the need to learn about it.”
“I think opportunities to work with refugees are limited in our area and so it isn’t a ‘pressing’ concern. Doesn’t mean it isn’t important, but we focus on the concerns that our students will likely face in their service provision at higher rates.” |
| Limited Opportunity |
“Large amount of topics in learning objectives to cover over a semester.”
“I don’t have a lot of time dedicated to the topic.”
“It doesn’t appear in many of the counseling texts as an area to address.” |
| Complexity
|
“Many students lack knowledge about the refugee experience and [have a] misunderstanding of the difference between refugees and immigrants.”
“Students think it’s too hard.”
“My state doesn’t want educators discussing ‘diversity’ topics.”
“Their previous political beliefs can be an obstacle.”
“Addressing this topic as it relates to intersectional identity, and culturally responsive treatment knowledge and resources.” |
Focus group participants elaborated on these themes. The second point from the survey results that stood out to them, after noticing the variability with which counselor educators were discussing refugees, was the sense that competence to work with refugee clients was not important or relevant to students. They made sense of this as being from a place of experiencing the privilege of not having to be aware of the level of forced displacement in the world. One focus group participant highlighted that this ignorance has consequences: “The privilege of not needing to be competent is harmful to communities.” Participants also explored this lack of interest and/or relevance further, stating: “It takes work to gain the competence, and if it’s not something that is of interest, folks are not seeking it out.” The underutilization of mental health services for refugees is further exacerbated by the lack of culturally competent counselors. This lack of interest may also be fueled by stereotypes about the population. Focus group participants shared their perceptions that “a lot of people are afraid of getting into it because of whether it’s like the competence piece or fear of vicarious traumatization or . . . I guess just like lack of interest” and “working with refugees, there is this . . . view of this population as broken. So there is a fear that either I’m going to do harm or not be helpful enough.” Another potential source for this ambivalence is also economic. Focus group participants discussed that there “isn’t a lot of money in it” when referring to working with refugee clients and that it is often grant-funded work in community agencies. They all discussed how counseling students are often entering the profession seeking to work in private practice, providing services reimbursed by medical insurance rather than counseling work in community settings.
Counselor educators are also affected by the limited time, resources, and applicability of current counseling theories to be able to incorporate the complexity needed when addressing refugee concerns in counseling courses. Focus group participants shared that counselor educators themselves “lack the competence to talk about this population” or “don’t feel comfortable enough as educators.” The textbooks used in counseling courses also do not provide enough information on the topic to help guide the discussion in class. One participant mentioned, and others reiterated it multiple times during the focus group, that “we don’t have more than a chapter.” Educators then must seek out additional resources or adapt existing approaches, with one participant sharing that “our counseling theories are not really applying to this population, so we have to spend a lot of time either adapting them or unlearning them.”
Despite these barriers, focus group participants shared multiple reasons why counselor educators and counselors need to persist in developing competence. They all highlighted the scenarios in which counselors may encounter issues related to forced migration or clients from refugee backgrounds. Participants shared that “every border university should have really solid training and education for this population,” and “if you don’t work with refugees, you might have a client that has a family member or friend from that background,” and “in the school setting, like children have to go to school, and so they’re finding themselves being faced with working with refugees.” Participants also shared that they learned a tremendous amount from their refugee clients, deepening their own skills and ability to adapt: “Learning experience for me is like you learn from them probably more than they learn from you,” and “you have to really be flexible to learn from them as much as they’re learning from you to be able to be helpful.” Participants also shared how rewarding the work has been and how they have seen students benefit from “the joy and the reward of working with this population.” Another participant shared that “once they’ve experienced this work, they just love it. There is so much joy in it.”
Description of Training Opportunities
Participants also shared opportunities they had to learn about refugee concerns as educators. These included conferences, reading journal articles, attending workshops, work experiences, and personal lived experiences. Participants shared specific workshops that were useful, such as the Trauma Systems Therapy for Refugees training, Global Mental Health training from Johns Hopkins University, and consultation with local refugee resettlement agencies. These may be a starting place for counselor educators who want to gain training before integrating refugee concerns into their courses. The study findings included several resources available to counselor educators, such as case studies and experiential learning opportunities.
Incorporating refugee concerns throughout master’s-level counseling courses may be useful in facilitating multicultural competence among counselors to work with refugees and other diverse populations. The concern about whether teaching counselors to work with refugees is relevant is striking, given the high need for mental health services among this population and the limited access to those services. Given this need for mental health services and the ethical mandate for counselors to work toward access to mental health care for underserved groups, counselor educators can and must do more to overcome the challenges and complexity involved in facilitating multicultural competence among counseling students.
Discussion
The purpose of the study was to explore the ways that counselor educators address refugee concerns in counseling courses to highlight barriers and resources for counselor education. The research question was: What are the experiences of counselor educators who address refugee concerns in master’s-level counseling courses? Counselor educators who do so incorporate refugee concerns throughout the curriculum using various methods while navigating challenges of complexity, limited time and resources, and potential disinterest. The study results demonstrate the importance of incorporating refugee representation throughout the curriculum at the master’s level. The results suggest various approaches, building on current literature that advocates for opportunities to engage in service learning or immersive experiences. In the following sections, I share resources from the extant literature. These experiential opportunities build students’ abilities to be flexible in “unlearning” traditional theories and serving diverse populations. The diversity of approaches reflects an opportunity for flexibility and creativity in classrooms as well as a threat to the standardized inclusion of multicultural competence to work with refugees across counseling. Part of the variability in how counselor educators are incorporating refugee concerns in their classes stems from the lack of intentionality with which it is addressed. For example, educators often wait for students to bring it up themselves rather than purposefully incorporating refugee concerns in the classroom. CACREP may more intentionally address forced migration and its effect on mental health to offer a framework for its inclusion in master’s-level courses and textbooks. A thorough list of competencies for working with refugee clients and ways of assessing and building these competencies could inform educational approaches. The challenges faced by counselor educators suggest future areas of advocacy needed for our profession to meet the counseling needs of refugee populations.
The Multicultural and Social Justice Counseling Competencies offered a framework advocating for counselors to understand the social context of their clients, intentionally broach concerns related to power and privilege, and advocate for systemic change (Ratts et al., 2016). For counselors to be prepared to utilize this framework with refugee clients, they must have basic knowledge of the sociopolitical context globally, an ability to confront their own biases and attitudes toward refugees, as well as skills to broach topics of power and privilege with refugee clients and to advocate for equitable access to counseling services. This study provides findings and resources counselor educators may utilize in their educational spaces, facilitating this competence for master’s-level counseling students.
Resources for Counselor Educators
Participants discussed various methods such as utilizing film and literature, experiential learning, and case studies. They shared the importance of intentionally exposing students to migrant stories and experiences at the master’s level. Existing literature provides a few examples of assignments and useful resources. These might be adapted to different courses across the curriculum.
Incorporating literature and film in counseling courses may facilitate self-awareness and empathy. These also allow for experiential learning before the clinical courses. The United Nations (2022) published an article listing recent films on refugee stories that included Flee, Simple as Water, Encanto, Captains of Za’atari, and Three Songs for Benazir. The Penguin Book of Migration Literature presents a diverse collection of fiction and poetry from migrant perspectives throughout history. Houseknecht and Swank (2019) recommended asking students to search “interview with a refugee” on YouTube and identify a video that is at least 10 minutes long and write a reaction paper as if the interviewee was their client.
Experiential learning can encourage students to actively experiment and then bring back their learning and reflection into the classroom (Houseknecht & Swank, 2019). Service learning components within courses improved multicultural and social justice knowledge and skills (Midgett & Doumas, 2016). A cultural immersion and social action project may be useful in developing multicultural competence and social justice advocacy competence (Pechak et al., 2020). Service learning early in the program, while students are developing their conceptualizations of the counseling profession, may be more beneficial for students to gain social justice and multicultural competence skills (Midgett & Doumas, 2016). Students need applied experiences within the community to develop these skills (Midgett & Doumas, 2016). Houseknecht and Swank (2019) described a role-play activity to simulate counseling with an interpreter where the students who act as counselors and clients write their responses and the student acting as an interpreter reads them.
Participants shared the use of case studies, suggesting that those who have experience with refugees may build them from their experience. Case studies can provide an opportunity for students to conceptually apply skills such as diagnosis, treatment planning, case management, career counseling, and ethical decision-making. Snow et al. (2021) recommended the website iamanimmigrant.com as a source of immigrant stories. Kondili et al. (2022) presented two case studies that incorporate a community and advocacy approach. Case studies can be presented in various courses that allow for intersectional identities where immigration status is one factor that interacts with other aspects of the client’s social identities, the counselor’s social identities, and the overall context. Snow et al. (2021) also presented a useful case study and guide for counselor educators on ways to incorporate refugee concerns throughout various counseling courses.
Study Limitations
The current study contributes to a deeper understanding of how counselor educators may attempt to incorporate refugee concerns and the challenges they face. However, it has some limitations. One main limitation was the lack of any demographic data on participants, which limits the information on context, such as the location in which the participants are teaching and their professional experience in the field. An online survey design was chosen because it may allow for more candid responses through anonymity and privacy (Blease et al., 2023). It also allowed participants to complete the study on their own time at their convenience, and it ensured complete anonymity. However, it did not allow further probes to gain further description or meaning behind the survey statements. The focus group partially filled that gap. The number of participants across both data collection methods was low, potentially because of the low number of counselor educators who incorporate refugee concerns into their courses.
Future Research
The leaders of the counseling profession need to make it more likely that refugee clients can find counselors who can understand refugee experiences, promote mental health literacy among refugee communities, demonstrate respect, and assess clients’ understanding of mental health (Snow et al., 2021). Counselor educators have a responsibility to train counselors to become advocates with a social justice orientation (Clark et al., 2022). Further research can support counselor educators as they endeavor to train counselors and advocates addressing the refugee crisis. Theories of mental illnesses and their treatment that are indigenous to the populations served need to be identified and utilized within counseling. The need to continuously adapt Western models poses an accessibility barrier for non-Western groups. Building on the limitations of this study, future qualitative studies may further investigate the rewards and challenges related to incorporating refugee concerns into counseling classrooms. Quantitative studies could identify the effects of training counselors to work with refugees on students’ overall competence and the accessibility of counseling services to refugee populations and other underserved groups. The impact of the political environment devaluing and silencing equity approaches in education poses new barriers. This was a point that survey participants made but focus group participants did not discuss. This may be because they were not experiencing that barrier at the time. Research should explore how counselor educators navigate these challenges and their threats to our professional values. As demographic data was not collected for this study, further research could explore the connection between professional identity and context and their approaches to educating counselors on working with refugee clients.
Conclusion
Advocating for social justice and positive social change is an aspect of ethical professional identity for counselors and counselor educators (ACA, 2014). Increasing the competence of counseling professionals would make counseling more accessible to refugees, currently an underserved group. Professional counselors risk losing perspective on the societal and group dynamics of wellness when they provide mental health services in individualized settings. However, a commitment to equity, justice, and beneficence is a part of counselors’ professional ethics and identity (ACA, 2014). As health professionals, counselors must advocate for conditions that promote wellness within communities. Therefore, developing advocacy skills and a commitment to social justice is crucial to establishing cultural competence and ethical practice with refugee clients. With the rising numbers of refugees globally, there is a greater need for counselors who are trained and competent to counsel refugee populations; it may become more likely that counselors will encounter refugee clients in their careers. Counselors may need to grow their knowledge base, skills, and awareness related to refugee issues. Counselor preparation programs and supervisors play an important role in facilitating that competence. Further training and research in this area will support the multicultural and social justice competence of counselors to meet the growing need globally and in the United States.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
American Counseling Association. (2014). ACA code of ethics. https://bit.ly/acacodeofethics
Atiyeh, S., & Gray, G. (2022). Counsellors’ competency to counsel refugees: A constructivist grounded theory study. Counselling and Psychotherapy Research, 22(1), 32–42. https://doi.org/10.1002/capr.12477
Bartholomew, T. T., Gundel, B. E., Kang, E., Joy, E. E., Maldonado-Aguiñiga, S., Robbins, K. A., & Li, H. (2021). Integrating cultural beliefs about illness in counseling with refugees: A phenomenological study. Journal of Cross-Cultural Psychology, 52(8–9), 705–725. https://doi.org/10.1177/00220221211038374
Bemak, F., & Chung, R. C.-Y. (2021). Contemporary refugees: Issues, challenges, and a culturally responsive intervention model for effective practice. The Counseling Psychologist, 49(2), 305–324. https://doi.org/10.1177/0011000020972182
Bengtsson, M. (2016). How to plan and perform a qualitative study using content analysis. NursingPlus Open, 2, 8–14. https://doi.org/10.1016/j.npls.2016.01.001
Blease, C., Torous, J., Dong, Z., Davidge, G., DesRoches, C., Kharko, A., Turner, A., Jones, R., Hägglund, M., & McMillan, B. (2023). Patient online record access in English primary care: Qualitative survey study of general practitioners’ views. Journal of Medical Internet Research, 25, e43496. https://doi.org/10.2196/43496
Cabell, A., Burgess, D., Brown, E., & Medina, C. (2024). Counseling trainees’ experiences working with Afghan refugees: Building cultural humility. Counselor Education and Supervision, 63(1), 41–57. https://doi.org/10.1002/ceas.12290
Church World Service. (2025). Daily state of play: Trump’s indefinite refugee ban and funding halt. https://cwsglobal.org/blog/daily-state-of-play-trumps-indefinite-refugee-ban-and-funding-halt
Clark, M., Moe, J., Chan, C. D., Best, M. D., & Mallow, L. M. (2022). Social justice outcomes and professional counseling: An 11-year content analysis. Journal of Counseling & Development, 100(3), 284–295. https://doi.org/10.1002/jcad.12427
Council for the Accreditation of Counseling and Related Educational Programs. (2023). 2024 CACREP standards. https://www.cacrep.org/for-programs/2024-cacrep-standards
Damra, J. K., & Qa’aymeh, S. (2024). Exploring the supervisory needs of school counselors in refugee school settings. International Journal for the Advancement of Counselling, 46, 703–720. https://doi.org/10.1007/s10447-024-09568-x
Duden, G. S., & Martins-Borges, L. (2021). Psychotherapy with refugees—Supportive and hindering elements. Psychotherapy Research, 31(3), 402–417. https://doi.org/10.1080/10503307.2020.1820596
Hosseini, Z., Syed, H., Raza, Z., Mansouri, M., Magan, I. M., & Awaad, R. (2023). A systematic review of evidence-based interventions for Afghan refugee mental health: A cultural adaptation analysis. Journal of Cross-Cultural Psychology, 55(1), 25–46. https://doi.org/10.1177/00220221231213884
Houseknecht, A., & Swank, J. (2019). Preparing counselors to work with refugees: Integration of experiential activities. Journal of Creativity in Mental Health, 14(1), 127–136. https://doi.org/10.1080/15401383.2019.1566039
Interiano-Shiverdecker, C. G., Kondili, E., & Parikh-Foxx, S. (2020). Refugees and the system: Social and cultural capital during U.S. resettlement. International Journal for the Advancement of Counselling, 42, 48–64. https://doi.org/10.1007/s10447-019-09383-9
Kondili, E., Interiano-Shiverdecker, C., & Hahn, C. (2022). Counseling and social justice advocacy interventions with refugees: Two case studies. Journal of Multicultural Counseling and Development, 50(4), 219–229. https://doi.org/10.1002/jmcd.12270
Kuo, B. C. H., Soucie, K., & Huang, S. (2020). Developing clinical trainees’ multicultural counseling competencies through working with refugees in a multicultural psychotherapy practicum: A mixed-methods investigation. International Journal for the Advancement of Counselling, 42, 249–268. https://doi.org/10.1007/s10447-019-09392-8
Midgett, A., & Doumas, D. M. (2016). Evaluation of service-learning-infused courses with refugee families. Journal of Multicultural Counseling and Development, 44(2), 118–134. https://doi.org/10.1002/jmcd.12041
O’Brien, C. V., & Charura, D. (2023). Refugees, asylum seekers, and practitioners’ perspectives of embodied trauma: A comprehensive scoping review. Psychological Trauma: Theory, Research, Practice, and Policy, 15(7), 1115–1127. https://doi.org/10.1037/tra0001342
Olmos-Vega, F. M., Stalmeijer, R. E., Varpio, L., & Kahlke, R. (2023). A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher, 45(3), 241–251. https://doi.org/10.1080/0142159X.2022.2057287
Pampati, S., Alattar, Z., Cordoba, E., Tariq, M., & Mendes de Leon, C. (2018). Mental health outcomes among Arab refugees, immigrants, and U.S.-born Arab Americans in southeast Michigan: A cross-sectional study. BMC Psychiatry, 18, Article 379. https://doi.org/10.1186/s12888-018-1948-8
Pechak, C., Howe, V., Padilla, M., & Frietze, G. A. (2020). Preparing students to serve a refugee population through a health-focused interprofessional education experience. Journal of Allied Health, 49(3), 131–138. https://www.proquest.com/scholarly-journals/preparing-students-serve-refugee-population/docview/2441573255/se-2
Prasad, B. D. (2019). Qualitative content analysis: Why is it still a path less taken? Forum: Qualitative Social Research, 20(3), 36. https://www.qualitative-research.net/index.php/fqs/article/view/3392/4502
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44, 28–48. https://doi.org/10.1002/jmcd.12035
Refugee Council USA. (2024). 2024 fiscal year: US refugee admissions. https://rcusa.org/wp-content/uploads/2024/10/FY24-Refugee-Arrivals-Report.pdf
Rometsch, C., Denkinger, J. K., Engelhardt, M., Windthorst, P., Graf, J., Nikendei, C., Zipfel, S., & Junne, F. (2020). Care providers’ views on burden of psychosomatic symptoms of IS-traumatized female refugees participating in a humanitarian admission program in Germany: A qualitative analysis. PLoS ONE, 15(10), e0239969. https://doi.org/10.1371/journal.pone.0239969
Salami, B., Salma, J., & Hegadoren, K. (2019). Access and utilization of mental health services for immigrants and refugees: Perspectives of immigrant service providers. International Journal of Mental Health Nursing, 28(1), 152–161. https://doi.org/10.1111/inm.12512
Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334–340. https://doi.org/fvxrh4
Sandelowski, M. (2010). What’s in a name? Qualitative description revisited. Research in Nursing & Health, 33(1), 77–84. https://doi.org/10.1002/nur.20362
Satinsky, E., Fuhr, D. C., Woodward, A., Sondorp, E., & Roberts, B. (2019). Mental health care utilisation and access among refugees and asylum seekers in Europe: A systematic review. Health Policy, 123(9), 851–863. https://doi.org/10.1016/J.HEALTHPOL.2019.02.007
Snow, K. C., Harrichand, J. J. S., & Mwendwa, J. M. (2021). Advocacy and social justice approaches with immigrants and refugees in counsellor education. Canadian Journal of Counselling and Psychotherapy, 55(1), 7–27. https://doi.org/10.47634/cjcp.v55i1.68482
Tribe, R. H., Sendt, K., & Tracy, D. K. (2019). A systematic review of psychosocial interventions for adult refugees and asylum seekers. Journal of Mental Health, 28(6), 662–676. https://doi.org/10.1080/09638237.2017.1322182
The UN Refugee Agency. (2025). Figures at a glance. https://www.unhcr.org/about-unhcr/overview/figures-glance
USA for the UN Refugee Agency. (2022). Oscars 2022: Five powerful movies about the refugee crisis. https://www.unrefugees.org/news/oscars-2022-five-powerful-movies-about-the-refugee-crisis
U.S. Department of State. (2018). Admissions & arrivals. http://www.wrapsnet.org/admissions- and-arrivals
Shadin Atiyeh, PhD, NCC, ACS, LPC, CCC, CRC, is an assistant professor at Wayne State University and was a 2017 Doctoral Fellow in Mental Health Counseling with the NBCCF Minority Fellowship Program. Correspondence may be addressed to Shadin Atiyeh, 5425 Gullen Mall, Detroit, MI 48202, shadin.atiyeh@wayne.edu.
Sep 5, 2025 | TPC Outstanding Scholar
Ashley Ascherl Pechek, Kristin A. Vincenzes, Kellie Forziat-Pytel, Stephen Nowakowski, and Leandrea Romero-Lucero received the 2024 Outstanding Scholar Award for Quantitative or Qualitative Research for their article “Teaching Suicide Assessment and Intervention Online: A Model of Practice.”
Ashley Ascherl Pechek (she/her), PhD, NCC, ACS, LPC (CO), currently works as an associate professor at Commonwealth University of Pennsylvania in the clinical mental health counseling graduate program. She has been a Licensed Professional Counselor in Colorado since 2010 and has worked with a variety of clientele, including children and adolescents, military families, and at-risk youth. Dr. Pechek earned her PhD in counselor education and supervision from Adams State University in 2018 and has been teaching in online CACREP-accredited programs for the last 10 years. Her research interests include online learning, creativity in counselor education, military families and veterans, self-care, and suicide assessment and intervention.
Kristin A. Vincenzes (she/her), PhD, NCC, ACS, BC-TMH, LPC, is a counselor educator and full Professor at Commonwealth University of Pennsylvania in the clinical mental health counseling graduate program. She has over 13 years of experience teaching in graduate counseling programs, including 10 years during which she served as a program director developing and growing a new program. Dr. Vincenzes has fully written two CACREP self-studies and has led her program through both initial accreditation and preparation for re-accreditation. She is a Licensed Professional Counselor in Pennsylvania as well as an Approved Clinical Supervisor, National Certified Counselor, and a Board Certified TeleMental Health Provider. She has 29 peer-reviewed publications, including both journal articles and book chapters, and has presented 53 times across different local, state, regional, and national venues. Her scholarship interests focus on trauma, the military, wellness for service professionals and leaders, and online education.
Kellie Forziat-Pytel (she/her), PhD, NCC, ACS, LPC (PA), currently works as an Assistant Professor at the Commonwealth University of Pennsylvania–Lock Haven. She is a part-time research support for the Clearinghouse for Military Readiness at Pennsylvania State University. Her specialty areas consist of prevention work, military, trauma, and grief and loss, and their impact on individuals, families, and the community.
Stephen Nowakowski (not pictured), is a former graduate student of clinical mental health counseling at Commonwealth University of Pennsylvania.
Leandrea Romero-Lucero (she, her, hers), PhD, ACS, LPCC, CSOTS, is an Associate Professor and Program Director for the 100% online clinical mental health counseling program at Commonwealth University of Pennsylvania–Lock Haven. Dr. Romero-Lucero holds a PhD in counselor education and supervision, has been licensed in the state of New Mexico as a mental health counselor since 2008, holds the Approved Clinical Supervisor and Certified Sex Offender Treatment Specialist certifications, and is an approved supervisor in New Mexico. Dr. Romero-Lucero’s research interests are grief and loss for kinship caregivers, supervisor training and development, and burnout among providers who work with adult and juvenile sex offenders.
Read more about the TPC scholarship awards here.
Sep 5, 2025 | TPC Outstanding Scholar
Taylor J. Irvine and Adriana C. Labarta received the 2024 Outstanding Scholar Award for Concept/Theory for their article, “Enhancing Counselor Trainee Preparedness for Treating Eating Disorders: Recommendations for Counselor Educators.”
Taylor J. Irvine (she/her), PhD, NCC, ACS, LMHC, is an Assistant Professor of clinical mental health counseling at Nova Southeastern University. Dr. Irvine has clinical experience working in community mental health and residential eating disorder treatment settings. Her main clinical and research interests include couples and infidelity, eating disorders, and body image concerns. Dr. Irvine has presented and published on these topics nationally and internationally, spotlighting culturally responsive and evidence-based methods across counseling research, training, and practice domains. Currently, Dr. Irvine serves as the Chair of Chi Sigma Iota (CSI) International’s Counselor Community Engagement Committee, in addition to several professional counseling committees and editorial boards. She is also a past CSI Leadership Fellow and Emerging Leader for both the International Association of Marriage and Family Counselors and the Association for Assessment and Research in Counseling.
Adriana C. Labarta (she/her), PhD, NCC, ACS, LMHC, is an Assistant Professor of clinical mental health counseling at Nova Southeastern University. Dr. Labarta has clinical experience working with diverse clients in residential, partial hospitalization, intensive outpatient, outpatient, and university counseling settings. Her primary clinical and research interests include eating disorders, body image concerns, multicultural counseling, and self-compassion. Dr. Labarta is an actively engaged member of several counseling organizations and serves as an editorial board member for Teaching and Supervision in Counseling and Counseling Outcome Research and Evaluation. She was previously selected as an Emerging Leader by the Southern Association for Counselor Education and Supervision and the Association for Assessment and Research in Counseling.
Read more about the TPC scholarship awards here.
