Gaining Administrative Support for Doctoral Programs in Counselor Education

Rebecca Scherer, Regina Moro, Tara Jungersen, Leslie Contos, Thomas A. Field

Initiating and sustaining a counselor education and supervision doctoral program requires navigating institutions of higher education, which are complex systems. Using qualitative analysis, we explored 15 counselor educators’ experiences collaborating with university administrators to gain support for beginning and sustaining counselor education and supervision doctoral programs. Results indicate the need to understand political elements, economical aspects, and the identity of the proposed program. Limitations and areas for future research are presented.  

Keywords: counselor education and supervision, doctoral, university administrators, counselor educators, support

 

The Council for Accreditation of Counseling and Related Educational Programs’ (CACREP) 2009 CACREP Standards (2008) included a new requirement for core faculty in both entry-level (i.e., master’s) and doctoral programs. This requirement endured in the 2016 CACREP Standards (2015). Although West et al. (1995) predicted the necessity of growth of CACREP-accredited doctoral-level counselor education programs in the mid-1990s, it was not until 2013 that core faculty in all CACREP-accredited programs were required to possess doctorates in counselor education and supervision (CES; or be grandfathered in from previous employment experience; CACREP, 2008). Master’s-level programs that are seeking new CACREP accreditation, as well as existing programs that are seeking to maintain accreditation, must therefore hire faculty with doctorates in CES. This requirement has created a need for greater numbers of doctoral graduates in counselor education, and institutions with master’s-level programs may be seeking to establish new doctoral-level programs to meet this need.

The creation of a doctoral program requires intricate navigation of complex systems of administration, accreditation, funding, laws, facilities, infrastructure, and politics. Additionally, universities have different requirements and levels of approval for new program development (S. Fernandez, personal communication, November 27, 2017). Counselor educators proposing a CES doctoral program must have an understanding of the complexity of the specific university (e.g., its organization, the history of university support for doctoral programs, the mission of the institution, the needs of the surrounding community, and the resources required for program development and implementation). Furthermore, counselor educators must have a firm grasp of accreditation standards for both the university’s regional accreditation bodies (e.g., Commission on Colleges of the Southern Association of Colleges and Schools), as well as specialty CES accreditation through CACREP.

Structure of Universities
     The hierarchical structure of universities varies from institution to institution. In this section, we provide a general outline of how universities are structured to help counselor educators who are interested in proposing a CES doctoral program. This information is very important when considering how to advocate for a doctoral program because of the many organizational layers and levels associated with an institution.

Typically, counseling programs are housed in a department, college, or school of the university (e.g., College of Education). The program is led by a program head, coordinator, or department chair. This person reports to the dean of the college. The dean reports to the provost or chancellor or chief executive officer. The president of the university then supersedes this level.

It is important for faculty members to assess the priorities of their institution for academic, student, and financial affairs. For example, a small private college in an urban area may have a mission to train adult learners and to provide access to education through lower admissions standards and flexible pathways to degree completion. In contrast, a large, public, research-intensive university may have a mission to support exceptional research and secure external grant contracts, and to raise college rankings through metrics such as low acceptance rates (The Carnegie Classification of Institutions of Higher Education, 2019). Based on administrative experience with doctoral program creation, structural information must be taken into consideration when advocating to administrators on behalf of CES doctoral program development.

Successful Initiation of Doctoral Programs
     In the higher education literature, there are a few publications on the creation of doctoral programs. Researchers have proposed that doctoral programs can be successfully initiated in the context of three circumstances: (a) top-down initiation, (b) filling a need in the local area, or (c) focusing on new delivery methods (Brooks et al., 2002; Haas et al., 2011; Slater & Martinez, 2000). In regard to top-down initiation, some authors have proposed that doctoral programs are likely to be launched if the initial idea comes from the provost or president of the university. Slater and Martinez (2000) described the process of successful initiation of a doctoral program in a small institution in Texas. They reported that the president suggested the idea to the dean, with later onboarding of faculty members.

Doctoral programs also seem to be initiated successfully if a need exists for such a program in the local area (Brooks et al., 2002; Haas et al., 2011). Haas and colleagues (2011) emphasized the importance of faculty members and administrators assessing program fit within the region. In both the Brooks et al. (2002) and Haas et al. (2011) studies, the importance of current delivery modalities in successfully recruiting support for a doctoral program, including the use of online delivery and interdisciplinary studies, was presented.

Rationale and Purpose
     At the time of writing, no studies could be identified in the CES literature regarding how to successfully gain administrative support for starting a doctoral program in CES. Another manuscript in this special issue (Field et al., 2020) illustrates a potential pipeline problem in counselor education, in particular the need for more CES doctoral programs in the North Atlantic and Western regions of the country. CES faculty members who are contemplating starting a CES doctoral program currently have little guidance on how to gain support for starting a program. In addition, no studies could be located regarding how to successfully sustain an existing doctoral program in CES. The purpose of this study was to collect and analyze qualitative data to address the research question guiding this study: Which strategies are helpful in gaining initial and ongoing support from administrators for a CES doctoral program, and how successful are those?

Method

This study was conducted as part of a larger basic qualitative study sampling counselor educators. The purpose of the larger qualitative study was to identify perceptions of doctoral-level counselor educators regarding four major issues pertinent to doctoral counselor education: (a) components of high-quality programs, (b) strategies to recruit and retain underrepresented students, (c) strategies for successful dissertation advising, and (d) strategies for working with administrators. In order to explore these four major issues, four research teams were assembled, one of which included the authors of this manuscript. All four coding teams worked together to select these four issues, as it was felt that these issues were most pressing for faculty who were seeking to establish new doctoral CES programs and that little information and guidance existed in these areas. In-depth interviews were then conducted with doctoral-level counselor educators in CACREP-accredited programs to answer a series of research questions that addressed the issues above. Faculty from CACREP-accredited programs were selected because the focus of the larger project was to support faculty who intended to seek CACREP accreditation for new doctoral CES programs.

In the basic qualitative tradition, qualitative data were collected, coded, and categorized using the constant comparative method from grounded theory methodology (Corbin & Strauss, 2015; Merriam & Tisdell, 2016). Basic qualitative designs involve the collection and analysis of qualitative data for the purpose of answering research questions outside of other specialized qualitative focus areas (e.g., developing theory, understanding essence of lived experience, describing environmental observations). Because we were not seeking to develop theory, understand lived experience, or research any other specialized qualitative focus area with this study, and because the research question did not require a specialized approach to data analysis, the large research team selected the basic qualitative approach described above.

Each coding team designed interview questions to directly answer their specific research question. The research questions explored in this study were as follows: Which strategies are helpful in gaining initial and ongoing support from administrators when seeking to start a new doctoral program in CES, and how successful are those? The interview questions that were developed and used as the basis for data collection for this study were: 1) What guidance might you provide to faculty who want to start a new doctoral program in counseling, with regard to working with administrators and gaining buy-in? and 2) What guidance might you provide to faculty who want to sustain an existing doctoral program in counseling with regard to working with administrators and gaining ongoing support?

Participants
     Participants met two inclusion criteria for entrance into the study: (a) current core faculty members in a doctoral CES program that was (b) accredited by CACREP. Email requests were sent to 85 CACREP-accredited programs; faculty from 34 programs responded (40% response rate). Interviews were conducted with 15 full-time faculty members at CACREP-accredited CES doctoral programs. Participants were each from separate and unique doctoral programs, with no program represented by more than one participant.

The 15 participants were selected one at a time, using a maximal variation sampling procedure to avoid premature saturation (Merriam & Tisdell, 2016). The authors used maximal variation to understand perspectives from faculty of diverse backgrounds who worked at different types of institutions. Participant selection was predicated on six criteria grounded in research data about factors that may impact perceptions about doctoral program delivery: (a) racial and ethnic self-identification (Cartwright et al., 2018); (b) gender self-identification (Hill et al., 2005); (c) length of time working in doctoral-level counselor education programs (Lambie et al., 2014; Magnuson et al., 2009); (d) Carnegie classification of university where the participant was currently working using The Carnegie Classification of Institutions of Higher Education database (Lambie et al., 2014); (e) region of the counselor education program where the participant was currently working (e.g., Field et al., 2020), using the regional classifications commonly applied in the counseling profession; and (f) delivery mode of the counselor education program where the participant was currently working, such as in-person or online (Smith et al., 2015). As an example of this procedure, the first two participants were selected because of variation in gender, years of experience, and Carnegie classification. The third and fourth participants were selected on the basis of differences from prior interviewees with regard to ethnicity and region. Interviews continued until data seemed to reach saturation and redundancy at 15 interviews.

Although unintended, participant characteristics closely approximated CACREP statistics for faculty characteristics. The demographics of counselor educators in the sample was 73.3% White (n = 11), with 73.3% (n = 11) of participants working at research-intensive (i.e., R1 and R2) institutions. The sample was highly experienced, with an average of 19.7 years (SD = 9.0 years) as a counseling faculty member, with a range of 4 to 34 years. More than half of the participants (n = 9) had spent their entire career in doctoral counselor education.

Procedure
     The last author of this manuscript sought IRB approval. Once we received IRB approval, potential participants were contacted from 85 CACREP-accredited programs with doctoral-level graduate studies in CES. Fifteen faculty were interviewed based on maximal variation sampling described above. All but one participant (n = 14) was interviewed via the Zoom video conference platform, chosen because of its privacy settings (i.e., end-to-end encryption). Interviews were recorded using the built-in Zoom recording feature. One participant was interviewed in person at a national counseling conference. This interview was recorded using a Sony digital audio recorder.

Interview Protocol
     Each videoconference interview was begun by collecting demographics and informed consent. Following the introductory phase, interviewees were asked eight questions that addressed the research questions of the larger study. Two of the questions were specific to this sub-research team. Interview questions were developed using Patton’s (2015) guidelines to inform question development. Specifically, the questions were open-ended, neutral, avoided “why” questioning, and asked one at a time. The questions were piloted with peer counselor educators prior to the start of the research project in order to get feedback on clarity and ease of answering. Participants received the questions by email before their scheduled interview. The participants were identified using alphabetical letters to blind participant identity to all members of the research team.

Each semi-structured interview lasted at least 60 minutes, during which participants responded to questions that were evenly distributed among the four research teams. Participants were therefore able to respond to interview questions with significant depth. Data did not appear saturated until 15 interviews had been conducted. Each research team was asked to review the transcripts developed from the 15 interviews to deduce whether adequate saturation had been achieved and until consensus was reached.

Transcription
     All interview recordings were transcribed by graduate students. These students had no familiarity with the interviewees and were trained in how to transcribe verbatim. Once completed, each transcript was sent back to the interviewees to ensure accuracy. After all interviewees checked their document, the sections of the transcripts with the questions related to each team were copied and pasted into a document organized by the participants’ alphabetical identifiers. Each team was responsible for coding and analyzing the responses to their respective questions from the interviews.

Coding and Analysis
     The first, second, third, and fourth authors served as coding team members. The fifth author conducted the interviews as part of the larger study and assisted with writing sections of the methodology only. The demographics of the coding team were as follows. Team member ages ranged from mid-30s to 40s. All four identified as White cisgender females. Two of the coding team members were employed as full-time counselor educators, one identified as an administrator and counselor educator, and one coding team member was completing doctoral training as a counselor educator. Two participants had worked in doctoral counselor education programs, and two had not. We have served on both sides of the faculty–administrator relationship. These differences in backgrounds allowed for both etic and emic positioning pertinent to the topic of working with administrators to start and sustain doctoral programs in CES.

Because of the nature of both insider (emic) and outsider (etic) perspectives, the authors used a memo system when coding the manuscripts. This memo system involved three components. First, we created a blank memo every time a transcript was coded. Second, each time an interviewee’s transcribed response provoked some response within one of us, we raised it to the group and reflected on our individual experience. This response was documented in a memo. Third, one of us took notes to bracket any biases that might have been present. Identified biases often stemmed from our own experiences as faculty members talking to administrators, our service in an administrative role, or our own personal experiences developing doctoral programs. This occurred during joint coding team meetings and individual coding meetings once the open coding had been solidified into a set of codes. The memos were kept in a shared, encrypted, electronic folder for later review.

The following steps were followed by the coding team in the current study to ensure trustworthiness of analysis. The four coding team members jointly coded the first three participant transcripts to gain consensus. Following this open coding process, the second author condensed the open codes for the next phase of analysis. The coding team members then reached consensus on the condensed codes. Following agreement, we used the condensed codes to continue the coding process for the next two transcripts in joint coding meetings. This process allowed for discussion to assist with consistent understanding of the codes across the team. Following the joint open coding of the fifth transcript, the remaining 10 transcripts were assigned to one of us for open coding to be completed independently. After the open coding process was completed, the fourth author proposed a framework of the emerging themes. She examined the open codes and considered discussions that emerged throughout the team process to identify the emergent themes from the data. Open codes were only included in the analysis if they emerged in at least four transcripts, which resulted in the removal of three codes from the final results. All team members reached consensus for the themes that were originally identified by the fourth author.

Results

The data analysis process resulted in three emergent themes regarding strategies for gaining initial and ongoing support from administrators for CES doctoral programs and the level of success of those strategies. The three themes were political landscape, economic landscape, and identity landscape. Each theme had five associated subthemes. Each theme and subtheme are discussed in more detail below, and brief participant quotes are inserted to highlight the experiences of the participants in their own words for the purpose of thick description (Merriam & Tisdell, 2016).

Political Landscape
     Considering the political landscape appeared to be a crucial strategy for recruiting administrative support when having conversations with administrators about CES doctoral programs. Participants described the importance of understanding the context of conversations with administrators within the larger political system of higher education institutions. The subthemes represented factors that influenced political decisions.

Political Endeavor: “Watching Your Politics”
     Participants reported that conversations with administrators were highly political in nature and having these conversations was a form of political endeavor. One example of political endeavor was to ensure that other academic units and programs were in support of a CES doctoral program. As one participant stated, “First make sure that you’ve got your politics in order, so social work agrees with you and psychology agrees with you. So, you’ve got support of any competitor on campus.” If other academic units or programs are opposed to a CES doctoral program, it may result in administrators being cautious about supporting the program because of fears that they may be caught in the middle of a turf battle.

Gaining administrative support seemed to be predicated on the ability to “strategically build relationships” with administrators, as one participant put it. One participant commented on the complexity of developing these relationships with administrators. This participant believed that faculty needed to strike a balance of being flexible and adaptive to the administrators’ agenda and “order of the day,” while also retaining one’s “own ideology and belief systems.” Building relationships with administrators also seemed to involve avoiding unnecessary conflict that may reduce administrator support for faculty ideas. One participant cautioned that “watching your politics” and “keeping your mouth shut when you know you shouldn’t be speaking up against key administrators” was important during conversations with administrators to avoid unnecessary conflict that could “hurt your own doc program.” Learning this form of engagement seemed to be a struggle for some participants. One participant stated that they “don’t know how to navigate those conversations effectively” and felt “saddened and frustrated” as a result.

Status, Prestige, and Recognition: “A Huge Feather in One’s Cap”
     Participants conveyed that CES faculty could gain administrative support through the strategy of arguing how a doctoral program could enhance status, prestige, and recognition for an institution. One participant commented that “all university presidents want doctoral programs. They want them because of the prestige.” This participant elaborated that faculty should therefore “show them how doctoral programs bring recognition, how it raises you in the rankings, and all of those kinds of things.” Some participants noted that the degree to which administrators cared about enhanced status, prestige, and recognition depended on the type of institution. For example, administrators who work at an institution that is less concerned with college rankings may be unpersuaded by the potential for enhanced status and recognition.

Participants also encouraged CES faculty to strategically engage in actions that increase recognition for the program and university. Some potential strategies that may appeal to administrators include being “identified as an expert, and to go out and do public radio broadcasts and be featured in the newspaper. Be featured in national publications.” This recognition helps with both program and university visibility, which participants believed was important to administrators. Participants also shared that visibility can help to protect the program from losing administrative support. As one participant stated, “If you’re invisible in the eyes of the administrators, they’re not going to think of you if some opportunities are coming to the fore.” This participant further commented that administrators needed to be reminded of the doctoral program through continual visibility efforts, as administrators often operate from an “out of sight, out of mind” position.

Demonstration: “Wanting Empirical Evidence”
     Participants identified the strategy of sharing evidence with administrators to support and sustain doctoral programs. As one participant stated, “Once you get to the doctoral level, then we’re talking about people wanting empirical evidence.” In the early stages of program formation, this evidence might be a comprehensive proposal that is supported by data. As one participant stated, faculty need to develop a “solid plan” and be “as prepared as possible” for conversations in which administrators will “ask a ton of questions.”

Once a program is formed, it seems crucial that programs continuously provide updates to administration about program successes to sustain administrative support. Participants identified several approaches to demonstrating the success of a program. Some participants indicated that it was important to keep administration informed about student successes that occurred during doctoral study. One participant reported that their program kept administration informed via email about “every little success of the doctoral program” and provided the following examples: “Every time somebody successfully defends a dissertation, every time somebody presents at a conference, every time somebody gets a job congratulated, the president knows about it.” Other participants believed that it was helpful to report program outcomes such as graduation rates and employment statistics, which requires faculty to maintain contact with alumni to understand where they are working after graduation. It therefore seems possible that administrators may differ in which types of evidence they value, requiring faculty to carefully consider which information their administration most values when sending them updates of program successes. As one participant stated, “I think the question is, what information do you need to feed to administration to be convincing?”

Scrutiny: “Internal Credibility Is Super Important”
     Participants reported that program faculty should understand the different ways that administration will scrutinize the credibility of a doctoral program. One participant defined credibility as, “Do what you’re doing well.” Administrators might withdraw support for a program that is perceived as not producing quality graduates or has problems such as not graduating students. Administrator scrutiny of the program’s financial situation also appears to be an important consideration. Administrators who are concerned about the financial viability of the program may withdraw their support.

Timeline and Trajectory: “It’s a Long Journey”
     Participants reported that political decisions, such as starting and sustaining academic programs, particularly doctoral programs, may be influenced by unique timelines and trajectories. Participants encouraged faculty to develop the strategy of thinking long-term about cultivating administrative support for a doctoral program. One participant emphasized the need to “work together” with administrators in a collaborative fashion and make compromises so that administrators will support the doctoral program throughout the “long haul” and “long journey” of the program.

The length of administrator tenure at the university is another factor that faculty are advised to consider. One participant stated that faculty tend to have longer tenure than administrators at their university. As a “lifer,” this participant saw “a lot of rotation in and out of leadership.” Administrator turnover can result in changes to administrative priorities and agendas, which can impact support for a CES doctoral program. This participant encouraged faculty to “be cognizant of the fact that winds change.” 

Economic Landscape
     Considering the economic landscape and economic realities of starting and sustaining a doctoral program was the second main overarching theme. Developing an understanding of the economic landscape is important context for faculty when preparing for discussions with administrators. Several subthemes comprise the economic landscape, each detailed below.

Financial Aspects: “It Takes a Lot of Money”
     Of utmost importance when discussing starting and sustaining CES doctoral programs with administrators is understanding the financial resources required. Many participants spoke about the cost of CES doctoral programs for universities. Participants believed that a crucial strategy to gaining administrator support was being able to explain how programs can be at least revenue-neutral or even generate revenue for the university, as administrators are less likely to support a CES doctoral program that is a drain on financial resources.

Participants varied in their perceptions of whether CES doctoral programs could generate revenue for the university. The key distinction between these participants seemed to be whether they believed doctoral programs should charge students tuition or fully fund them. Some participants believed that “high-quality doc programs do not make money for institutions” because they should be fully funding doctoral students rather than generating tuition revenue. These participants proposed that faculty should instead be “thinking creatively about funding sources” and seeking alternative methods of offsetting the financial burden on the institution. Examples of identified alternate funding sources included grants and undergraduate teaching opportunities for doctoral students.

Others were aware of this prevailing belief that doctoral programs do not generate revenue and argued the opposite: “Most faculty, when they want to start a doctoral program, they repeat this thing that they hear, which is ‘doctoral programs cost money, they don’t make money.’ And that’s not true.” These participants proposed that student tuition should be used to fund doctoral programs. One participant argued that if tuition exceeded the cost of faculty salaries, the program was likely to be generating revenue. This participant believed that counseling programs could generate money because they were relatively inexpensive. Unlike hard science disciplines, CES doctoral programs do not require expensive lab equipment, and CES faculty salaries are “lower compared to other programs.”

Tangible Benefits to Ecosystem: “How Do We Help?”
Participants discussed that administrator support for a doctoral program can be bolstered through demonstrations of how the program is supporting the local community. One participant shared that their program provides data to administrators about the number of hours of free counseling that the program provides to the community, which in turn helps the dean to gain the provost’s support for the program. Such data can help administrators when they conduct a cost–benefit analysis for whether to start a new program or sustain an existing program. Likewise, another participant encouraged faculty to take an “ecological view” and consider “how do we help . . . the surrounding communities?” 

Need for Resources: “Pit Bulls in a Fighting Ring”
     Participants discussed the need to address the competition for resources when attempting to gain administrator support. Participants mentioned the scarcity of resources that included faculty positions (i.e., lines) and physical building space. This scarcity resulted in programs needing to compete for resources. One participant stated, “I think we’re all going to be like pit bulls in a fighting ring over resources at this point.” Another participant shared a similar statement: “Once we get outside of our building, it is very territorial. So, we have to basically anticipate resistance from other pockets in the university if we want a new program at the doctoral level.” This participant elaborated that the provost needs to be aware of these dynamics and that faculty should attempt to make a strong case for needing resources if they are in competition with other programs.

Competition for resources seemed to occur not only within a university’s departments but also between CES programs at different universities. Doctoral applicants appear to be increasingly making enrollment decisions based on tuition costs and graduate assistantships, which increases the pressure for programs to provide financial support packages. One participant reported that it is becoming less feasible to operate a doctoral program without “some form of stipend or assistantship” because “if you don’t, there’s too many other programs that do.” This participant elaborated that administrators must support the program with assistantships and concluded, “I wouldn’t try to start a program without it.”

Some participants discussed strategies to maximize resources across the college or school in which the program exists, such as with college-wide methodology courses. Such strategies seemed particularly important when adapting to the pressure of accepting more students to make the program revenue-neutral. One participant suggested that such resource sharing was “of utmost importance… in the early beginnings of programs.”

Faculty and Program Responsibilities
     Faculty have more complex responsibilities when operating a doctoral program compared with a master’s program, such as attending conferences with students and engaging in the larger campus community. As one participant stated, “It’s also being at events, interacting with administrators, making sure when walking around campus or buildings that they know who you are and that they can connect with what you’re doing.” Participants explored the economic aspects of the responsibilities that individual faculty members and the larger program have when responsible for the doctoral education of counseling students: “At our institution, you don’t get a lot of credit per se, or release time or extra pay for all of the work it takes to mentor doctoral students.” This credit that is or is not allocated to doctoral education impacts faculty members’ well-being. Another participant cautioned faculty to be aware of “faculty burnout” that accompanies tensions around adequately funding faculty positions: “If you shrink, and you still maintain the same number of students, there is simply not enough time, not enough emotional capacity, to do the good work.” Another participant shared that their doctoral programs felt like “hell on wheels” because “we ended up with a program that had more than 100 students with two real tenured faculty running the program.”

Influence of University: “Know the Size and Culture”
     This subtheme represented faculty considerations of the larger university system context where the counseling program is situated. As one participant summarized, “part of it is looking at the context of the program in the university.” Participants particularly referenced size as an influencing factor. As one participant stated, “Know the size and culture of your institution.” University size influenced participants’ access to decision-makers: “We’re so small that I could literally walk out of my office and two minutes later I can be in the provost’s office. I can ask a question. They’re very approachable, and so I don’t feel intimidated.” Understanding the institution’s mission and its funding priorities is crucial to forging successful alliances with administrators regarding whether to start and sustain a CES doctoral program. Understanding where a CES doctoral program fits within the institution’s academic structure therefore helps faculty to effectively communicate with administrators, and consistently reviewing this can help inform ongoing dialogues with administrators.

Identity Landscape
     The overarching identity landscape theme represents how programs both understand their internal identity regarding doctoral education, as well as the external identity factors that contribute to the program. Each subtheme is detailed below with participant quotes.

Operationalize and Define Commitment: “Faculty Have to Buy In”
     Gaining faculty buy-in prior to conversations with administrators and gaining approval for a doctoral program was a consistent message relayed by participants. One participant reflected, “Everybody has to be on board and has to buy in to the concept that the mission can’t be the mission of one person.” Another participant recommended that faculty leadership (e.g., program directors) need to operationalize this commitment through intentional dialogues with faculty. This participant stated that “the evidence for faculty buy-in isn’t always there until you probe.” They elaborated that faculty leadership can facilitate discussions around the following questions: “Are you willing to do X, are you willing to do Y?” and “If we start a doctoral program, do you feel like you have the skills you’ll need or do you fear that you’re going to be left behind?” Such conversations appeared important to developing a unified collective commitment to the doctoral program, which was critically important when challenges arose. Other participants reflected on personal buy-in and encouraged self-reflection in this regard: “Things to consider including one’s own personal meaning making.” Participants reflected that doctoral education was significantly different than master’s-level education and required a different level of commitment. Administrators are unlikely to support a doctoral program if the faculty are divided in their commitment to the program.

Understanding Differences: “Know What Your Program Is Worth”
     Participants spoke about the need for faculty to possess knowledge about multiple aspects of doctoral education when conveying information to administrators. Faculty should be familiar with the differences between master’s and doctoral education, between doctorates in other disciplines within the university, and among doctoral programs at different universities in the state. This information assists faculty “to really know what your program is worth and to be able to explain it.” For example, faculty should make administrators aware of how doctoral education can enhance master’s-level training rather than result in master’s students being “ignored” and treated as “second class citizens.”

Participants indicated that administrators may not be familiar with the counseling profession and thus may need education. Participants reported the need for “educating your administrative colleagues about what counselor ed is, what they do, how we train.” Another participant stated that “even at the dean level, they don’t know what the heck a mental health counselor is. Not a clue.” Consistent with this, administrators may also need information about other aspects of the profession, such as the value of specialized accreditation. One participant reported, “I think that we can do a better job of telling our admin the pros of CACREP versus the cons.” Education about CACREP accreditation was important because of the costs associated with accreditation fees and hiring core faculty to meet the CACREP doctoral standards.

Quality in Programs: “High-Quality Output”
     Participants reflected on the importance of program quality as a reflection of the programs’ overall identity. Program outputs seemed to be a particularly important measure of program quality. Some participants, particularly those at research-intensive universities, emphasized the importance of research-related outputs such as “grants, high-quality output, and visibility.” Across participants, employment rates were a particularly important measure of program quality, especially employment in academic and administrative jobs post-graduation. Participants reported that such metrics were useful as a “selling point” to administrators, especially if needs existed for doctoral-level graduates in the local area. As one participant stated, “Some of those outcomes become really important to administrators, and I think that we need to be good at putting those outcomes in front of them.”

Participants also shared concerns with program quality. These concerns often centered on admitting more students than can be adequately mentored through the dissertation process. One participant was “concerned about doc programs that bring in cohorts of 20 and churn them out” because they feared that “big doc programs” are “just course-based models without a whole lot happening outside of that. . . . And, you know, I worry about dissertation mentoring.”

Program accreditation was explored as an influencing factor in program quality that ultimately influences the overall program identity through reputation. One participant stated, “We built the program around the accreditation standards and took those standards very seriously.” Another participant explored how the accreditation process can influence administrators’ opinions of the program: “If we had bombed that visit, from the president to the vice president on down, we would have looked really bad.”

Advancing the Institutional Mission: “It Has to Match”
     Study participants commented on the importance of the identity of the doctoral program connecting to the mission of the larger institution. One participant encouraged faculty to consider the institutional mission when communicating with administrators: “When we advocate for programs, we need to understand the mission of the institution.” This participant reported that administrators in a university that values community service may be in favor of doctoral programs that “create more service providers for the local community.” Another participant stated that “it has to match the university’s mission. I hear that more and more and more.” This participant acknowledged that a proposed doctoral program would only receive administrative support if it “fits with the strategic plan of the university.” Participants indicated that the program should align not only with the institutional mission but also with the mission of the college or school where the program is housed.

Stakeholder Dynamics: “Making the Administrators Happy”
     Participants discussed the variety of stakeholders that faculty should consider when developing a CES doctoral program. Such stakeholders include the students being educated, faculty in the program, administrators who make decisions about the program, and employers of future program graduates. Participants reflected that each stakeholder group can contribute meaningfully to the identity of the program.

At times, a stakeholder group’s contributions and agendas may be at odds with those of another stakeholder group. This is particularly problematic when tensions exist between a stakeholder group and administrators. For example, faculty may prefer a smaller program than administrators. One participant stated that “one of the things that I’ve fought with faculty about my whole life, has been that [faculty] want small classes and they want few students.” This participant added that administrators tend to close smaller programs when pressured to cull the number of doctoral programs at an institution, and thus smaller size represents a potential threat to the program: “Any time an administrator is going to cut a program or deny resources to a program, they do it with the program with the least number of students in it. It’s just the absolute way it’s done.” This participant proposed that faculty stakeholders must therefore understand the dynamics of higher education administration when advocating, as “making the administrators happy with the numbers” is an important priority.

Discussion

In this study, we conducted a qualitative analysis of interviews with 15 experts in the field to examine the research question. We identified participant-reported strategies for gaining initial and ongoing support from administrators for a CES doctoral program. The overarching themes of political, economic, and identity landscapes emerged from the data, alongside associated strategies necessary for gaining support. Navigation of complex university systems, including accreditation, finances, legal concerns, infrastructure, and politics, seem to be required for successful initial administrator approval of a CES doctoral program. Awareness of institutional mission and history, purpose, community needs, fiscal realities, and the university’s organizational chart also can facilitate approval and successful program sustenance.

Implications for CES Faculty
     The findings from this study may be utilized by existing master’s degree counseling program faculty who want to create a CES doctoral program. Faculty should embark on a data-driven process to inform administrators of tangible benefits across multiple systems and articulate the financial resources necessary for long-term success. As new CES doctoral programs are proposed, faculty should ensure that university administrators are aware of the relative worth of counselors and counselor educators, particularly in contrast to other mental health disciplines that may exist on campus. They may need to document the tangible benefits that CES programs bring to the university that are in alignment with the university’s mission and strategic plan. In 2013, Adkison-Bradley noted, “As universities change and grow, academic programs are often required to justify their request for resources or asked to explain how they uniquely contribute to the overall mission of the college and surrounding communities” (p. 48). Faculty could benefit from open dialogue with administrators and mentors about what it costs the institution to have a doctoral program compared to what revenue and resources a doctoral program can generate. CES faculty also can provide data to explain how accreditation requirements that may appear expensive to administrators (e.g., 1:6 faculty–student ratios in practica; 1:12 faculty–student ratios) do benefit students, clients, and communities, including protection of “broad public interests” (Urofsky, 2013, p. 13).

Faculty must engage in systemic thought that goes beyond the program and department. Bronfenbrenner’s (1979) ecological systems model provides a useful model for program faculty to understand. This model includes four main systems in which individuals exist—microsystem, mesosystem, exosystem, and macrosystem, with each system growing in size and complexity. Faculty without this perspective risk experiencing their department in a bubble and may not realize how their smaller microsystem (i.e., program, department) fits within the larger macrosystem of the university. The political landscape can become entangled in the developing exosystem where these systems overlap. This exosystem includes considerations for the college’s or school’s strategic priorities where the doctoral program is located. Faculty also should consider larger systemic interactions, such as the doctoral program’s relationship with the local community, with other master’s and doctoral programs in the state, and with other doctoral programs nationally.

The 2016 CACREP Standards (2015) require doctoral education to focus on leadership. However, the standards require this education to be in relation to counselor education programs and in professional organizations, not specifically in institutions of higher education as larger systems. It is unknown how or if students receive formal education about how to navigate university systems, as it is not typically included in CES doctoral program curricula. However, in our own personal experiences as faculty members and doctoral students, we have found that this knowledge seems to be acquired through observation, experience, and on-the-job mentoring. Unfortunately, this learning may occur when new and junior faculty are under pressure to establish themselves for tenure and promotion. Senior faculty, including those nearing retirement, are likely to possess this systemic knowledge and understanding. This knowledge could be conveyed via formal or informal mentoring programs; however, junior faculty in counselor education programs report a lack of mentoring experiences (Borders et al., 2011). The lack of mentoring could be from a variety of reasons, as junior faculty members may be intimidated by senior faculty (Savage et al., 2004), or senior faculty may lack the commitment to put forth the long-term effort to gain support for a new CES doctoral program.

Faculty must be willing to invest in learning about the processes involved in doctoral program creation—to listen, be respectful, and exercise patience for the time required for program approval, funding, and development. The results of this study indicate that program generation is a political process, and junior faculty must be aware of their environment. Faculty have different levels of input and leadership at different institutions, such as with different forms of shared governance (Crellin, 2010). Faculty who do not understand political savviness, the role of fiscal constraints, and the historical precedents for doctoral program initiation may struggle more than those who understand the lens by which individual institutional decisions are made.

Implications for University Administrators
     University administrators could utilize the results of this study to understand how to work with faculty who are requesting the initiation of a new doctoral program. Administrators could consider establishing dedicated time and orientation to new and junior faculty to assist them in conceptualizing how faculty requests are prioritized within the institution, perhaps via a formal mentoring program (Savage et al., 2004). For example, if the university’s current vision is to respond to the lack of STEM (science, technology, engineering, and mathematics) graduates in the local job market, counseling faculty could better manage their expectations about the estimated timeline of new degree program creation while aligning their new CES doctoral degree proposal to a more attainable target date. Communication about the timeline of decisions and the patience involved in systemic change (e.g., state legislature involvement) could also benefit the faculty perspective. Opportunities for learning about the organization are a crucial ingredient in organizational change (Boyce, 2003).

Although it is the responsibility of deans and department chairs to communicate the university’s vision and strategic plan, administrators should also trust the CES faculty’s distinct knowledge of the field and dynamic accreditation standards. Faculty are uniquely qualified to anticipate shifts in the profession that could impact their programs. From our experience, CES faculty who serve as internship clinical supervisors may also possess unique knowledge of the needs of the surrounding communities through their supervisees’ reports of client needs.

It is suggested that administrators include a university organizational chart in new faculty orientation or in the faculty handbook so that faculty can be aware of the hierarchy within the university. The orientation should include a clear explanation of how the particular institution prioritizes agendas and provide a history of the institution, with specific examples of prior program creation in the face of competing needs (e.g., missions, financial). Faculty can then understand how the university invests in its future.

Limitations and Suggestions for Future Research
     Several limitations exist with qualitative research in general, and with this unique project specifically. In general, qualitative research is limited by researcher bias, interviewer bias, interviewee bias, and participant demographics (Corbin & Strauss, 2015). To control for potential bias during the analysis process, the coding team used several strategies to enhance trustworthiness, including recruiting coding team members who had identities as both CES faculty and administrators, bracketing biases throughout coding, using consensus to resolve discrepancies in coding, and using memos to document decisions. Future studies could seek to triangulate the data from this study to determine whether the findings are transferable to the perspectives of other faculty in CES doctoral programs.

The focus of this particular research study was to explore faculty perspectives regarding how to gain administrative support for initiating and sustaining CES doctoral programs. As such, the perspectives of administrators were not surveyed regarding how to gain administrative support for CES doctoral programs (beyond those counselor educator faculty participants who have served in administrative roles). Future studies, perhaps in the form of quantitative research, could include these perspectives to determine whether the perspectives of CES doctoral faculty are consistent or divergent with administrator experiences regarding how to work effectively with administrators.

We sought to understand strategies for successfully gaining initial and ongoing administrative support for a CES doctoral program. This exploration included both participants who had recently started new programs and those who had long worked in CES doctoral programs. However, an analysis of thematic differences between participants who had and had not spearheaded the creation of a CES doctoral program was not conducted. Future research could explore whether strategies varied for those who had recently started a CES doctoral program versus those who had not. In addition, data were not organized and analyzed by differences in participants’ institution type (i.e., private or public), because it was outside the scope of the research question. Finally, the study focused solely on faculty at CACREP-accredited institutions. It is unknown whether the perspectives of participants in this study would be consistent with faculty at non–CACREP-accredited institutions.

Conclusion

The counseling profession continues its efforts to address the pipeline shortage of doctoral-level CES faculty to meet CACREP accreditation requirements. To meet this need, some master’s-level programs are seeking to start CES doctoral programs. The findings from this study may be useful to CES faculty when planning a strategic approach for collaboration with administrators regarding the initiation of new CES doctoral programs. This strategic approach will involve exploring political elements, economical components, and the identity of the proposed program. The findings of this study indicate these areas of knowledge promote a more comprehensive planning process to help prepare for working with administrators on the creation of a doctoral program.

 

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

 

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Rebecca Scherer, PhD, NCC, ACS, CPC, is an assistant professor at St. Bonaventure University. Regina Moro, PhD, NCC, BC-TMH, LPC, LMHC, LCAS, is an associate professor at Boise State University. Tara Jungersen, PhD, NCC, CCMHC, LMHC, is an associate professor and department chair at Nova Southeastern University. Leslie Contos, NCC, CCMHC, LCPC, is a doctoral candidate at Governors State University. Thomas A. Field, PhD, NCC, CCMHC, ACS, LPC, LMHC, is an assistant professor at the Boston University School of Medicine. Correspondence may be addressed to Rebecca Scherer, B43 Plassman Hall, 3261 West State Road, St. Bonaventure, NY 14778, rscherer@sbu.edu.

Lifetime Achievement in Counseling Series: An Interview With Mona Robinson

Joshua D. Smith, Neal D. Gray

Each year TPC presents an interview with a seminal figure in counseling as part of its Lifetime Achievement in Counseling series. This year I am honored to introduce Dr. Mona Robinson. She identifies as a counselor with expertise in rehabilitation counseling, is among the distinguished faculty at Ohio University, and is an internationally recognized scholar. I am grateful to Dr. Joshua Smith and Dr. Neal Gray, who continue to bring the contributions and wisdom of leaders in the profession to TPC readers. Here they present a view to Dr. Robinson’s accomplishments throughout her career, along with her reflections on the CACREP and CORE merger and the evolution of the profession. —Amie A. Manis, Editor

Picture of Dr. Mona Robinson

     Mona Robinson, PhD, LPCC-S, LSW, CRC, is a professor at Ohio University and Program Coordinator for both their Counselor Education Program and their Human Services Program. She is the Immediate Past Chair of the Department of Counseling and Higher Education. She holds a BS in psychology, an MA in rehabilitation counseling, and a PhD in rehabilitation services (Rehabilitation Counselor Education) from The Ohio State University. Dr. Robinson is a certified rehabilitation counselor, a licensed professional clinical counselor supervisor, and a licensed social worker.

     Prior to her employment at Ohio University, Dr. Robinson served as a counselor and administrator of vocational rehabilitation counseling and employment services to clients with severe mental illness and other barriers to employment. Additionally, she served as a consultant and adjunct professor at Wilberforce University. Her areas of expertise include psychiatric rehabilitation, disability advocacy, multicultural counseling, ethics, and dual diagnosis.

     Dr. Robinson serves as the institute director for study abroad programs held in Italy and Botswana. She is currently 1st Vice President for the National Council on Rehabilitation Education, Accessibility Coordinator for the Association for Multicultural Counseling and Development 2019 Summit, and a member of their 2019 Day of Service Committee. She has served as Past President of the National Association of Multicultural Rehabilitation Concerns, Ohio Rehabilitation Association, and Ohio Rehabilitation Counseling Association. She is a past board member of the National Rehabilitation Association and the Ohio Counseling Association Executive Council, and a Past President and Past Secretary of the Central Ohio Counseling Association.

     In addition to her extensive professional service, she is also a current member of numerous professional organizations, including but not limited to the American Counseling Association, American Rehabilitation Counseling Association, Association for Multicultural Counseling and Development, National Rehabilitation Counseling Association, Ohio Rehabilitation Association, and Ohio Rehabilitation Counseling Association. She is on the editorial boards of the Journal of Applied Rehabilitation Counseling and the International Journal of Applied Guidance and Counseling, a Vocational Expert for the Social Security Administration Office of Hearing Operations, and a Site Team Chair for the Council for Accreditation of Counseling and Related Educational Programs (CACREP).

     Dr. Robinson’s awards and honors include the 2008 and 2014 Ohio University College of Education Distinguished Faculty Graduate Teaching Award; the 2009 Sylvia Walker Multicultural Education Award; and the 2010 Visiting Scholar to South Korea Award, through which she taught global communication at the Kyungpook National University. She was a presenter at the 2012 International Conference on Education in Honolulu, Hawaii, and a speaker at the 2017 4th Biennial Bhutan International Counseling Conference held in Thimphu, Bhutan. Dr. Robinson has been the recipient of the 2014 Ohio University College of Education Distinguished Faculty Outstanding Outreach Award, the 2016 and 2017 Ohio University Faculty Newsmakers Award, the 2017 Virgie Winston-Smith Lifetime Achievement Award, and a 2018 National Association of Multicultural Rehabilitation Concerns Fellow Award. Dr. Robinson was an invited speaker at the University of Botswana in 2017 and 2019 for the Ultimate Motivational Speaker Competition. Lastly, she was the keynote speaker for the Seminar on Guidance and Counseling Conference held in Yogyakarta, Indonesia, in October 2019.

     In this interview, Dr. Robinson shares insights on growth and change within the counseling profession, her experience as a woman of color in counselor education, and her outlook on the future development of the profession.

  1. As a rehabilitation counselor educator, how has the merger between the Council on Rehabilitation Education (CORE) and CACREP impacted your role and the counseling profession?

     For me personally, I am pleased to see the merger finally come to fruition. In the past, I worked as a vocational rehabilitation counselor and a licensed professional clinical counselor, so I certainly see the value of both specialty areas. I view myself as a counselor with a specialty area in clinical rehabilitation counseling. I am fortunate to work in a program that has historically integrated clinical mental health counseling, rehabilitation counseling, and school counseling at the master’s level. Holding accreditation with both CORE and CACREP meant we had to go through the accreditation process twice. However, since the merger occurred, we now have one accreditation cycle and our students can obtain credentialing under CACREP for both clinical mental health and rehabilitation counseling.

     With respect to the counseling profession, I continue to be involved in discussions regarding the merger, including the revisions to the 2023 CACREP standards, particularly as they relate to clinical rehabilitation counseling. For the purpose of clarification, I think it is noteworthy to mention that rehabilitation counselors receive the same general training as clinical mental health counselors with the exception of diagnosis and treatment of mental and emotional disorders. Traditional rehabilitation counselor training focuses on vocational rehabilitation, specifically as it relates to assisting people with physical and mental disabilities in obtaining meaningful employment and/or independent living opportunities that improve their quality of life. Clinical rehabilitation counselor training would continue to focus on vocational rehabilitation with the inclusion of a clinical mental health counselor curriculum that focuses on treating mental and emotional disorders that lead to licensure as a professional clinical counselor as well as certification as a certified rehabilitation counselor.

     Over the years, I presented at national conferences regarding the advantages and disadvantages of the merger. One of the main points of contention in the field of rehabilitation counseling centers around the lack of coursework necessary to treat and diagnose mental and emotional disabilities, including completing an internship in a setting that treats and diagnoses mental and emotional conditions. I firmly believe that the counseling profession as a whole will benefit from the merger with the infusion of clinical rehabilitation standards. This is a first step toward standardization so that all counseling programs can offer the same educational requirements that lead to licensure. Having a standardized counseling program will aid licensure portability as well as serve as a precursor to a national license for counselors. Counseling students reap the benefits of being taught by counselor educators with multiple specialty areas. Rehabilitation counselor educators play a pivotal role in teaching students knowledge from their specialty areas in addition to the clinical mental health competencies.

  1. What are the benefits and challenges associated with that merger, and where do you see rehabilitation counseling going in the future?

     Students in rehabilitation counseling programs will benefit from a more well-rounded education that gives them an opportunity to work with people with physical, mental, and emotional disabilities. Having this additional knowledge will prepare students to work in integrated medical and behavioral settings. Counselor educators who teach from a holistic approach allow students an opportunity to gain skills that will assist them in achieving better outcomes for their clients. In addition to the obvious time considerations, one accreditation cycle for all programs instead of two has positive financial implications for students and institutions alike. Some of the challenges associated with the merger include concerns that rehabilitation counselor educators may need to take additional counseling coursework to become eligible for licensure as a professional clinical counselor. Currently, rehabilitation counseling professionals who teach in rehabilitation counselor programs come from varying backgrounds, including vocational rehabilitation counselors (public and private sector), rehabilitation specialists, physical therapists, and occupational therapists; while beneficial to rehabilitation counseling, they may not be eligible to become licensed as professional clinical counselors without taking additional courses or obtaining another degree. Additionally, there are concerns about rehabilitation counselors losing their professional identity. Therefore, adopting a curriculum that focuses on vocational rehabilitation learning outcomes while infusing clinical mental health learning outcomes will aid in alleviating these fears. Long term, a reunification of the rehabilitation counseling professions (i.e., rehabilitation counselor educators, vocational rehabilitation counselors, rehabilitation specialists, physical therapists, and occupational therapists) will need to happen, as splintering of the profession occurred well before the CORE and CACREP merger process began. It is my hope that the merger will bring about changes in counseling that are beneficial for all counseling professionals.

  1. What do you consider to be your major contribution to the development of the counseling profession and why?

     Increasing faculty diversity as well as student diversity has been a cornerstone of my contribution to the development of the counseling profession. I have been intentional about recruiting AND retaining diverse students and faculty worldwide. The counseling profession has historically been predominantly White. However, the clients that present for counseling continue to come from increasingly diverse backgrounds. Hence, recruitment and retention of African American students and faculty are essential in the 21st century to meet the needs of diverse client populations. Therefore, I will continue to present and publish on the topic of diversity and the need to be responsive to all aspects of diversity. Undertaking my mission to speak about the necessity to respect diversity not only in conversation but also through action is an endeavor that I will continue to pursue.

     Another contribution of mine is mentorship. When working in academia, one of the most valuable resources faculty members can acquire is a mentor. Personal relationships and support systems are important factors for a successful career. I believe that participation in formal and informal networks and mentoring relationships is critical in the persistence of African American female faculty in the academy. Mentors provide support, guidance, information, and advice to their mentees who may be struggling with career advancement. A mentor can serve as a support system for a faculty member by providing protection, coaching, and even validation for them through acceptance, friendship, and role modeling.

     I believe in the importance of mentoring counselors, students, and faculty. While recruitment is important, retention efforts are even more crucial. I have spent countless hours focusing on the recruitment and retention of African American students and faculty. Additionally, I enjoy speaking locally, nationally, and internationally about issues that affect people of color, including those with varying disabilities. While licensed professional clinical counselors are trained to work with people with mental and emotional conditions, they often lack knowledge to effectively assist people with physical disabilities. I have been fortunate to fill the gap by providing trainings in this area. 

  1. What three challenges to the counseling profession as it exists today concern you most?

    Despite the fact that counseling has been a helping profession for decades, it still lags behind social work and psychology in terms of recognition as a profession. If the counseling profession aspires to obtain the same status as other helping professions such as social work and psychology, we must utilize our specialty areas as one cohesive profession. Social workers have done this successfully for decades through being known by the profession first, and then by their specialty areas. For example, someone may seek out a medical social worker that works in a hospital setting. In essence, the setting determines the specialty area of the social worker; counseling should consider adopting the same process. Counselor training is frequently viewed as not being on par with psychology. Therefore, adopting a standardized curriculum for training counselors will aid in eradicating this myth. 

     Another challenge is the lack of access to billing for Medicare on the part of counselors. Part of the reason for this disparity is that counselors are not viewed as having the appropriate training to serve as professional helpers similar to social workers and psychologists. While the need for trained professionals continues to increase, counseling has not been embraced by the mainstream. Efforts are underway to achieve parity that will allow counselors to bill Medicare—to date, this has not happened. Again, adopting a standardized curriculum will increase the likelihood of counselors serving as vendors for Medicare.

     A third area of concern is the looming financial crisis that many institutions of higher learning face. Declining enrollments and increasing tuition costs make recruiting and retaining quality students and faculty a challenge. More attention should be given to offering alternatives to traditional classroom settings as a way to reach more students. Developing and implementing a curriculum that appeals to a broader audience is one way to attract diverse faculty and students. Institutions that offer welcoming environments and appreciate differences will be at the forefront of any future growth.

  1. What needs to change in the counseling profession for these three concerns to be successfully resolved?

I think it will be important for the counseling profession to take the time to respect diversity in all forms, not only in language but also in action. More unification is necessary between disciplines. Embracing an approach that demonstrates that we are ALL counselors first will be an important first step toward unification of the profession. Professional conferences should be inclusive of all specialty areas when offering sessions. Counselors should take the time to learn about other specialties. We show ourselves as a much stronger profession if we train counselors who can provide services to a diverse population, and that includes meeting the needs of people with disabilities.

     With respect to billing parity, counselors should band together to advocate for Medicare. Standing as one unified profession will allow our voices to be heard on a broader scale. Finally, offering a diverse curriculum that meets the needs of underrepresented and underserved populations will aid in increasing enrollment in institutions of higher learning.

  1. As a woman of color, what has been your experience in counselor education? What advice would you give to others from your experience?

     I am thankful for my position and experiences as a counselor educator. I have had many experiences that most counselors do not get to have, and for that I am eternally grateful. I have had the opportunity to travel all over the country and abroad. My entire career as a counselor educator has consisted of working at a predominately White institution (PWI). I believe my training at a Research I PWI contributed to my gaining access to my position. I was fortunate to have mentors who advocated on my behalf and helped open doors that probably would not have been opened otherwise. I worked my way up from an assistant professor to a professor over a 10-year period. I served as the first African American department chair in the College of Education. Throughout my tenure, I actively recruited diverse students and faculty to the university. I had to work harder to prove I was as qualified as the dominant culture. I’ve had decisions challenged as well as faced harassment simply because of the color of my skin. At the end of the day, I’ve learned to do my best and not worry about it. The advice I would give to others based upon my experiences is to be the best you can be and do not let anyone make you feel that you are less—know your self-worth. I always share these words with my mentees: “We have to be better.” Last but not least, self-care!

  1. If you were advising current counseling leaders, what advice would you give them about moving the counseling profession forward?

     Unity makes strength. If we stand together as a profession, we will remain relevant. Advocate for the profession as a whole. Be knowledgeable about Medicare and other issues that affect our profession. Be a part of advocacy efforts that benefit all counselors. Be open-minded to being a counselor first with varying specialty areas. Listen to the concerns of the members of our professional counseling organizations, and finally, recruit students—they are our future!

 

This concludes the fifth interview for the annual Lifetime Achievement in Counseling Series. TPC is grateful to Joshua D. Smith, PhD, NCC, and Neal D. Gray, PhD, for providing this interview. Joshua D. Smith is a counselor at the Center for Emotional Health in Concord, North Carolina. Neal D. Gray is a professor and Chair of the School of Counseling and Human Services at Lenoir-Rhyne University. Correspondence can be emailed to Joshua Smith at jsmit643@uncc.edu.

Strengthening the Behavioral Health Workforce: Spotlight on PITCH

Jessica Lloyd-Hazlett, Cory Knight, Stacy Ogbeide, Heather Trepal, Noel Blessing

The coordination of primary and behavioral health care that holistically targets clients’ physical and mental needs is known as integrated care. Primary care is increasingly becoming a de facto mental health system because of behavioral health care shortages and patient preferences. Primary care behavioral health (PCBH) is a gold standard model used to assist in the integration process. Although counselor training addresses some aspects of integrated care, best practices for counselor education and supervision within the PCBH framework are underdeveloped. This article provides an overview of the Program for the Integrated Training of Counselors in Behavioral Health (PITCH). The authors discuss challenges in implementation; solutions; and implications for counselor training, clinical practice, and behavioral health workforce development.

Keywords: integrated care, primary care, counselor training, PITCH, behavioral health workforce development

In 2016, 18.3% of adults were diagnosed with a mental illness and 4.2% of adults were diagnosed with a serious mental illness (SMI; Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Of those with a mental illness, only 41% received mental health services, leaving more than half unserved (SAMHSA, 2015). Many of these untreated adults turn to their primary care provider (PCP) for help and report preference for behavioral health services within primary care (Ogbeide et al., 2018). In fact, data show that primary care has become the de facto mental health system in the United States (Robinson & Reiter, 2016).

Although PCPs attempt to provide pharmacological interventions and appropriate behavioral health referrals, patients often return still experiencing distress because they are unable to follow through on referrals (Cunningham, 2009; Robinson & Reiter, 2016). On average, this circular process results in substantially longer medical visits (e.g., 20 minutes versus 8 minutes) and fewer billable services (e.g., one versus five or more; Meadows et al., 2011). This also results in a significant increase in health care spending, with patients incurring 30%–40% higher costs because of the presence of a mental health condition (de Oliveira et al., 2016; Wammes et al., 2018). There is a need for professionals trained in behavioral health care working within the primary care setting (Serrano et al., 2018).

Counselor training addresses some aspects of the role of behavioral health professionals in primary care. The most recent version of the Council for Accreditation of Counseling and Related Educational Programs (CACREP) entry-level program standards mandates that all accredited programs, regardless of specialty, orient counseling students to “the multiple professional roles and functions of counselors across specialty areas, and their relationships with human service and integrated behavioral health care systems, including interagency and interorganizational collaboration and consultation” (CACREP, 2016, Standard F.1.b.). As patients’ needs and training mandates increase, there is a demand for counselor training programs to respond with models and practices for counselor training in behavioral health in primary care settings.

The Program for the Integrated Training of Counselors in Behavioral Health (PITCH) is a 4-year project sponsored by a Health Resources and Services Administration (HRSA) Behavioral Health Workforce Education and Training (BHWET) grant received by the Department of Counseling at the University of Texas at San Antonio. The purpose of this article is to describe this innovative program. Toward this end, we briefly outline the Primary Care Behavioral Health (PCBH) consultation model undergirding PITCH. Next, we describe the need for behavioral health integration in primary care settings. Then, we delineate our implementation of PITCH to date, including specialized field placements, training curriculum, and program evaluation methodologies. Following, we discuss challenges and resolutions gleaned from the first 1.5 years of implementation. Finally, we explore implications for counselor education to further enhance counselor preparation and engagement in behavioral health care delivery in primary care settings.

Primary Care Behavioral Health
The coordination of primary and behavioral health care that holistically targets clients’ physical and mental needs is known as integrated care (SAMHSA, 2015). One model used to assist in the integration process is the PCBH consultation model—a team-based and psychologically informed population health approach used to address physical and behavioral health concerns that arise in the primary care setting (Reiter et al., 2018). A hallmark of the PCBH model is integration of behavioral health consultants (BHCs), who dually function as generalist clinicians and as consultants to the primary care team (Serrano et al., 2018).

A BHC is different than a traditional counselor. In fulfilling their roles and functions, a BHC:

Assists in the care of patients of any age and with any health condition (Generalist); strives to intervene with all patients on the day they are referred (Accessible); shares clinic space and resources and assists the team in various ways (Team-based); engages with a large percentage of the clinic population (High volume); helps improve the team’s biopsychosocial assessment and interventions skills and processes (Educator); and is a routine part of psychosocial care (Routine). (Reiter et al., 2018, p. 112)

BHCs conduct brief functional assessments, collaborate with patients on treatment goals, implement evidence-based treatment interventions, and provide PCPs with feedback and recommendations for future patient care and support (Hunter et al., 2018). In addition, BHCs see patients for approximately 15–30-minute visits, with an average range between two and six visits per episode of care (Ray-Sannerud et al., 2012). In many ways, the BHC role involves a new professional identity for mental health professionals (Serrano et al., 2018). To date, BHC training and employment has typically involved social workers and psychologists. However, the counseling profession is increasingly recognized and engaged in integrated PCBH (HRSA, 2017).

Need for Integrated Services
Primary care settings must begin to consider behavioral health integration in order to increase the quality of life of their patients. Over recent years, there has been a significant increase in patients who receive psychotropic medication for mental health complaints in the primary care setting (Olfson et al., 2014). PCPs are managing increasingly complex diagnoses beyond anxiety and depression. These include bipolar, disruptive, and other comorbid disorders (Olfson et al., 2014). Individuals diagnosed with an SMI such as these also show a high prevalence of chronic health conditions, including diabetes and cardiovascular disease. Untreated psychological symptoms can often present themselves in somatic forms and can have a strong impact on chronic health conditions (McGough et al., 2016). People with SMIs prefer behavioral health services from their PCP; however, treatment outcomes for those with SMIs that seek services from their PCP are generally of lesser quality (Viron & Stern, 2010). Patient, provider, and systemic-level factors influence this phenomenon. Relevant factors may include impacts of patients’ mental health diagnoses on treatment adherence, misdiagnosis from PCPs, and minimal collaboration between medical and behavioral health providers (Viron & Stern, 2010).

The PITCH program addresses several critical needs of individuals seeking behavioral health services in the local community, where conditions that necessitate behavioral health services, including mental illness and substance use disorders, are common. In a focus group run in 2011 with members of the community, the group identified mental health as a key concern (Health Collaborative, 2013). Although mental health services were offered in a psychiatric facility for children, adolescents, and adults, members of the focus group reported that the demand for mental health providers and psychiatric beds exceeded the supply. The stigma associated with mental health also was seen as a barrier to care. As a result, many people go undiagnosed and untreated (SAMHSA, 2015).

PITCH also addresses the need for interdisciplinary approaches to behavioral health workforce development. The expansion of PCBH consultation services amplified this need (Robinson & Reiter, 2016). Unlike other models of integrated care (i.e., Collaborative Care Model, Chronic Care Model), the PCBH model makes available primary care–focused behavioral health services across an entire clinic population and across all possible patient presentations. This model also requires a skilled mental health professional adept at a variety of patient presentations and able to manage processes like clinic flow and a new role as consultant—skills and roles not commonly present in training for specialty mental health services (Robinson & Reiter, 2016).

PITCH: An Overview

PITCH is housed within a CACREP-accredited master’s-level clinical mental health counseling (CMHC) program enrolling more than 100 students each year. The principal investigator (PI) of PITCH is a professor specializing in clinical supervision, bilingual counselor education, and professional advocacy. Other PITCH team members include an assistant professor (Co-PI, university liaison) specializing in family counseling, program evaluation, and ethics; an assistant professor and board-certified clinical health psychologist (consultant); and an external project evaluator.

The primary purpose of PITCH is to develop a highly trained workforce of professional counselors to provide integrated behavioral health care (IBH) to rural, vulnerable, and underserved communities in primary care. Sub-goals of the PITCH program include establishing meaningful, longitudinal interdisciplinary partnerships as well as a graduate-level certificate in IBH to support sustainability. Toward this, 12 advanced counseling students enrolled in the aforementioned CMHC program are selected to participate each year from a competitive application pool. Selected trainees are required to complete two specialized IBH courses and two 300-hour clinical rotations in designated primary care settings. In exchange, trainees receive a $5,000 stipend upon completion of each semester rotation. Additionally, PITCH staff coordinate quarterly interprofessional trainings, including workshops focused on primary care, behavioral health, supervision, funding, and policy.

Specialized Field Placements
A unique feature of the PITCH program is the development of specialized field placement sites. Other behavioral health integration projects have relied on existing clinical placement sites (Sampson, 2017). Often these sites have low levels of existing integration, as well as underdeveloped infrastructure to support behavioral health delivery in primary care. When existing clinical site placements do have some integrated services, they are most often co-located services (Peek & the National Integration Academy Council, 2013). Instead of field site development, previous efforts have emphasized student training through workshops (Canada et al., 2018). These workshops are often open to community members. Individuals are then charged to bring knowledge back to extant clinical sites. Although this offers some positive benefits, it may not be as impactful. Further, this approach may fall short of establishing infrastructure to support longitudinal changes (Serrano et al., 2018).

To start development of specialized field placements, we identified potential sites interested in IBH delivery. We then set up initial meetings with sites to discuss the PITCH project and to determine the feasibility of placing a BHC trainee. If sites were amenable, we scheduled a series of follow-up visits to provide orientation to clinic staff on IBH, the PCBH model, and the role and scope of BHCs. During these visits, we also provided consultation on infrastructure components, such as electronic medical record documentation procedures, suggestions for clinic flow, and room spacing (Robinson & Reiter, 2016). Throughout the field placement, we remained active in checking with sites to make workflow adjustments as needed. Trainees complete certificate-based coursework prior to beginning field placements as well as during the clinical rotations.

Trainee Curriculum
Selected trainees are required to complete two specialized courses in IBH, as well as two 300-hour clinical rotations at one of the specialized field placement sites discussed above. The PCBH model scaffolds all aspects of the PITCH training and delivery. We utilize this model to support conceptualization of the BHC role in primary care settings, interventions, and supervision.

As part of the PITCH program, two didactic courses were created to provide training in IBH and PCBH. The courses were developed and instructed by the PITCH IBH consultant. The first course, IBH-I, introduces students to the primary care setting (e.g., family medicine, pediatrics, geriatrics), the PCBH model of care, behavioral health consultation, health behavior change, and common mental and chronic health conditions encountered in primary care, and offers a basic understanding of brief, cognitive-behavioral–based and solution-focused interventions used in primary care (Reiter et al., 2018; Robinson & Reiter, 2016).

Students must complete the following assignments in the course: two exams, an IBH journal article review, a primary care clinic tour, an interview with a PCP, a presentation on one commonly seen problem in primary care (e.g., insomnia, chronic pain, depression), and a term paper highlighting treatment on a common problem in primary care using the 5A’s model (Hunter & Goodie, 2010). The 5A’s is a behavioral change model that includes assessing, advising, agreeing, assisting, and arranging. Upon demonstrating satisfactory performance, students may enroll in IBH-II.

The primary purpose of the second course is to begin applying foundational knowledge of PCBH as well as practice functional and contextual assessment and cognitive-behavioral intervention skills in the primary care setting. Trainees demonstrate their skills through a series of in-class role-plays, leading up to a final evaluation of their performance in a 30-minute initial consultation visit with a standardized patient. Trainees must complete both courses to maintain their status in PITCH. Both courses are open as electives to students enrolled in the counseling program or a related discipline (e.g., social work).

PITCH trainees also complete two semester-long clinical rotations in primary care. Trainees are assigned to one of the specialized field placement sites based on availability, interest, and anticipated fit. Trainees are required to clock 300 hours each semester, 120 of which must represent direct clinical engagement. Direct clinical engagement time includes patient visits, consultation with the primary care team, and facilitating psychoeducational groups tailored to unique clinical populations. Trainees are required to participate in at least 1 hour of clinical supervision with an on-site supervisor each week. Additionally, trainees attend a bi-weekly group supervision course on campus instructed by a CMHC faculty member. After successful completion of didactic and clinical courses of the PITCH program, trainees are eligible to earn a graduate certificate in IBH. Adjustments to specialized field placement sites and the trainee curriculum are made as needed based on ongoing informal and formal evaluation of the program.

Program Evaluation
The HRSA BHWET grant supporting PITCH prioritizes evaluation activities related to workforce training and development effectiveness (HRSA, 2017). In partnership with our external evaluator, we are conducting program evaluation across several domains of PITCH, including evaluations focused on trainees and clinical sites (e.g., level of integration).

Trainee-Focused Metrics
We have several evaluation metrics that are focused on trainees. Trainees complete the Behavioral Health Consultant Core Competency Tool (BHC CC Tool; Robinson & Reiter, 2016) and the Primary Care Brief Intervention Competency Assessment Tool (BI-CAT; Robinson, 2015) at the beginning, midpoint, and conclusion of clinical rotations. The BHC CC Tool measures and tracks skill development across four domains of BHC practice: clinical practice, practice management, consultation, and documentation. The BI-CAT includes domains of practice context, intervention design, intervention delivery, and outcomes-based practice. On-site observations of trainees also are conducted using the PCBH Observation Tool as part of the certificate coursework. These competency tools were developed based on observations of BHC clinical behaviors likely to work effectively in a PCBH model of service delivery. These measures have not yet been formally assessed for psychometric properties or predictive outcomes (Robinson et al., 2018).

In addition to tools that target individual trainee development, program evaluation efforts also attend to the macro experiences of trainees in the program. Specifically, trainees participate in focus groups facilitated by the external evaluator at the end of each semester. Focus groups provide the opportunity to understand pathways and barriers to program development. We also have developed an online database to track trainees’ postgraduation employment trajectories and sustained engagement in PCBH.

Site-Focused Metrics
Although this particular HRSA grant is primarily concerned with trainee-focused outcomes (e.g., employment), we also ask identified clinical site liaisons to complete the Integrated Practice Assessment Tool (IPAT; Waxmonsky et al., 2013) at the start and finish of each rotation. Scores on the IPAT provide a snapshot estimation of the level of integration of clinical sites. Levels of integration correspond to those identified by A Standard Framework for Levels of Integrated Healthcare (Heath et al., 2013) and range from 1–6. Levels 1 and 2 are indicative of minimal, coordinated collaboration, with behavioral health and PCPs maintaining separate facilities and systems. Levels 3 and 4 reflect shared physical space and enhanced communication among behavioral health and PCPs; however, practice change toward system-level integration is underdeveloped. Finally, Levels 5 and 6 are indicative of transformed, team-based approaches in which both “providers and patients view the operation as a single health system treating the whole person” (Heath et al., 2013, p. 6). Focus groups also were conducted with members of selected clinical training sites to explore barriers and pathways to PCBH delivery as a function of level of integration. At this time, the IPAT has not yet been formally assessed for psychometric properties.

Rapid Cycle Quality Improvement
Finally, program evaluation efforts include ongoing rapid cycle quality improvement (RCQI), a quality-improvement method that identifies, implements, and measures changes to improve a process or a system (Center for Health Workforce Studies, 2016). RCQI can be targeted at different aspects of the program. To date, RCQI has targeted trainee competencies related to functional assessment interviews, breadth of referrals concerns, and patient visit length. For example, after tracking trends in daily activity logs submitted by trainees, we noted a majority of referrals centered on anxiety and depression. We then provided supplemental training on identifying behavioral health concerns related to chronic health conditions, such as diabetes and asthma. Following this instruction, we reviewed the daily activity logs and noted greater breadth of referral concerns.

Challenges and Solutions

Best practices for PCBH implementation within the context of workforce development are still developing. Further, available guidelines do not speak to counselor training programs specifically. In the section below, we discuss challenges we have encountered in the first 1.5 years of implementation of the PITCH program. We also share solutions we have generated to support optimal training experiences.

Challenge: On-Site Clinical Supervision
A significant challenge we encountered was related to on-site clinical supervision for the PITCH trainees. National accreditation standards require trainees to participate in regular supervision with both an on-site and university supervisor (CACREP, 2016). The on-site supervisor must have at least 2 years of postgraduate experience, as well as hold a master’s degree in counseling or a related field (e.g., psychology, social work). Furthermore, best practices for BHC training support a scaffolded supervision approach (Dobmeyer et al., 2003), wherein trainees’ initial time is spent completing 360 clinic shadowing visits with an experienced BHC. As trainee skills develop, leadership within patient visits transitions from co-visits to visits. In time, the trainee leads the visits, with an experienced BHC in independent practice shadowing. Additionally, the PCBH model emphasizes preceptor-style supervision, where the supervisor is readily available on-site for patient consultation as needed (Dobmeyer et al., 2003).

Solution: Changes to Specialized Field Placement Sites
During Year 1 of PITCH, almost two thirds of the specialized field placement sites we partnered with did not employ the PCBH model at the time, and thus did not have a BHC available to provide on-site clinical supervision. To meet this need, we provided intensive PCBH and supervision training to four doctoral students enrolled in our counselor education and supervision program. Doctoral student supervisors were asked to spend at least half a day on-site with trainees with this amount tapering off with time and experience.

Although this solution met national accreditation requirements for supervision (CACREP, 2016), we noticed stark differences between the clinical experiences of trainees placed at field sites with an on-site BHC versus doctoral student supervisors. As such, we made the difficult decision in Year 2 to separate from all but two field placement sites that lacked an on-site BHC to provide supervision. The inclusion of a BHC to supervise became a requirement for all the new sites we partnered with in Year 2. Additionally, we made modifications to our grant funding allocations to support graduate assistantships focused on supervision for two of the four doctoral supervisors utilized in Year 1.

Challenge: Knowledge About PCBH and the BHC Role
We encountered internal and external gaps in knowledge about the PCBH model, the BHC role, and the general culture of primary care settings. Internally, members of our faculty less connected to PITCH expressed support but also concern about alignment of PITCH training experiences and the experiences of other counseling students. Specific points of concern related to the brevity of visits, frequency of single encounters with patients, and the underpinning medical model. Additionally, because of patient privacy restrictions, PITCH field placement sites do not permit audio or video recording of clinical work, which is a typical supervision practice for counseling trainees. PITCH trainees also expressed some tension between the professional identity and skills training obtained in the CMHC program to date with the PCBH model and BHC role. Externally, we observed varying degrees of provider knowledge and buy-in about the PCBH approach to integrated practice. Areas of provider disconnect were more prominent at placement sites without existing integrated primary care services.

Solution: Ongoing Education and Advocacy
At the internal level, we provided a brief educational session about the PCBH model at regular faculty meetings. It was important to emphasize PCBH as a different context of practice that, similar to school counseling, requires modes of practice outside of traditional 50-minute sessions. We also sought faculty consultation related to curriculum and structure for our specialized coursework. For example, faculty members expressed concern about missing opportunities for recorded patient visits, so we developed two assignments for the clinical courses that could meet this need. The first was a mock visit with a classmate that was video recorded and transcribed. Students then analyzed micro-skills and reflected. The second assignment consisted of a live observation by the university- or site-based supervisors of the trainee’s work on-site with a patient.

We also encountered various levels of provider buy-in at our different sites. We encouraged students to reframe this resistance as an opportunity for learning and advocacy. As students gained knowledge about what we call the primary care way, students could better contextualize the questions or concerns of providers. For example, students could understand the premiums placed on time and space. From this position, students could tailor their approach to PCPs to enhance the PCP workflow. Additionally, faculty and supervisors emphasized the importance of ongoing psychoeducation about the PCBH model to their teams. Students are encouraged to be proactive in reviewing daily patient schedules for prospective services (i.e., scrubbing the schedule) and educating providers about how BHC services can augment patient care. The use of the BHC competency tools also facilitated this process, which encouraged students to consistently engage in behaviors conducive to BHC practice.

Challenge: Shortage of Spanish-Speaking Service Providers
A final challenge we faced related to a shortage of Spanish-speaking service providers. Some sites offered formal translation services (i.e., in-person medical translator, phone- or tablet-based translators), while others utilized informal resources (i.e., other staff members). When placing students, we prioritized placement of bilingual trainees at locations with the greatest number of Spanish-speaking patients. However, we were not able to accommodate all sites.

Solution: Recruitment and Resources
We have implemented several solutions to address this challenge. Among these, we have moved to weighing Spanish language fluency more heavily in PITCH selection criteria. We also are exploring future partnerships with the bilingual counseling certificate program that is housed in the University of Texas at San Antonio Department of Counseling. Additionally, we provide basic training and support to trainees related to the use of translators (in-person and virtual), and we have employed Spanish-speaking doctoral graduate assistant supervisors where possible for extra support.

Discussion

The implementation of PITCH provides challenges but also solutions to the growing need for counselor education to focus on training in primary care. Patients prefer behavioral health services in primary care (Ogbeide et al., 2018). Thus, equipping the behavioral health workforce to provide services in this setting has proved to be imperative. Although primary care and interprofessional education is relatively new to counselor education, other behaviorally inclined disciplines (e.g., psychology, social work, nursing) have provided a training blueprint for counselor education programs to use and continue developing a place for themselves in primary care (Hooper, 2014; Vogel et al., 2014).

Serrano and colleagues (2018) shared recommendations for PCBH workforce development. These recommendations include: (a) development of an interprofessional certification body; (b) PCBH-specific curricula in graduate studies, including both skills and program development; (c) a national employment clearinghouse; and finally, (d) coalescing knowledge around provision of technical assistance sites. Below we discuss the implications of counselor education programs seeking to advance PCBH workforce development.

Standardized Training Models
An important implication for training future counselors is the use of standardized training models (Tang et al., 2004). Throughout this article, much of the focus has centered on the PCBH consultation model (Reiter et al., 2018). In recent years, training standards have emerged for BHCs in primary care. These standards focus on a psychologically informed, population-based approach to treatment, in which BHCs are trained to create clinical pathways, collaborate with medical providers, conduct a brief functional assessment, and provide a brief behavioral intervention, mostly consisting of skills training and self-management (Reiter et al., 2018)—all of which is done in under 30 minutes. This clinical practice approach has become the de facto model in most BHC preparation programs throughout the United States (Hunter et al., 2018) and is currently endorsed by the Veterans Administration and the Department of Defense for integrated primary care (Funderburk et al., 2013). However, inconsistencies exist in how the PCBH model is taught, and there is a lack of available internship opportunities for master’s-prepared behavioral health providers to receive clinical training (Hall et al., 2015). This challenge is especially relevant to future counselors, who lack a standardized model of training for primary care (Hooper, 2014). Our experience suggests that programs such as PITCH accomplish the joint goals of focusing on instruction and supervised practice in PCBH, developing BHC competencies, and meeting accreditation standards of orienting counselors to their role in integrated care settings (CACREP, 2016).

Behavioral Health Integration
One of the largest challenges facing the PCBH model is behavioral health integration (Hunter & Goodie, 2010). Moreover, the PCBH model requires full integration (e.g., Level 5–6 integration) to be maximally effective. Traditionally, PCPs would refer patients to a local mental health practitioner for issues related to depression or anxiety (Cunningham, 2009). However, these referrals would result in a low rate of success and deter many individuals from seeking out mental health services in the future (Davis et al., 2016). Co-located care (an in-house mental health practitioner conducting traditional psychotherapy or counseling) became the logical next step. This level of integration resulted in quicker referrals but led to poor communication and confidentiality issues between PCPs and mental health providers. This also left out other common, behaviorally influenced conditions in primary care such as diabetes, chronic pain, hypertension, and tobacco cessation (which are not routinely addressed or treated by mental health providers). Full integration (in which PCPs and mental health providers work collaboratively in the same setting) has become the ideal standard for the integration of behavioral health services in primary care (Heath et al., 2013).

Despite the many benefits, full integration might be impractical for clinics just beginning PCBH services. Clinics may not have the staff support, leadership support, and organizational buy-in to be successful because “successful integration is really hard” (deGruy, 2015). Integration, in a sense, causes a necessary disruption in how a clinic functions and serves patients. Although necessary, it is still a disruption and it can take time for a team to normalize their new way of practicing primary care. Clinics may need specific support to help establish pathways for behavioral health referrals (Landis et al., 2013), allow clinic staff more time to adjust to integrated services, and provide a pathway for the development of fully integrated services (Reiter et al., 2018). Investing in technical assistance experts can aid in integration efforts (Serrano et al., 2018). Additionally, clinics that already offer co-located services might benefit from a quality-improvement plan (Wagner et al., 2001) such as a plan-do-study-act model (PDSA; Speroff & O’Connor, 2004) to move to a higher level of integration. A sample PDSA cycle might consist of identifying barriers to improved patient care, creating a team-based plan for addressing barriers, designating a project overseer, tracking outcomes across time, and evaluating project success (Speroff & O’Connor, 2004). Both suggestions are great steps toward full integration and can be performed by counselors and counselor educators with training in PCBH and program evaluation (Newcomer et al., 2015). Funding for counselors in BHC roles would assist in meeting the aforementioned goals.

Funding for Counselors in PCBH
One of the greatest barriers to providing accessible behavioral health services in primary care is funding (Robinson & Reiter, 2016). Insurers are just beginning to reimburse for same-day services (both a PCP and BHC visit; Robinson & Reiter, 2016). However, this recent development has primarily benefited psychologists and social workers in primary care and excludes licensed counselors, who account for 14%–25% of the mental health labor force (U.S. Department of Health and Human Services, 2016). Licensed counselors are a crucial part of the growing behavioral health workforce (Vogel et al., 2014) and bring a strong wellness and systems-based perspective to primary care (Sheperis & Sheperis, 2015). Furthermore, licensed counselors, along with other behavioral health providers, can help in a variety of ways such as reducing patient costs in the medical system (Berwick et al., 2008), reducing patient emergency room visits (Kwan et al., 2015), and implementing continuous quality improvement (Wagner et al., 2001).

Robinson and Reiter (2016) offered several suggestions regarding funding for BHCs unable to conduct same-day billing. The first is for BHCs to understand that PCPs will always be the main source of clinic revenue. Therefore, BHCs can provide support to the primary care team through behavioral consultation; improve screening and clinical pathway procedures; provide support for difficult patients and frequent visitors; and reduce PCP visit time through warm handoffs, with the patient witnessing the transfer of their care between PCP and BHC. Second, BHCs can secure bottom-up support from PCPs by providing “curbside” consultation services (consulting face-to-face with PCPs about a patient without directly treating the patient). It comes as no surprise that PCPs feel more supported when BHCs are an available part of the medical team. Third, BHCs can generate top-down support through billing for group visits such as drop-in group medical appointments and 30-minute follow-up visits (Robinson & Reiter, 2016). Finally, grants represent another potential source of funding for behavioral health implementation (HRSA, 2017, 2018). HRSA and SAMHSA have been a tremendous resource in providing training grants specifically aimed at increasing the BHC workforce (e.g., HRSA, 2017) and addressing the nation’s opioid epidemic (e.g., HRSA, 2018). In Texas, the Hogg Foundation has provided training grants for training future BHCs. Finally, the counseling profession must continue advocacy efforts toward establishing licensed counselors as Medicare providers. With this key change, licensed counselors would be more readily employable in medical settings (Dormond & Afayee, 2016).

Conclusion

Primary care has been the de facto mental health system in the United States for decades. Providing comprehensive primary care to patients is imperative, and in order to do this well, our workforce needs to be equipped to meet the growing behavioral health needs where patients show up to receive care. Given clinical measures such as successful patient outcomes and CACREP accreditation standards targeting integrated health care knowledge, it behooves counselor training programs to consider developing models for BHC training. This article presents the key aspects of the PITCH program in the hopes that our model will be useful to other counselor education programs as the profession moves toward integrated practice models in order to meet the ever-changing needs of the health care landscape.

Conflict of Interest and Funding Disclosure
PITCH is funded by a Behavioral Health Workforce Education
and Training grant from the Health Resources and Services
Administration. There is no known conflict of interest.

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Jessica Lloyd-Hazlett, PhD, NCC, LPC, is an associate professor at the University of Texas at San Antonio. Cory Knight, MS, is a master’s student at the University of Texas at San Antonio. Stacy Ogbeide, PsyD, ABPP, is a behavioral health consultant, licensed psychologist, and associate professor at the University of Texas Health Sciences Center San Antonio. Heather Trepal, PhD, LPC-S, is a professor and coordinator of the Clinical Mental Health Counseling Program at the University of Texas at San Antonio. Noel Blessing, MS, is a doctoral student at the University of Texas at San Antonio. Correspondence may be addressed to Jessica Lloyd-Hazlett, 501 W. Cesar E. Chavez Blvd., DB 4.132, San Antonio, TX 78207, Jessica.lloyd-hazlett@utsa.edu.

Training Counselors to Work With the Families of Incarcerated Persons: A National Survey

Jessica Burkholder, David Burkholder, Stephanie Hall, Victoria Porter

The national epidemic of increasing imprisonment rates in the United States, also known as mass incarceration, disproportionally impacts communities of color. Additionally, the needs of children of incarcerated parents have been neglected. This study examined whether topics pertinent to mass incarceration and the impact on families are being addressed in counselor education programs. Of the 95 counselor educators who participated in the study, results indicated that the majority did not have training to work with families of the incarcerated and did not include information about working with families of the incarcerated in their courses. In addition to exposing students to discussions of implicit bias and data on mass incarceration, specific treatment modalities and protocols need to be developed and validated.

Keywords: mass incarceration, children, counselor education, communities of color, incarcerated parents

The rise of mass incarceration is dramatically affecting families and communities across the nation, with a disproportional impact on communities of color (Glaze & Maruschak, 2008; Graham & Harris, 2013; A. Lopez & Burt, 2013; C. Lopez & Bhat, 2007; Mignon & Ransford, 2012; Western & Smith, 2018). With the increase of persons involved in the criminal justice and legal systems, their families have been found to be more at risk for facing long-lasting life challenges within both the family system and society (Glaze & Maruschak, 2008; Luther, 2016; Mignon & Ransford, 2012; Phillips & Gates, 2011). Client advocacy is one of the most critical roles of the professional counselor (Hipolito-Delgado et al., 2016). The counseling profession is characterized by working with diverse individuals from heterogeneous communities. Counselors are needed to function as advocates, especially when families and communities are facing a sociocultural crisis (American Counseling Association [ACA], 2014; Hipolito-Delgado et al., 2016).

Both ACA and the Council for Accreditation of Counseling and Related Education Programs (CACREP) have identified advocacy, multicultural competence, and social justice as priorities in training and practice (ACA, 2014; CACREP, 2015). The ACA Code of Ethics instructs that “when appropriate, counselors advocate at individual, group, institution, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients” (ACA, 2014, Section A.7.a., p. 5). It also directs counselors to gain “knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population” (ACA, 2014, Section C.2.a., p. 8).

Counselor educators are directed to “infuse material related to multiculturalism/diversity into all courses and workshops” (ACA, 2014, Section F.7.c., p. 14). When describing professional and ethical practice, the CACREP standards require programs to instruct students on “the advocacy processes needed to address institutional and society barriers that impede access, equity, and success for clients” (CACREP, 2015, Standard F.1.e., p. 10). Further, the curriculum guidelines for social and cultural diversity emphasize counselor advocacy when instructing counselor educators to cover “strategies for identifying and eliminating barriers, prejudices and processes of intentional and unintentional oppression and discrimination” (CACREP, 2015, Standard F.2.h., p. 11). Although mass incarceration and its effects are not specifically mentioned in the ACA Code of Ethics or CACREP standards, these broad directives provide support for the specific argument that the scope of this crisis and its impact on families require attention in counselor training. Consequently, the purpose of this research study is to describe the current state of how counselor educators are providing training to counselor trainees to support families of the incarcerated.

The Rise of Mass Incarceration
The national epidemic of increasing imprisonment rates, commonly referred to as mass incarceration, has been a topic of alarm for nearly five decades (Garland, 2001; Glaze & Maruschak, 2008; Graham & Harris, 2013; A. Lopez & Burt, 2013; C. Lopez & Bhat, 2007; National Research Council [NRC], 2014; Sykes & Pettit, 2014). Although the United States accounts for 4.4% of the world’s population, nearly one quarter (22%) of the world’s prisoners are in the United States (American Psychological Association [APA], 2014; NRC, 2014). According to The Sentencing Project (2012), the United States continues to have the highest incarceration rate in the world, consistently increasing since the mid-1970s. The most recent statistics indicate that the United States has an incarcerated population of 2.2 million individuals (APA, 2014; Kaeble & Cowhig, 2018; NRC, 2014). This represents a 500% increase over the last 40 years (The Sentencing Project, 2012). More than 20% of those released return to incarceration within one year (Durose et al., 2014; Western & Smith, 2018). Researchers have found a correlation between imprisonment and individuals belonging to underserved (e.g., lower levels of education, low income, psychiatric treatment and substance abuse histories) and minority populations (Alexander, 2012; Cnaan et al., 2008; NRC, 2014).

Despite the race gap narrowing since 2007, Blacks are imprisoned at a rate 6 times that of Whites and at double the rate for Hispanics (Bronson & Carson, 2019). Because incarceration disproportionately affects minority group members, families of the incarcerated are more likely to be concentrated in minority communities (Graham & Harris, 2013). Consequently, even those children in the community whose parents are not facing incarceration are likely to be impacted by mass incarceration (Wakefield & Wildeman, 2011), as their communities may experience lower incomes, lopsided gender ratios, disrupted social integration and roles, high levels of joblessness, and increased crime (Crutchfield & Weeks, 2015).

An Invisible Group
Results from the National Survey of Children’s Health (U.S. Department of Health and Human Services, 2018) found that more than 7% or 5 million children in the United States have experienced a parent being incarcerated. Gathering current statistics is difficult for researchers. The majority of data on children of incarcerated parents has measured the number of parents in prison, leaving unknown data about the number of parents spending time in jail (Cramer et al., 2017). Because of this, there is reason to believe that the current number of children of incarcerated parents exceeds previous findings of 2.7 million children.

Children of incarcerated parents have frequently been described as an invisible group (Bernstein, 2005; Bouchet, 2008) that bears the collateral consequences of mass incarceration. There are many reasons for the invisibility. Although the children have not committed any crimes, their parent’s incarceration impacts much of what is important to them—family bonds, housing stability, safety, self-image, and social relationships. The criminal justice system does little to support family relationships and there is frequently poor communication between social service organizations and families that may be beneficial for the children (Bernstein, 2005). Those caring for the children often experience high levels of stress (Poehlmann et al., 2010), and families fear stigmatization and may keep secrets or refrain from disclosing an incarceration (Phillips & Gates, 2011).

When a parent is incarcerated, one of the first losses is physical separation between parent and child. Most parents report no physical contact with their children following incarceration (Bocknek et al., 2009). Visitation with parents has been found to be beneficial to the attachment relationship and the child’s overall well-being (Poehlmann et al., 2010) but is often infrequent and not child friendly. Visits can be costly, and relationships may be strained with the child’s caregiver. Children frequently have to travel long distances, endure long wait times, and meet with parents in environments that can feel intimidating and stressful. Mignon and Ransford (2012) found that almost half of the mothers they surveyed never had a visit from their children, and visits became less frequent for those with longer sentences. Yet prisons that implemented child-friendly visitation interventions and allowed for physical interaction demonstrated greater visitation benefits to those children (Poehlmann et al., 2010). Some benefits included improved maternal perceptions of the relationship and improved self-esteem in the children.

This loss associated with the physical separation of parent and child has been discussed in the literature and is commonly referred to as ambiguous loss because children experience the loss without closure. The ambiguity of their parent’s abrupt removal can disrupt children of incarcerated parents from finding meaning in the loss and disrupt the development of coping strategies (Bocknek et al., 2009). Children also experience stigmatization associated with ambiguous loss. In contrast to children who are separated from their caregivers by death, deployment, or divorce, it is often not socially acceptable for children of incarcerated parents to grieve the loss of parents because such parents are viewed as criminals (Phillips & Gates, 2011).

Children of incarcerated parents experience the loss of both fathers and mothers, and there are substantially more fathers in prison than mothers. But since the late 1970s, the growth rate for women in prison is more than double the growth rate for men (Sawyer, 2018). When mothers are incarcerated, the disruptions the child experiences are magnified, as children are more likely to lose their home and their primary support. Children with incarcerated mothers have been found to experience more stress and more risks than those with incarcerated fathers (Poehlmann et al., 2010). Maternal incarceration is often more closely associated with factors such as poverty, substance abuse, and mental health issues (Turney & Goodsell, 2018).

Experiencing the incarceration of a parent has been found to impact the long-term well-being of children (Turney & Goodsell, 2018). Children of incarcerated parents have increased risk for health issues, stigmatization, poverty, negative social interactions, behavior problems, school truancy and failure, and substance abuse (Poehlmann et al., 2010; Turney & Goodsell, 2018). Turney (2018) found that children with incarcerated parents are more than 5 times more likely to face adverse childhood experiences than those without an incarcerated parent. Often these children were already at risk, and the incarceration compounds these inequities. It is important to note that the research on children of incarcerated parents is fraught with selection bias and focus on negative outcomes. Very little research exists that examines protective factors and environments beyond urban, lower-income communities of color. Graham and Harris (2013) cautioned that this narrow research focus can decrease potential positive outcomes. A review of the current literature on children of incarcerated parents revealed that this narrow research trend continues.

Stigmatization and Families of the Incarcerated
Many experts consider stigmatization to be one of the most significant negative consequences of parental incarceration. Families are not stigmatized based on a specific trait they possess, but rather based on being associated with the incarcerated person (Phillips & Gates, 2011). This phenomenon is known as courtesy stigma and results in a spoiled identity for family members (Luther, 2016). The stigmatization may come from other family members, peers, teachers, social service agencies, and mental health providers. Children may be seen as “guilty by association” or perceived as being “deviant” like the parent that is incarcerated (Luther, 2016, p. 1265). In order to avoid stigmatization, families often keep the incarceration a secret, but children tend to fare better when they know the truth. Stigmatization can increase feelings of shame and impact the child’s willingness to reunite with parents (Harris et al., 2010). Foster and Hagan (2015) found parental incarceration leads to social exclusion for children into their 30s, and as a result can contribute to intergenerational socioeconomic inequality.

Purpose of the Research
The longstanding need for increased support in communities impacted by mass incarceration is clear (Harris et al., 2010). Increased awareness of the United States’ imprisonment crisis has prompted research initiatives to better understand community needs. Recent data on adverse childhood experiences suggested that children with incarcerated parents are even more vulnerable than previously thought (Turney, 2018). The developmental needs of families and children of the incarcerated are not being appropriately attended to in the literature (Holmes et al., 2010; Turney, 2018). Although research is clear that children of incarcerated parents and the family system face disequilibrium when parental incarceration occurs (Harris et. al., 2010; Luther, 2016; Phillips & Gates, 2011; Wachter Morris & Barrio Minton, 2012), 58% of new professional counselors reported having either minimal training or no training at all in individual or family-level trauma and crisis preparation (Wachter Morris & Barrio Minton, 2012). Brown and Barrio Minton (2018) found that school counselors wanted more training and resources to work with children of incarcerated parents and their families. This lack of training created barriers and ethical dilemmas in attempting to support children with incarcerated parents. Brown and Barrio Minton recommended counselors learn about families of the incarcerated through reading and participating in professional development opportunities, but the curricular experience of professional counselors working with populations affected by incarceration appears predominantly absent from the literature.

The incongruence between the urgency of mass incarceration affecting communities and the lack of literature exploring how to support families of the incarcerated demands further research. Two key research questions organized our exploration: (1) Are topics pertinent to mass incarceration and its impact on families being addressed in the classroom? (2) If so, how are these topics being included?

Method

Participants
The sample included full-time counseling professors in CACREP-accredited counseling programs in the United States. The researchers compiled an email list of 356 CACREP liaisons from the list of accredited programs on the CACREP website. Upon receiving IRB approval, CACREP liaisons were contacted and asked to forward the email invitation to full-time faculty in their departments. The request for participants was also posted to the Counselor Education and Supervision Network Listserv. The email served as an invitation to participate, contained a synopsis of the purpose of this research, and included an online Survey Monkey link. Informed consent was collected using an electronic consent form. Demographic information was gathered after consent had been obtained.

Ninety-five counselor educators began and completed the survey. Sixty-nine female and 26 male individuals participated, ranging in age from 29 to 78 years. A majority of the participants identified as White or of European descent (n = 61, 64%); 18 (19%) identified as African American/Afro-Caribbean or of African descent; five (5%) identified as Hispanic/Latinx, five (5%) identified as Asian/Polynesian or of Pacific Island descent, and five (5%) identified as multiracial. One person (1%) did not identify a race or ethnicity.

Of the participants, 20 (21%) were full professors, 22 (23%) were associate professors, 43 (45%) were assistant professors, nine (10%) were non–tenure track full-time instructors, and one (1%) was a clinical coordinator. Sixty-five (68%) came from master’s-only programs, and 30 (32%) came from combined master’s and doctoral programs. All CACREP regions were represented with 33 (35%) from the Southern region, 27 (28%) from the North Atlantic region, 21 (22%) from the North Central region, nine (10%) from the Western region, and five (5%) from the Rocky Mountain region.

Survey
The researchers created a brief survey that could lead to a description of the current state of counselor training on issues of mass incarceration and families of the incarcerated. Using broad survey research was necessary because there is currently nothing on this topic in the counseling literature. Eight questions were included in the survey: 1) Do you include the topic of mass incarceration in any of your courses? 2) If yes, what courses? 3) If yes, how do you cover this topic? 4) Do you include working with families of incarcerated persons in any of your courses? 5) If yes, what courses? 6) If yes, how do you cover this topic? 7) Have you received any training on these topics? and 8) If yes, describe.

Results

When asked whether they included the topic of mass incarceration in their courses, only 35 (36.8%) of the counselor educators surveyed answered yes. The most frequently noted course was Multicultural Counseling, under many different titles such as “Social and Cultural Diversity Issues in Counseling” or “Cultural Diversity.” Other courses noted were Foundations of Clinical Mental Health, Career Counseling, Addictions, Diagnosis, Trauma, Practicum, and Internship. Only one participant responded, “every class I teach.” When surveyed whether they included working with families of the incarcerated in their courses, 27 (28.4%) of the counselor educators answered yes. This too was most frequently covered in a multicultural counseling course but also was included in school counseling, child and adolescent counseling, and crisis counseling courses.

Using an open-ended question, participants were asked to describe how they covered the topics. The vast majority of the responses were “discussion.” These discussions were prompted by topics or readings on issues such as “systematic oppression,” “the intersection of race and social class,” “mandated clients,” and “vicarious trauma.” Two participants described developing a special topics course on incarceration and one participant invited a guest speaker related to families of the incarcerated.

When counselor educators were asked whether they had received training on these topics, only 30 (31.58%) reported that they had. But, when the participants described the training that they had received, it is notable that 19 (63.3%) of those reporting training described experiences with incarcerated persons, not specifically the families. Seven (23.3%) of those who responded had attended conference presentations on the topics of incarceration and families of the incarcerated. Two participants (6.7%) had completed research on incarcerated persons. Only one counselor educator (3.3%) described an extended training experience specific to families of the incarcerated. Finally, one (3.3%) participant described the topics being integrated into their doctoral program that was combined with rehabilitation counseling.

Discussion

The purpose of this research was for counselor educators to articulate whether topics relevant to mass incarceration and the effect on families were addressed in their classrooms, and if so, how they were addressed. Because no similar research has been reported, this study was singular in seeking to investigate how or if counseling faculty prepare their students to work with families affected by incarceration. This study did not aim to produce generalizations that apply beyond the research sample.

Nevertheless, it is essential to compare what was discovered in this study with what is documented in the literature. This study found that the majority of counselor educators were not covering mass incarceration or families of the incarcerated in their coursework, nor had they received training to do so. The findings of this study also provide the beginnings of a blueprint for what counseling programs and faculty can do to prepare students to work with children and families affected by incarceration.

For this study, comparing our findings with a body of literature is difficult because such literature does not exist, excepting the study by Wachter Morris and Barrio Minton (2012). Wachter Morris and Barrio Minton reported that 57.51% of professional counselors reported having minimal to no training in working with individual or family-level trauma and crisis preparation. Although Wachter Morris and Barrio Minton’s research did not target families of the incarcerated, this population does fall under the umbrella of individual and family trauma. Like that study, the present study demonstrated that a majority of counseling students are likely not receiving intentional, purposeful training on working with the trauma associated with incarceration. Although close to 30% of our participants did include mass incarceration and families of the incarcerated in their courses, the majority of how the topics were addressed was based on whether it arose out of discussion of broader multicultural topics. It also is reasonable to conclude that because a counseling literature search focused on training students to work with children of incarcerated parents only resulted in one webinar (Brown, 2016), a large majority of professional counselors are not adequately prepared to work with this population.

The findings of the present study may generate discussion of future recommendations and directions that counselor educators and supervisors may explore and implement. The majority of faculty in this research were not trained in the topics of mass incarceration and counseling children and families of the incarcerated, and unsurprisingly the majority did not include any training for their students. As with any topic under the umbrella of multiculturalism, counseling faculty should incorporate mass incarceration and working with children of incarcerated parents when addressing implicit bias with students (Boysen, 2010). In light of the massive numbers impacted by mass incarceration, we recommend this topic be included as required content in counselor education training. One way to ensure its inclusion would be to include persons who are incarcerated and their families in accreditation standards. At a minimum, the topic should be included in textbooks and used in case examples throughout training programs.

Counselor educators should highlight the stigma and spoiled identity that children of incarcerated parents experience and describe stigma management techniques (Luther, 2016) counselors can teach when working with these children. In addition to exposing students to data on mass incarceration and discussions of implicit bias (e.g., Alexander, 2012; Kaeble & Cowhig, 2018; Phillips & Gates, 2011), specific treatment modalities and protocols need to be developed and validated that fulfill the education and ethical expectations (ACA, 2014; CACREP, 2015) to address systemic barriers, advocacy, and cultural competence (Hipolito-Delgado et al., 2016).

Continuing education trainings could provide an opportunity for counseling associations and programs to address important content that may not receive adequate or consistent attention in required coursework. Counseling associations could choose conference themes that would encourage training and research on the needs of families of the incarcerated. Counseling programs could consider continuing education trainings as a method of communicating the program’s values and priorities, such as attention to social justice. Additional benefits may include strengthening their reputation, improving retention, maintaining relationships with alumni, and building relationships with the local clinical community.

Limitations and Future Research
The researchers recognize that the small, purposive, and heterogenous sample limits generalizability of the findings. Additionally, issues with data that rely on self-report have been well documented (Coughlin et al., 2009). Although these limitations make the present study narrow in scope and generalizability, these limitations are features of the positivist tradition aimed at finding “facts” and “truth.” This nascent study sought to establish a beginning understanding of how counselor educators are addressing mass incarceration in the classroom.

There are many directions for future research. It would be valuable to use qualitative research methods to learn from counselor educators who are effectively integrating and instructing on families of the incarcerated to provide a template for pedagogical inclusion. Research focusing on counseling students can serve to further the understanding of curricular experiences with mass incarceration and children of incarcerated parents. Research with practicing counselors can provide insight into the current landscape in the profession, including how families and children of incarcerated parents are affected and how professionals address these concerns. In that vein, outcome research with these children would be useful, as would the development of an instrument that can identify key clinical treatment areas.

Conclusion
Mass incarceration is a national crisis impacting more than 5 million U.S. children and their families (U.S. Department of Health and Human Services, 2018). This study was an attempt to provide a foundational understanding of the preparedness of counseling faculty and how they train students on this issue. The magnitude of the crisis, alongside the absence of counselor training, should cause counselors to consider our responsibility to ensure adequate counselor preparation in this area. By doing so and providing recommendations for programs to consider, it is hoped that more research will be undertaken to further underscore the importance of the topic and illuminate new understandings.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Jessica Burkholder, PhD, NCC, ACS, LPC, is an associate professor at Monmouth University. David Burkholder, PhD, ACS, LPC, is an associate professor and department chair at Monmouth University. Stephanie Hall, PhD, NCC, ACS, LPC, is an associate professor and founding department chair at Emory & Henry College. Victoria Porter is a master’s student at Monmouth University. Correspondence may be addressed to Jessica Burkholder, 400 Cedar Ave, West Long Branch, NJ 07764, jburkhol@monmouth.edu.

Case Formulation and Intervention: Application of the Five Ps Framework in Substance Use Counseling

Scott W. Peters

Substance use and misuse is exceedingly common and has numerous implications, both individual and societal, impacting millions of Americans directly and indirectly every year. Currently, there are a variety of empirically based interventions for treating clients who engage in substance use and misuse. The Five Ps is an idiographically based framework providing clinicians with a systematic and flexible means of addressing substance use and misuse that can be used in conjunction with standard substance use and misuse interventions. Additionally, its holistic and creative style provides opportunities to address concerns at various points with a variety of strategies and interventions that will best suit clients’ unique situations. It can assist both novice and experienced clinicians working with clients who present for counseling with substance use and misuse. Following a discussion of the Five Ps, a brief case illustration will demonstrate the framework.

Keywords: substance use and misuse, Five Ps, idiographic, systematic, flexible

Substance use and misuse in the United States is extremely common. For the year 2016, the Centers for Disease Control and Prevention (CDC) found that 18% of the U.S. population aged 12 and older had used illicit substances or misused prescription medications (CDC, 2018). The National Survey on Drug Use and Health asserted that close to 30% of respondents aged 12 and older reported use of illicit substances in the past month (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). Although these statistics are significant, it should be noted that “Most people who use abusable drugs, even most people who use them nonmedically, do so in a reasonably controlled fashion and without much harm to themselves or anyone else” (Kleiman et al., 2011, p. 2). In the context of this article, the word abusable indicates substances that when taken are pleasurable enough to result in excessive dosing or increased frequency of intake (Linden, 2011).

However, there are others who use substances to such an extent that it causes significant distress and impairment in their lives, a phenomenon clinically referred to as a substance use disorder (SUD). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) bases an SUD on a “pathological pattern related to the use of a substance” (American Psychiatric Association, 2013, p. 483). In his report on alcohol, drugs, and health, the U.S. Surgeon General Vivek Murthy reported that more than 20 million Americans have an SUD (U.S. Department of Health and Human Services, 2016). Clients who engage in substance use and misuse can present with a variety of issues beyond use (Bahorik et al., 2017; Compton et al., 2014; Poorolajal et al., 2016). Thus, there exists a need to concurrently examine and address the potentially complex nature of client substance use and misuse.

Implications of Substance Use and Misuse

Substance use and misuse carries numerous potential repercussions. Societally, substance use and misuse consequences exceed “$400 billion in crime, health, and lost productivity” (U.S. Department of Health and Human Services, 2016, p. 2). Published data on those incarcerated appears to be several years old. However, it does suggest that more than 60% had a substance use disorder and 20% were under the influence at the time of their offense (National Center on Addiction and Substance Abuse at Columbia University, 2010). Regrettably, most do not receive treatment while incarcerated (Belenko et al., 2013). Additionally, many individuals who engage in substance use and misuse have co-occurring major medical conditions, such as cancers, cardiovascular accidents (strokes), and respiratory and cardiac illnesses (Bahorik et al., 2017). This population often experiences stigma and suboptimal health care results (McNeely et al., 2018; van Boekel et al., 2013). Substance use and misuse has significant impact on the occupational sector as well. Substance use and misuse has been correlated with both higher rates of absenteeism and workplace injuries (Bush & Lipari 2015). Those who engage in substance use and misuse often have higher rates of unemployment (Compton et al., 2014; Dieter, 2011). This can result in lack of access to treatment services, contributing to increased stress.

Substance use and misuse also has a negative impact on intimate partners, such as assuming increased responsibility and navigating unpredictability (Hussaarts et al., 2012). More ominously, substance use and misuse has been correlated with intimate partner violence (Murphy & Ting, 2010). Further, substance use and misuse is a significant risk factor for suicidality (Poorolajal et al., 2016). Finally, the number of U.S. adults with a comorbid SUD and mental illness has been shown to be almost 8 million, with only about 5% receiving treatment for both (SAMHSA, 2017). Concurrently treating both is very complex, challenging, and expensive. This can be even more problematic given the lack of health care access for large numbers of Americans (Schoen, 2013).

A Holistic Alternative

Addressing client substance use and misuse can be quite complicated, and as mentioned previously, substance use and misuse impacts users and society in a variety of ways beyond substance intake. There are several approaches to managing client substance use and misuse that have demonstrated effectiveness. Among those are 12-step programs (Humphreys et al., 2004), mindfulness-based interventions (Chiesa & Serretti, 2014), evidence-based approaches such as cognitive behavioral therapy (McHugh et al., 2010), and family counseling (O’Farrell & Clements, 2012). These approaches can be accomplished via outpatient counseling, partial hospitalization programs, inpatient and medically managed substance treatment programs, as well as residential and therapeutic communities. However, each has some shortcomings. Twelve-step attendance is most beneficial with inpatient substance use and misuse treatment (Karriker-Jaffe et al., 2018). Evidence-based approaches, such as cognitive behavioral therapy, tend to be nomothetic, assuming homogeneity and generally geared toward symptom amelioration (Robinson, 2011). Mindfulness-based strategies are not as effective when used alone as when used with other approaches (Sancho et al., 2018). Research on the success of family-based interventions has methodological challenges, such as small sample sizes and the difficulty of examining long-term outcomes (Rowe, 2012).

In addition, using these approaches may result in omitting the uniqueness of clients as a consideration in treatment. SAMHSA (2020) pointed out the significance of addressing clients individually based on their distinctive needs in order to provide the best chance for recovery from substance use and misuse. SAMHSA’s recommendations fit well with a more holistic framework in that such a structure allows clinicians to develop a multidimensional picture of clients. By examining and exploring clients’ use or misuse within the context of a multidimensional framework, interventions can be personalized, and areas of concern can be targeted. Such a framework may enhance the effectiveness of the aforementioned interventions (Wormer & Davis, 2018). Some of these evidence-based approaches will be demonstrated later in a case illustration.

As shown above, there are numerous ways to examine and treat client substance use and misuse. For example, some interventions use an individual lens, such as cognitive behavioral therapy, which examines connections between thoughts, feelings, and behaviors (Morin et al., 2017). Other approaches observe substance use and misuse from a family or systems perspective, looking at familial patterns such as communication and normalization of substance use (Bacon, 2019). Delivery of mindfulness-based interventions may help to address stressful events that previously triggered substance use (Garland et al., 2014). In addition, there are frameworks that use a formulation model examining various aspects of clients (Johnstone & Dallos, 2013) such as causal, contributing, environmental, and personal features, providing a much more expansive view of clients’ concerns.

Client substance use and misuse can be quite challenging for counselors, both novice and experienced. Case formulation, also referred to as conceptualization, is a skill new counselors often lack (Liese & Esterline, 2015). Using a framework to assist in case formulation may prove useful to beginning counselors. Experienced counselors, even with competence in a variety of approaches, can also benefit from using a framework to help address anticipated challenges (Macneil et al., 2012). Case formulations have been used in a number of areas such as those with psychosis, anxiety, and trauma (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). One such framework is the Five Ps (Macneil et al., 2012). Macneil and his colleagues (2012) posited that diagnosing was insufficient and it was critical to include other factors such as causal, lifestyle, and personal factors in conceptualizing the case and formulating a plan. Applying this approach with clients who engage in substance use and misuse would allow more individual and flexible ways to intervene with client substance use and misuse. In addition, the collaborative nature of the Five Ps reinforces the concept of an idiographic formulation. This is in keeping with the inherent uniqueness of clients, their concerns, and a variety of factors.

The Five Ps is a type of framework utilizing five factors developed by Macneil et al. (2012). They conceptualized a way to look at clients and their problems, systematically and holistically taking into consideration the (1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors. Presenting problems are concerns that clients find difficult to manage. Predisposing factors include biological, environmental, or personality considerations that may put clients at risk of further substance use and misuse. Precipitating factors are those that proximally bring about substance use and misuse and its resulting difficulties. Perpetuating factors are those that sustain and possibly reinforce clients’ current substance use and misuse challenges. Protective factors are those that help to moderate actual or potential substance use and misuse impact. The Five Ps framework promotes a very clear and systematic approach to case formulation or assessment that potentially provides a wealth of data. It also provides opportunities for a variety of interventions and strategies targeted to clients and their substance use and misuse or contributing factors.

Given the variations of substances, the level of use, the functional impairment, co-occurrence with other mental disorders, and inherent client differences, an idiographically based framework seems particularly appropriate with this population. The Five Ps permits counselors to both assess and intervene essentially simultaneously. It allows for client individualization, use of a variety of strategies, ongoing assessment, and modifications as needed. Furthermore, the Five Ps helps clients and counselors explore relationships between each factor and the presenting problem. This framework is idiographic in nature, as it looks at clients individually and holistically (Marquis & Holden, 2008). Idiographic case formulation can be useful for complicated cases, such as those encountered with clients engaged in substance use and misuse (Haynes et al., 1997). It is systematic, while allowing for flexibility and creativity. It can be used in outpatient, inpatient, and residential settings and possibly as part of an aftercare program.

Following is a case illustration demonstrating how the Five Ps may be helpful in formulating and engaging in a clinical application. It should be noted that several evidence-based substance use and misuse approaches were integrated in an eclectic approach throughout the case example to demonstrate the idiographic nature of the Five Ps. Many formulation models are administered within a cognitive behavioral grounding (Chadwick et al., 2003; Easden & Kazantzis, 2018; Persons et al., 2013). The Five Ps does not adhere to any particular theoretical orientation, thus allowing for a greater repertoire of strategies to draw from to help clients with substance use and misuse.

Implementing the Five Ps: The Case of Dax

A brief description of Dax, a hypothetical client, and the events that prompted him to seek services is followed by a detailed application of the Five Ps in addressing Dax’s substance use and misuse. It should be noted that the strategies and interventions applied here are used as illustrations and are specific to Dax and his concerns. In addition, the interventions demonstrated are not to be assumed the only ones that can be applied to Dax. They are examples that the author chose to illustrate the Five Ps in practice.

Dax is a 33-year-old married father of two children: a 9-year-old son, Cam, and a 7-year-old daughter, Zoe. He was recently driving home from work in the evening and law enforcement stopped him because of erratic driving. The officers evaluated him, detained him, and subsequently arrested him for driving while intoxicated. As part of his adjudication, Dax was required to attend five counseling sessions and have a clinician’s report provided to the court. Dax presents as extremely frustrated and embarrassed at being mandated to attend counseling sessions. He is confident that he does not have a problem and that counseling should be reserved for those who cannot stop drinking. Dax drinks two to three times a week, usually having one or two shots of whiskey and two to three draft beers. The night he was pulled over, he had had two additional beers and one additional shot of whiskey on top of his usual consumption after a telephone argument with his wife, Sara. Additionally, he reports significant stress and conflict in his marriage as well as concerns over some upcoming diagnostic tests for their daughter related to a heart murmur. Dax denies any other negative consequences from his alcohol use. He denies any significant increase in alcohol use or any other substance use.

Presenting Problem

While being mandated to attend counseling, Dax shares concerns that he is afraid of what his daughter’s test results will show. He fears that she will need open-heart surgery and that she may die. The clinician can intervene here by simply normalizing and validating his fears about the test results. A logical analysis using gentle Socratic dialogue may help to challenge his emotional reactions to his daughter’s heart murmur (Etoom & Ratnapalan, 2014). In addition, mindfulness strategies can assist in helping Dax to cognitively diffuse from present to future events (Harris, 2019). He is also adamant that he does not have a problem with alcohol. Here, a conversation about what counseling entails as well as psychoeducation related to the effects of alcohol on executive functioning may prove beneficial (Day et al., 2015). Acknowledging that his reticence is due to being obligated to attend counseling may assist in relationship building (Tahan & Sminkey, 2012). The clinician may also seek more information on the cause of the reported stress between him and his wife.

Predisposing Factors
Dax reports a strong paternal history of substance use and misuse. His father started out drinking occasionally and over the years slowly developed a dependency on alcohol. Dax further reports his paternal grandfather died from liver failure. Addressing the potential genetic link to substance use and misuse may prove beneficial in raising Dax’s awareness (Dick & Agrawal, 2008). For example, the clinician may ask Dax if they can share how genes are passed on and expressed, like genes for eye color or hypertension. This may open the door to a conversation regarding how his substance use and misuse may progress to alcohol use disorder and its definition as a pattern of alcohol use leading to clinically significant problems, including increase in use, failed attempts to stop, and use leading to an impaired ability to meet role obligations (American Psychiatric Association, 2013). There could be a discussion of alcohol use disorder being a disease, not that different from any other passed-on trait or disease. Additionally, Dax often struggles with strong and painful emotions, and alcohol helps to address them. Here the clinician may utilize strategies drawn from acceptance and commitment therapy related to his control strategy of using alcohol to avoid his emotions (Harris, 2019). The ball in the pool metaphor (i.e., holding a beach ball under the water works temporarily, but eventually it pops back up) can be compared to alcohol temporarily holding those painful emotions down, eventually to resurface. The clinician may also discuss strategies to help Dax regulate his reactions using emotion-focused interventions such as positive reframing to ameliorate the stress of his daughter’s cardiac condition (Plate & Aldao, 2017).

Precipitating Factors
This area explores significant occurrences that preceded or triggered the presenting problem and its consequences. Dax shares that he and his wife are conflicted about how to proceed with their daughter’s medical care. Sara is unequivocal in her confidence in Zoe’s cardiologist and his competence. Dax, however, is hyper-focused on surgery and seems to dismiss Sara’s position. At the end of his workday, he and his wife got into an argument over the phone about an upcoming diagnostic test and the possible results. Dax was quite upset, cursed at her, and then hung up the phone. He then stopped at a local pub and had several drinks.

Here, the clinician may use reality-based strategies that address choice and consequences (Wubbolding & Brickell, 2017). This may include a direct conversation about Dax’s decision to drink, resulting in his becoming impaired, with the consequence of being detained, charged, and adjudicated. Dax can then share his and his wife’s perspectives on their daughter’s care. This conversation can lead to investigating strategies for how each can be heard, including short role-plays with opportunities to practice (Worrell, 2015). The clinician can provide a variety of potential spousal responses, allowing for more adaptability and flexibility in Dax’s responses. The goal here is to build Dax’s competence in communicating, both in listening and expressing. Additionally, there may be a discussion using aspects of existentialism to process inherent anxiety and its connection to unknowable future events (May, 1950; Wu et al., 2015).

Perpetuating Factors
The emphasis here is on features that continue the presenting problem. For Dax, he shares that when he and his wife argue, it follows a very predictable pattern. They disagree, interrupt one another, yell, and he calms down by having several beers. He then withdraws and becomes sullen for a few days. Nothing gets resolved, and this cycle appears once again when they have conflict.

The clinician may discuss the concept of circularity and assist in moving from “vicious cycles” to “virtuous cycles and problem resolution” (Walsh, 2014, p. 162). This involves explaining that interactions can act as a kind of back-and-forth loop of action–reaction–action without any resolution, leaving both parties feeling unheard, misunderstood, and frustrated. The goals here are to both break the pattern and to facilitate healthy conversations. Here the clinician may incorporate a solution-focused strategy exploring a time with Dax when he and his wife have disagreed, but he did not interrupt and the outcome was positive (de Shazer, 1985). If he cannot identify a time, simple role-plays in which Dax does not interrupt or yell and instead experiences different outcomes may provide optimism to Dax. The counselor may also assist Dax in emotional regulation, which may prevent the initiation of arguments (Aldao & Nolen-Hoeksema, 2013). In addition, aspects of narrative therapy may provide an opportunity for Dax to re-author a unique outcome that gives meaning and provides a functional identity to him as a father and husband, thus building a sense of optimism (White & Epston, 1990).

Protective Factors
Here the focus is on investigating resources and/or supports that may help prevent client substance use and misuse from further becoming problematic. This factor has generally been underutilized despite being shown as beneficial to clients (Kuyken et al., 2009). This is often the opportunity for the client to share what may help them move forward, what their assets are, who can support them, and any other self-identified skills (de Shazer, 1985). These can be in the form of personal characteristics such as tenacity, intellect, or insight. They may also present in the form of family, friends, or hobbies. Oftentimes, when the topic of protective factors is used in substance use and misuse, it is related to deterrence of substance use, notably with adolescents (Liao et al., 2018). In the Five Ps context, protective factors are used to potentially prevent substance use and misuse from having more negative impact as well as to increase client resilience. This factor differs markedly from the first four. Protective factors move away from the problem areas that need interventions to hope and optimism and look to future success and competence (Macneil et al., 2012). Once the protective factors are identified, the ensuing conversation provides opportunities to imagine future outcomes in which protective factors may come into play should situations occur that the client finds problematic. Second, it also tends to shift the conversation toward what is present and going well in their lives and away from those areas that cause distress and suffering (de Shazer, 1985).

Discussion

In implementing the Five Ps framework with Dax, the clinician chose to use psychoeducation and strategies borrowed from acceptance and commitment, reality, Bowenian family systems, and solution-focused brief therapies to assist Dax with his substance use and misuse. The choice of the above approaches is only meant as an illustration and not as definitive ways to address this particular client. It is likely that other clinicians presented with Dax would use a different combination of approaches. The Five Ps is a systematic way to look at clients and their presentation, and its idiographic construction takes clients’ uniqueness into account. It also allows clinicians to target specific areas of concern (Macneil et al., 2012) and may be used in a variety of clinical settings. Moreover, the Five Ps align with SAMHSA’s recommendation that clinicians tailor treatment to each client because no single treatment is particularly superior (SAMHSA, 2020).

Limitations and Future Research

There are limitations to the Five Ps framework as a way to formulate and intervene with clients’ substance use and misuse. First and foremost, it should be emphasized that this particular framework has not been empirically tested with client substance use and misuse. However, as mentioned previously, case formulations have been used across a variety of client concerns (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). Another potential limitation is that the Five Ps may not be particularly beneficial for substance use and misuse in which there is clinical evidence of an SUD that includes significant withdrawal symptoms. Client substance use and misuse at that level may need medical stabilization and detoxification prior to utilization of the Five Ps. In addition, there may be clients who are simply not ready or able to address some or most of the dimensions of the Five Ps. Furthermore, clients like Dax who are mandated to attend substance-related counseling may have service plans that are not congruent with the Five Ps framework. In spite of these limitations, there may be several potential areas of inquiry.

Previous studies using frameworks to formulate have often used cognitive behavioral therapy as the primary intervention (Chadwick et al., 2003; Persons et al., 2013). Given that client substance use and misuse can be quite complicated, using various approaches within the Five Ps framework may yield positive results. As Chadwick et al. (2003) noted, examining positive client experiences may be one way to discover how to increase client participation in substance use and misuse treatment. Another potential area of study might involve comparing novice counselors to more experienced counselors. As mentioned previously, novice counselors often lack sufficient case formulation skills (Liese & Esterline, 2015). Examining the two groups’ experiences using the Five Ps may provide insight to assist counselor training programs related to substance use and misuse skill development. The implementation of the Five Ps with clients with mild substance use and misuse and those with more significant substance use and misuse, possibly using the DSM-5 diagnosis for SUD, may be another area to explore. This research could point to populations for whom the Five Ps is more and less effective. Studies utilizing the Five Ps with mandated clients may demonstrate its efficacy, notably with agencies that require substance-related counseling.

Conclusion

Client substance use and misuse is a significant problem in the United States, and it continues to cause difficulty for individuals, families, and society. There are numerous methods and combinations of methods to address substance use and misuse, such as family therapy, cognitive behavioral therapy, and self-help groups. Their effectiveness has been well researched, and this paper does not propose a superior way to address substance use and misuse. However, the Five Ps presents a framework in which counselors can examine and intervene with client substance use and misuse using a variety of approaches and strategies. The Five Ps can be used in a variety of settings such as a community mental health agency, primary care clinic, and inpatient or residential treatment centers. The systematic but flexible nature of this framework affords clinicians numerous ways to address substance use and misuse. For some, receiving substance use and misuse services can be stigmatizing. In fact, this stigmatization can come from those who are treating them (Luoma et al., 2007). In addition, the vast majority of those with an SUD never receive treatment (Han et al., 2015). Incorporating the Five Ps, with its holistic framework, may prove attractive to clients and counselors, thus potentially increasing the numbers of clients engaged in substance use and misuse treatment. As mentioned previously, the Five Ps is not meant to replace any other substance use and misuse intervention. It is another way to address the multifaceted and complicated nature of client substance use and misuse. Novice clinicians, who often have a more limited repertoire of strategies, may find the Five Ps valuable because of its systematic framework to clients. Experienced clinicians understandably have a larger catalogue of strategies to choose from. However, they may find this framework valuable as it provides one more way to address the often-encountered complex challenges of substance use and misuse.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Scott W. Peters, PhD, LPC-S, is an associate professor at Texas A&M University – San Antonio. Correspondence may be addressed to Scott Peters, One University Way, San Antonio, TX 78224, scott.peters@tamusa.edu.