Black People’s Reasons for Becoming Professional Counselors: A Grounded Theory

Michael D. Hannon, LaShawn M. Adams, Natalie Nieves, Estefanie Ceballo, David Julius Ford, Jr., Linwood G. Vereen

Drawing from the concepts of Critical Race Theory and the Theory of Nigrescence, we report the results of a grounded theory study to explain why a sample of 28 Black counselors chose their profession. Findings suggest that the contributors to this study were motivated to become counselors because of their inspiration to challenge cultural mandates (i.e., grounding motivator), to disrupt Black underrepresentation (i.e., secondary motivator), and to live out their personal and professional convictions (i.e., secondary motivator). Recommendations for counselor education, counseling practice, and counseling research are included.

Keywords: Black counselors, Black underrepresentation, grounded theory, Theory of Nigrescence, Critical Race Theory

Accredited counseling programs enroll White students and hire White faculty at significantly higher rates than they enroll Black students and hire Black faculty (Council for the Accreditation of Counseling and Related Educational Programs [CACREP], 2022). Black students and faculty in counseling programs have described their program climates as unsupportive and hostile (Bradley & Holcomb-McCoy, 2004; Brooks & Steen, 2010; Haskins et al., 2013). Given the overwhelming representation of White counselors (U.S. Bureau of Labor Statistics, 2023), this perception has a bearing on Black participation in the professional counseling workforce. To date, the counseling knowledge base offers little on the factors, motivators, and/or reasons that inspire people to become counselors, regardless of their racial and/or ethnic identities. These motivators, factors, and reasons are important, given the value professional counseling places on understanding individuals’ career development and trajectory.

Exploring constructs associated with the choices that Black counselors make about becoming counselors is uniquely important given the historical exclusion of Black counselors from the profession (National Center for Education Statistics [NCES], 2021; U.S. Bureau of Labor Statistics, 2023). Simultaneously, Black clients are seeking mental health support in record numbers and actively indicating that they want treatment from Black counselors (Substance Abuse and Mental Health Services Administration, 2018). The goal of this study was to develop a grounded theory of what motivates Black people to become professional counselors.

Review of the Literature and Theoretical Framework

Developing a theory that explains the reasons why Black people become counselors can benefit the counseling profession in at least three ways. First, it centers the voices, experiences, and insights of Black counselors. Centering them and their experiences is a critical and disruptive act that provides direct and unfiltered insights about factors that have contributed to their engagement and factors that inhibit that engagement, given how their specific experiences and insights are not significantly reflected in counseling research. Second, the results can provide counselors at all levels (e.g., counselor education program faculty and staff, counseling leaders, practicing counselors, and counseling students) an introductory evidence base that can inform more innovative ways to both recruit Black counselors and make counselor preparation programs more inclusive, supportive, and affirming. Third, the findings also provide counselor preparation programs and the agencies and institutions that employ graduates with an introductory evidence base that contributes to increasing the number of Black counselors, which has been documented to encourage more Black and other marginalized people to seek mental health support (Cook et al., 2017; Moreno et al., 2020; Noonan et al., 2016; Primm et al., 2010).

The reasons for the historical exclusion and ongoing underrepresentation of Black counselors are simple. We assert that Black counselors’ exclusion and underrepresentation are a direct consequence of systemic racism. Different forms of systemic racism are evidenced in at least two specific contexts: 1) systemic racism in counseling programs evidenced by limited enrollment of Black counseling students and hiring of Black faculty and 2) systemic racism in counseling journals evidenced by underreported research about career development for Black counselors.

Systemic Racism in Counseling Programs
     In its most recent report on counseling program racial demographics, CACREP (2022) noted that approximately 55% of all students in counseling programs were White, while just over 16% were Black. In 2017 CACREP reported approximately 60% of students in counseling programs were White, while less than 20% were Black. So, while there is more representation of other students of color in accredited counseling programs, the number of Black students has decreased. These trends continue in graduate education at institutions across the United States with respect to Black student enrollment. The NCES (2023) reported that Black students comprised 14% of the approximately 3 million students enrolled in U.S. postbaccalaureate programs, as compared to 62% of White students enrolled in 2019. Likewise, the NCES (2021) reported that of the approximately 810,000 full-time faculty at degree-granting institutions in 2018, 75% were White and 6% were Black. The recent Supreme Court ruling striking down race-based affirmative action in college admissions (Students for Fair Admissions, Inc. v. President and Fellows of Harvard College, 2023), along with assessments found to be culturally biased and inconsistent in predicting students’ success (e.g., Graduate Record Examination; Sullivan et al., 2022) have the potential to be barriers to Black student enrollment. These factors have clear implications for the counseling workforce, evidenced by White counselors comprising anywhere between 70% and 76% of the counseling workforce (U.S. Bureau of Labor Statistics, 2023). Unfortunately, Black counseling students and faculty have reported counseling program climates to be isolating, hostile, and tokenizing (Bradley & Holcomb-McCoy, 2004; Brooks & Steen, 2010; Haskins et al., 2013).

Career Development Among Black People in Helping Professions
     The research on the impact of race and racial identity on career development among Black people is consistent, indicating Black people consider their race in their career choices (Bell, 2018; Byars-Winston, 2010; Byars-Winston & Fouad, 2006; Chung, 2002; Fouad & Byars-Winston, 2005; Hackett & Byers, 1996; Rollins & Valdez, 2006). Unfortunately, very little research explicitly reports on Black people’s motivation to join helping professions, including counseling. June and Pringle (1977) offered a constructive critique of career theorists (i.e., Roe, Super, and Holland) whose research anchors career development theory in many counselor preparation programs, writing that “None of the three writers incorporated the influence of race in any significant manner in their theories” (June & Pringle, 1977, pp. 22–23). June and Pringle’s insights from more than 35 years ago are telling, given the absence of research that attempts to acknowledge the ways race and racism influence career choices among people who are not White. What follows is a review of the research reporting on influencing factors of Black people who choose to enter helping professions such as social work, family and consumer sciences, and nursing, which can potentially offer insights about why some Black people might choose to become professional counselors. Also included is research about how race influences the career counseling process for Black students and new professionals as they seek to identify viable career options.

     Creative Nursing published an article in 2008 (Anonymous, 2008) that provided readers with firsthand accounts of why a group of over 20 nurses chose to enter that profession. They overwhelmingly cited being called to the profession, suggesting that their career choice went beyond typical considerations such as financial stability or convenience. Social work researchers have similarly investigated this topic and have reported that Black social workers most frequently chose the profession because they wanted opportunities to work with people (Gockel, 1966) or had the desire to open a private practice (Butler & Butler, 1990). In their study of 120 social workers, Bowie and Hancock (2000) reported that the social workers chose gaining more social work education in order to advance their careers and learning new social work skills as among the most important reasons to enroll in graduate-level social work courses. Similarly, Burdette-Williamson and O’Neal (1998) reported undergraduates who chose family and consumer sciences as a major were most motivated by influential people, including but not limited to college advisors, parents, and/or college friends. These motivating factors to join helping professions align with Branch’s (2018) dissertation that reported on Black men’s reasons for becoming counselors. Branch cited prior experiences with therapy and Black male counseling mentors as reasons why Black men chose their career path leading to counseling.

Other researchers have centered Black people in the context of career development. The cultural formulation approach with Black clients (Byars-Winston, 2010; Byars-Winston & Fouad, 2006; Fouad & Byars-Winston, 2005) focuses on racial differences in variables related to career choice. Fouad and Byars-Winston (2005) reported differences among racial/ethnic groups in perceptions of career opportunities and barriers to those opportunities; they concluded that the career aspirations of Black and other people of color are similar, but their dreams differ by racial groups. Byars-Winston (2010) recommended the cultural formulation approach in career counseling with Black clients as a descriptive guide to inform counselors’ consideration, documentation, and influence of culture in the counseling relationship by integrating four cultural formulation dimensions (i.e., self and cultural identity, self and cultural conceptions of career problems, self in context, and cultural dynamics in counseling relationships) with the three functions of Black cultural identity (i.e., bonding, buffering, and bridging).

Research about career development among Black students in educational settings (pre-K through higher education) and interventions support using the cultural formulation approach. Rollins and Valdez (2006) sampled 85 Black high school students and found that students who experienced a higher degree of racism reported significantly higher career decision-making self-efficacy (i.e., belief in one’s ability to make a good career decision) but not career task self-efficacy (i.e., belief in one’s ability to successfully complete a career-related task). Rollins and Valdez found that higher ethnic identity achievement, parental socioeconomic status, and being female were related to higher levels of career self-efficacy. Similarly, Duffy and Klingamen (2009) reported in a study of 2,300 racially diverse first-year college students a series of statistically significant, positive correlations between higher levels of ethnic identity achievement and career decidedness. Ethnic identity was found to play little, if any, role in the career development progress of White students. However, for Black and Asian American students, after controlling for race, ethnic identity was found to significantly moderate the relationship between ethnic identity achievement and career decidedness. Duffy and Klingamen (2009) urged counselors to be cognizant of the role ethnic identity plays in students’ career development. The literature reminds us that there are unique considerations for the career development of Black people that explicitly focus on racial identities in general. The research also suggests that there is useful information to be gleaned from how Black people in other helping professions make their career choices, but comparatively little exists about Black counselors.

The literature reviewed here elucidates the challenges Black people confront as counseling clients, counseling students, counseling professionals, and counseling faculty. Researchers continue to document the ways that Black clients experience negative outcomes in counseling, as well as their desires to have counselors who share their racial identity. Barriers exist that exclude Black people from graduate programs, thus creating a shortage of counseling professionals. Similarly, Black faculty are also underrepresented in counseling programs. Still, the importance and value of more Black counselors exist, and the goal of this study was to provide a theoretical grounding to explain Black counselors’ motivation to join the profession.

Integrated Theoretical Framework

Our research team drew on Critical Race Theory (CRT) and the Theory of Nigrescence for an integrated theoretical framework. CRT posits that racism and White supremacy is embedded in everyday structures and systems and impacts the lived experiences of people of color (Garcia & Romero, 2022). Delgado and Stefancic (2001) articulated that race is a socially constructed concept and there is no biological superiority of one racial group over another. Secondarily, several groups are vested in maintaining the current racial hierarchy that esteems Whiteness as superior. Finally, racism is ordinary, common, and an intrusive force in and on Black and other people of color (McGee & Stovall, 2015). For these reasons, CRT provides an appropriate lens for investigation.

Cross et al.’s Theory of Nigrescence (1991) posits that a healthy racial identity is the result of a developmental process during the life span. During this process (i.e., pre-encounter, encounter, immersion/emersion, internalization, and internalization/commitment), Black people transition from not understanding how race affects their experiences to experiencing agency in their own understanding of racial identity of self and others. We believe that race is inextricably tied to Black people deciding to become counselors as they are aware of the deleterious effect of racism on their lives. We further contend that Black people who choose to become professional counselors are further along in their racial identity development, per Nigrescence Theory. These two theories provided us with a fitting and culturally relevant framework with which to administer this study. Our focus on the intersections of race and racism, racial identity development, and career development are congruent with the aims of CRT (Delgado & Stefancic, 2001) and Cross and colleagues’ (1991) Theory of Nigrescence.

Methods

Our goal with this study was to develop an introductory evidence base that identifies what motivates Black counselors to join the counseling profession. There has been a limited amount of research on the intersection of Black peoples’ racial identity and their career motivations. There has also been little research that reports on what motivates Black people to become counselors or how their experiences influence their decision to join the profession. Consequently, we chose a grounded theory design for this study because it is used to help answer complex research questions wherein data are collected and extensively analyzed to create a theory (Mills & Gay, 2019; Singh et al., 2010). To generate a grounded theory, we endeavored to collect data and identify patterns therein to learn what motivated a specific sample of Black people to become counselors (Corbin & Strauss, 1990; Creswell & Poth, 2016) by drawing on the causal conditions, the context(s), and the intervening variables that influence the phenomenon being studied (Vollstedt & Rezat, 2019). Our central research question for the study was: What motivates Black people to become professional counselors?

Researchers’ Positionality Statement
     Our research team consisted of six members at varying points in our counseling and counselor education careers. We all share a commitment to resisting and disrupting all forms of oppression. Michael D. Hannon is a Black, male, cisgender counselor educator and counselor whose clinical and research interests are Black men’s mental health and confronting anti-Black racism in professional counseling. LaShawn M. Adams is a Black, cisgender woman whose research focuses on Black women in higher education and feminist ideology. Natalie Nieves and Estefanie Ceballo are Latine cisgender women whose research interests focus on Latine culture from a relational–cultural theory perspective. Adams, Nieves, and Ceballo are doctoral candidates. David Julius Ford, Jr. is a Black, male, queer counselor educator and counselor whose research and clinical interests include Black men in higher education; career counseling; queer and trans Black, Indigenous, and people of color (BIPOC); and persons living with HIV/AIDS. Linwood G. Vereen is a Black, male, cisgender counselor educator and counselor whose research and clinical interests include Black people’s mental health, humanistic existentialism, Black existentialism, and humor in counseling. We affirm and celebrate our diverse range of salient and intersectional identities. Our diverse identities also informed the choice of our integrated theoretical framework, given we are all people of color at various points in our racial identity development and who have a shared professional identity.

Contributor Recruitment and Profile
     We used two sampling methods, criterion and snowball sampling (Mills & Gay, 2019; Patton, 2014), to recruit potential contributors. Criterion sampling (Patton, 2014) requires that contributors to a study meet a very prominent criteria for eligibility. Mills and Gay (2019) described snowball sampling as the process when researchers invite contributors to recommend additional eligible contributors. All contributors (i.e., participants) were required to meet the following four inclusion criteria: 1) identify as Black (i.e., continental African, Black American, Afro-Caribbean, Afro-Latine, and/or a member of the African Diaspora); 2) be a member of the counseling profession, evidenced by being a counseling student (i.e., enrolled in a counseling master’s, post-master’s, and/or doctoral program), a practicing counselor, and/or being a counselor educator/supervisor; 3) speak and understand American English; and 4) be at least 18 years old. All 28 contributors received $40 gift cards for their participation.

Upon receiving IRB approval, our research team began recruiting by inviting potential contributors with flyers and descriptions via counseling and counselor education email distribution lists and various social media platforms (e.g., X/Twitter, Instagram, Facebook, LinkedIn). Our recruitment efforts yielded over 51 responses from diverse Black counselors, and our final sample included 28 contributors. Twenty-three potential contributors were excluded due to either not fully meeting eligibility criteria and/or interview scheduling conflicts. Each contributor chose their own alias to protect their identity. Basic demographic data about the contributors is listed in Table 1.

Table 1
Contributor Demographics

Alias Age Yrs. of Counseling Exp. Gender Identity Ethnicity Professional Role
Ada 28 0–5 years Cisgender woman Black American Doctoral student;
practicing counselor
Aisha S. 46 15+ years Female Afro-Caribbean Practicing counselor
Andrea 24 0–5 years Female Afro-Caribbean Practicing counselor
Bianca 25 0–5 years Female Mixed race
(Black/Hispanic)
Practicing counselor
Capt. Ingenuity 37 0–5 years Male Black American Practicing counselor
Carlos 41 11–15 years Male Black American Doctoral student
Cheeta 39 0–5 years Female Black American Master’s student
Denise 42 15+ years Female Black American Doctoral student;
practicing counselor
Destiny 33 11–15 years Female Black American Counselor educator/supervisor; practicing counselor
Dorothy 45 6–10 years Female Mixed race (Black American & White American) Practicing counselor
Erykah 28 0–5 years Female Afro-Caribbean Doctoral student;
practicing counselor
Franchon 38 11–15 years Female Mixed race (Native and African American) Retired/former counselor
Grayson 45 0–5 years Female Black American Practicing counselor
Jacques 68 15+ years Male Mixed race (Creole Chamorro) Practicing counselor
Jalen 40 15+ years Male Black American Practicing counselor
Jena Six 55 0–5 years Female Did not reply Practicing counselor
Jesika 41 6–10 years Female Afro-Caribbean Master’s student;
school counselor
Jo 63 0–5 years Female Black American Practicing counselor
Marie J. 31 0–5 years Female Black American Doctoral student
Matt 60 15+ years Male Black American Doctoral student
Michelle 26 0–5 years Female Black American Master’s student
Mildred P. 51 0–5 years Female Black American Master’s student
Morris 22 0–5 years Female Black American Master’s student
Rene 29 6–10 years Female Black American Practicing resident in counseling
Sasha 41 0–5 years Female Black American Doctoral student
Serena 26 0–5 years Female Black American Academic advisor
Trey 32 6–10 years Male Black American Doctoral student
Victor 33 0–5 years Male Black American Practicing counselor

 

Data Collection and Analysis
     Our sole data collection method was one-time, individual, semi-structured interviews with 28 contributors. We all participated in the data collection process, conducting individual interviews lasting on average 45 minutes each. Each interview was conducted using web conferencing technology (i.e., Zoom), was audio recorded, and was professionally transcribed. We developed an interview protocol to address our overall research question, informed by our review of the literature and specifically inquiring about the reasons contributors chose to become professional counselors. The interview protocol can be found in the Appendix.

Our data analysis process was consistent with general grounded theory analysis methods (Miles & Huberman, 1994; Vollstedt & Rezat, 2019) and those identified by counseling researchers who have conducted and published grounded theory research studies (Hannon & Hannon, 2017; Singh et al., 2010), which included an interactive, three-step process of open coding, axial coding, and selective coding. Our open coding process began after the completion of the fifth interview, wherein members of our team conducted a detailed review of the interviews to find discrete ideas, events, or experiences (i.e., codes) that communicated the reasons why the contributors decided to become professional counselors (Corbin & Strauss, 1990; Singh et al., 2010). Open codes from the first five interviews helped us to develop a codebook as a basis for comparison for the remaining 23 interviews. Our team reached consensus on a list of open codes present in the 28 interviews and then began the axial coding process. Axial coding is a process in which “categories are related to their sub-categories, and the relationships tested against the data” (Corbin & Strauss, 1990, p. 13). In essence, our research team worked together to categorize the open codes, describing them more summatively as we considered the causal conditions, contexts, and intervening variables that explained why these contributors chose to become counselors (Corbin & Strauss, 1990). Finally, we engaged in selective coding of the interview data, which required us to identify a core category that described the central phenomenon (i.e., decision to become counselors) around which all other categories are integrated (Vollstedt & Rezat, 2019).

Trustworthiness
     To validate our discoveries, our research team employed a number of trustworthiness strategies. One strategy was member checking (Hannon & Hannon, 2017; Lincoln, 1995) at three different times: 1) during interviews (i.e., asking clarifying questions of contributors during interviews); 2) after interviews (i.e., forwarding transcribed interviews to contributors for additional information and/or corrections); and 3) after our agreement of findings (i.e., providing an executive summary of findings to contributors). No contributors requested content changes. A second trustworthiness strategy we leveraged was investigator triangulation (Denzin & Lincoln, 2000), or when a study includes multiple researchers to assist with accuracy and confirmability of analysis. The investigator triangulation was facilitated through activities such as team meetings to discuss our relationship to the research topic, our individual interpretations of the data, and the subsequent consensus coding that allowed us to intentionally monitor and address the influences of any potential biases. This investigator triangulation provided our team the opportunity to bracket any potential biases we had in our analysis process. A third strategy we used was individual journaling (Giorgi, 1985) to help inform our analysis meetings and determine the ways in which contributors’ accounts affected us emotionally and/or intellectually.

Findings

We endeavored to learn, and develop a grounded theory about, why a group of Black people decided to become counselors through this study. What we identified, grounded in the contributors’ responses, was a set of interacting and influencing factors that inspired them to become counselors. These Black counselors were motivated to join the profession based on their inspiration to challenge cultural mandates (i.e., grounding motivator), to disrupt Black underrepresentation (i.e., secondary motivator), and to live out their personal and professional convictions (i.e., secondary motivator). A visual representation of our grounded theory can be found in Figure 1. What follows is a description of our grounded theory.

Figure 1
Grounded Theory Diagram

 

Challenging Cultural Mandates (Grounding Motivator)
     Contributors’ responses indicated they were all motivated to join the profession, in part, to challenge cultural mandates imposed on them by both Black people and people from other racial and/or ethnic groups. These mandates were articulated by implying specific societal and/or career expectations for Black people and communicated ideas and stereotypes like, “Black people don’t do counseling” or professional counseling is not a financially viable career. There was variance in contributors’ answers about this, potentially influenced by their role and years in the profession (e.g., master’s student, practicing counselor, counselor educator/supervisor). The data suggested that the more years in the profession, the more explicit, unapologetic, and clear their rationale was to challenge these cultural mandates. For example, Sasha, a 41-year-old counseling doctoral student, discussed challenging stereotypes about the benefit of counseling for Black people: “In the Black community, they’re like, ‘Oh, I don’t need help, I don’t have mental issues.’ And that was part of my motivation to let them know it’s okay to get counseling.” Ada, a 28-year-old counselor and counseling doctoral student, described her experience receiving mixed messages about working in mental health from people with whom she attended her Black church, saying, “I remember expressing that interest . . . and most people were like, ‘That’s, like really needed, especially in our community.’ But this one older woman was just like, ‘You want to work with people who are like, messed up in the mind?’” Jalen, a 40-year-old counselor, spoke about the strategies he used to make his counseling career financially viable, noting, “In-home counseling led me into . . . people talking about how you can make more money by getting more credentials.”

Black (Under)Representation (Secondary Motivator)
     All of the contributors to this study explicitly spoke about being motivated to become counselors for more representation in the profession. We learned from the contributors that this motivator was influenced by two variables: 1) having an adult/senior influence, and 2) having negative personal counseling experiences. Many shared compelling stories of an adult/senior influence (e.g., a family member, a professor) who encouraged them to consider professional counseling as a career option. Additionally, many shared negative experiences as clients. Mildred P., a 51-year-old professional counselor, shared the importance of having a counselor that has a shared racial and/or ethnic identity, noting, “I’ve not seen counselors that look like me. And I feel like . . . if you can relate on the surface, then there’s a level of comfort.” Jo, a 63-year-old counselor who works with college students, addressed the need for more Black counselors who work with college students to increase representation and to amend negative counseling experiences she and Black student clients have had:

There was only one Black counselor there, and she can’t see everybody in the 48,000 population at [redacted university]. She can’t see everyone. And so, they [Black students] didn’t want to go. Or, they’ve gone before and their experiences weren’t the best. And they don’t go back. We know that that happens all the time. It’s even happened to myself. So, when I was thinking about what I can do, because I can complain, you know, and say, ‘Oh, we don’t have counselors, we don’t have counselors,’ or I can do something about it in my little area of the world.

     The experience of having an adult/senior influence on these contributors’ motivation to become professional counselors and increase Black representation was salient. Denise, a 42-year-old counselor educator, shared the profound impact of having a Black mentor who was a professional counselor. She shared, “What really was beneficial was seeing . . . a Black man willing to show someone the ropes. . . . I emailed that person, and they responded the same day. That just spoke so much to me of their integrity.” Serena, a 26-year-old Black counselor, recalled the importance of adult/senior influences in her desire to join the profession, noting,

ACA did a mentoring program and . . . I kind of forgotten I’d signed up. And then I got an email saying you’re connected to a mentor and it was great. She had two mentees and she was a counselor of color from [university redacted] and very passionate about empowering people of color, and she was the one, she was the first person to ask me, ‘Why do you want a doctorate?’ In all my—since undergrad—no one asked me that. . . . She was awesome. She introduced me to one of her doctoral students, another Black woman. We met a couple times over Zoom as well.

     Finally, Rene and Dorothy provided examples of the ways that negative counseling experiences inspired them to become counselors to increase Black representation in the field. Rene, a 29-year-old female counselor, shared, “In my own journey, I saw how difficult it is to find counselors who had similar identities. And that furthered my already very strong desire to be in the helping profession . . . be a part of that as well.” Dorothy, a 45-year-old counselor, offered a similar sentiment:

I had experiences growing up that led me to therapy personally. And it was really difficult to find a therapist who I could identify with, who I didn’t have to explain in detail about why something was upsetting to me. And I had some experiences that were so difficult that I didn’t return to counseling for several years. And so that was a real driving force in me deciding to enter this profession a little bit later in my life. Because I wanted to be able to offer that to people in similar situations.

Personal and Professional Convictions (Secondary Motivator)
     The responses from the contributors in our study indicated that they had personal and professional convictions that motivated them to become professional counselors. Throughout their stories, it was clear to our team that the contributors possessed personal and professional values that inspired them to take action (i.e., become counselors) which allowed them to experience personal and professional congruence. We interpreted the contributors’ personal and professional convictions as a consequence of two factors: 1) they all possessed altruistic dispositions, and 2) they all possessed values of justice and equity.

Evidence of the influence of altruistic dispositions on the contributors’ convictions and ultimate choice to become counselors were present in the following ways. Michelle, a 26-year-old counseling student, simply stated, “You know . . . it’s also just wanting to help people and wanting to show people compassion. And teach them that compassion for themselves. That’s big for me.” Likewise, Morris, a 22-year-old master’s student, shared,

Most of the time, my friends didn’t want to go to the counselors either. So we ended up just being there for each other and just trying to solve each other’s problems or give each other advice. So I just realized maybe I should seek this in a professional way.

Destiny, a 33-year-old counselor educator, supervisor, and clinician, reiterated this point, noting that she had “this compulsion to kind of really help people, to really just talk, and recognizing that . . . my empathy was so innate, and just other effective qualities that you would consider to be associated with a counselor.”

The contributors to this study also clearly valued equity and justice for individuals and communities, which guided their personal and professional convictions and ultimate decisions to become counselors. One example of this is from Aisha S., a 36-year-old counselor educator and supervisor. She described her motivation to be a counselor as being connected to a greater purpose, sharing, “What else stood out for me from those experiences that made me consider professional counseling . . . was being able to . . . think about how I can engage in advocacy efforts at the local level, at the grassroots level.”

Ada, a 28-year-old counselor and counseling doctoral student, shared a similar narrative that centered justice and equity as salient forces among her personal and professional convictions:

I think because I’ve been in that situation where . . . I’ve had to deal with microaggressions or . . . just flat out . . . ignorance, I think that those experiences, along with my own personal therapy, have helped me to pause and think about areas that I am privileged. . . . I don’t have to worry about being deported. I don’t have any disabilities. So, like, I don’t have to constantly think about things like, does this place have an elevator? Or, does this place, like, have a ramp or something like that?

     This presentation of a grounded theory explaining why a sample of Black people chose to become professional counselors illustrates the complex and interacting variables that influenced their career choice. It provides our profession insight into how we might continue to attract, retain, and support more diverse people entering the profession and hopefully experiencing career satisfaction.

Discussion

Our study sought to answer a critical question: What motivates Black people to become professional counselors? The findings of the study suggest a confluence of experiences, influences, and variables that led this group of Black people to ultimately join the profession. By leveraging concepts from two theories (i.e., CRT and Theory of Nigrescence), we discovered the salient reasons for 28 Black people to become professional counselors. Three explicit factors lent themselves to the development of a grounded theory that will hopefully engender further study. We offer an account of the ways the findings complement and/or challenge past findings on this issue, and present potentially new insights.

The challenging cultural mandates and Black (under)representation factors specifically address how our research base has informed counselors about Black people’s experiences with counseling and allied mental health professions. The contributors shared the ways systemic, individual, and/or internalized racism has influenced their experiences in and with counseling. Their responses explicitly align with tenets of CRT (Delgado & Stefancic, 2001). The contributors’ various accounts of experiences with racism in several forms (e.g., microaggressions, being tokenized, being excluded) reiterate all the ways in which racism is an intrusive force in the lives of Black and other people of color in the United States (McGee & Stovall, 2015). The counseling profession is at a crossroads with determining training standards and the ways that those training standards will prepare counseling students to meet the needs of diverse clients (CACREP, 2023; Hannon et al., 2023). The sociopolitical climate in the United States continues to be tenuous given anti-Black legislation in states like Florida and North Carolina that is outlawing teaching courses about Black people’s history and diversity, equity, inclusion, and belonging for university faculty and staff.

The personal and professional convictions factor offers potentially new insight about how salient the contributors’ values are for deciding to become counselors. The contributors’ decision to become counselors was a result of their altruistic dispositions and their commitment to justice and equity, factors that may assist professional counselors to inspire others to envision counseling as a catalyst for justice for Black people and people from other marginalized groups. These values are congruent with our various codes of ethics (American Counseling Association, 2014; National Board for Certified Counselors, 2023) and the Multicultural and Social Justice Counseling Competencies (Ratts et al., 2016). These specific motivations align closely with what has been reported about why some Black people chose to become nurses, citing a calling (Anonymous, 2008). Further, we tentatively assert the connection of this finding with Cross and colleagues’ (1991) Theory of Nigrescence. We believe that there may be a connection between what stage of racial identity development Black people are functioning from (i.e., pre-encounter, encounter, immersion/emersion, internalization) and their willingness to make choices that reflect their altruistic dispositions and justice values. There are two points of inference worth raising here. First, the contributors to this study explicitly and implicitly made mention of their own racial identity development being closer to the internalization stage when deciding to become a counselor, and we associate that with their inclination to advocate for and pursue justice for themselves and their communities. We wonder if a more mature racial identity development is a predictor of choosing to become a counselor among Black people. Second, the contributors discussed various forms of racism that they experienced in their preparation programs and how, at times, it prompted them to assess where they were in their racial identity development (e.g., operating from an internalization paradigm and moving to an immersion/emersion paradigm depending on the type or form of racism experienced).

The findings also complement prior studies about the career development of Black people in general (Bell, 2018; Byars-Winston, 2010; Byars-Winston & Fouad, 2006), and specifically about counselors (Branch, 2018). It also aligns with the salience of race in career choice and decision-making. The contributors to this study explicitly mentioned that race was an influence (e.g., Black [under]representation) and that their experiences in and with counseling were influenced by their racial identity, illuminating the relevance of CRT (Delgado & Stefancic, 2001; McGee & Stovall, 2015) and Cross et al.’s (1991) Theory of Nigrescence. Branch (2018) indicated that the most salient reason why a sample of Black men became counselors was because of prior positive experiences with Black male counselors (e.g., informal relationships, mentoring relationships, treatment). The study contributors’ negative counseling experiences and their relationships with their adult senior influencer demonstrated how their racial identity significantly impacted their career choices and overall professional development.

Implications
     We believe the results from our study can inform the ways that our profession engages with, attracts, supports, retains, and invests in Black counselors. What follows is a presentation of the implications of these findings within two specific contexts: 1) counselor education programs and 2) counseling practice. Counselor education programs must commit to increasing Black representation in their programs by taking explicit steps to challenge admission requirements found to be culturally biased and engage in bolder and more innovative recruitment and retention/support efforts (e.g., agreements with historically Black colleges and universities, predominantly Black colleges and universities, and/or minority-serving institutions) for Black students enrolled in their programs. Counselor education programs can intentionally engage with undergraduate student organizations to further orient potential Black applicants to the counseling profession at large. This research indicates that Black representation is essential in encouraging and promoting mental health services and wellness for Black people. Black representation also encourages Black people to join the profession, a factor that counseling institutions should acknowledge and utilize. An increase in Black representation in counseling programs provides the rationale to engage counseling students in the reflective work that helps them become clearer about their own racial identity development, their own assertions about the influence of race and racism on their own and clients’ lives, and their own career development trajectory. This can be exceptionally helpful in didactic instruction and individual and group supervision.

Finally, the results of our study affirm the need for the counseling profession to continue acknowledging the importance of collaboration between counseling organizations that have different but complementary roles. For example, professional counseling organizations composed of primarily White members should prioritize endorsing and collaborating with professional counseling organizations whose missions and membership are primarily Black (e.g., National Association of Black Counselors, African American Counseling Association, Black Mental Health Symposium). These demonstrations of solidarity, partnership, and membership communicate clear support for such organizations and reiterates the importance of Black counselors identifying pathways for Black clients to culturally affirming and culturally relevant mental health care. Further, the relationships between counselor preparation programs and professional counselors must continue to be mutually beneficial. Practicing counselors are best positioned to inform and advise on community and client needs, given their important role in rendering services. Leveraging the insights of professional counselors to inform counselor education and research is paramount to treating clients in culturally relevant and responsive ways.

Limitations
     We acknowledge the privilege that we have in conducting this study and the responsibility of sharing the results for the professional counseling readership. Likewise, we assume responsibility for sharing how the study is limited. One way is in the homogeneity of the sample. We recruited professional counselors who were Black, and the overwhelming majority of them were Black American, female, monolingual counselors. Although our contributors’ voices and experiences are critical for this discourse, a more diverse sample of Black counselors (e.g., Afro-Latine, continental African, Afro-Caribbean, bilingual and/or multilingual Black counselors) could possibly enrich the findings. This translates into another study limitation, which is the limited extent to which findings are transferable, given both the sample size and lack of ethnic diversity (Creswell & Poth, 2016). A third potential limitation is researcher bias. Although we attended to potential bias through trustworthiness strategies such as member checking, investigator triangulation, consensus coding, and research team debriefs, we acknowledge the intimate relationship we all have with this topic and the potential for our biases to influence our interpretations.

Future Research
     Counseling researchers should invest more time in learning and sharing about why people choose counseling as a profession, particularly those people who have been historically excluded from the profession for a variety of reasons. Additional studies about why a wider range of people with intersecting and/or other marginalized identities choose to become counselors can enrich our literature and counseling profession at all levels (e.g., students, practicing counselors, counselor educators). For example, Black counselors who are multiracial, are immigrants, and/or speak multiple languages might have very different reasons for joining the profession than Black American counselors. The results from such studies will assist the profession to work from an evidence base to develop programs, interventions, and other forms of support to attract a more racially diverse workforce. Results from these types of studies will allow our profession to develop applicable career development theories that specifically study the lived experiences of Black people and people from other marginalized groups and address their career needs.

Conclusion

This study and its results can continue to assist our profession to exist as the just, inclusive, and affirming profession we aspire for it to be. Actualizing the courage to empirically investigate the reasons Black and other socially, economically, and linguistically diverse people choose to become professional counselors can only benefit our preparation programs, our practicing counselors, and our ever-evolving research base. We maintain hope for the profession’s future to live out our code of ethics (ACA, 2014) in this regard. This is just one step in our effort to sound the clarion call for professional counseling to understand the impact of Black counselors in the field and the importance of institutions (e.g., colleges, universities, professional organizations) having social, cultural, economic, linguistic, and gender diversity among their staff. We trust this contribution moves us to even more action.

 

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest.
This study was funded by an Association for
Counselor Education and Supervision Research
Grant and Montclair State University.

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Appendix

Interview Protocol

Individual Interview Questions/Script
Thank you for agreeing to participate in this important study. If you remember, this study is designed to begin providing an empirical base for what factors motivate Black people to become professional counselors. Please note these interviews will be audio recorded. Do you have any questions before we begin? Please take your time in answering the following questions and please be reminded that you can skip any question and withdraw at any time.

All participants should be asked these questions:

Would you share with me what motivated you to become a counselor?

What about those experiences convinced you that professional counseling was a good fit for your career?

What did/do you find most helpful in your counselor training?

What did/do you find most challenging in your counselor training?

Are/were you one of few Black students in your counselor training program?

If so, what is/was that experience like for you?

If not, what is/was that experience like for you?

Do you believe you experienced/are experiencing anti-Black racism in your counselor training program?

If so, in what ways is this happening/did this happen?

If participant is/was a practicing counselor, please ask:

What is most rewarding for you as a Black practicing counselor?

What role, if any, do Black counselors have in helping increase Black representation in counseling?

Do you believe anti-Black racism exists in professional counseling? If so, in what ways?

Are you one of few Black counselors where you practice?

If so, what is that experience like for you?

If not, what is that experience like for you?

If participant is a counselor educator, please ask:

How long have you been a counselor educator?

What motivated you to become a counselor educator?

What role, if any, do Black counselor educators have in helping increase Black representation in counseling?

Do you believe anti-Black racism exists in counselor education? If so, in what ways?

Are you one of few Black counselor educators where you teach?

If so, what is that experience like for you?

If not, what is that experience like for you?

Please conclude all individual interviews with this question and information:

Is there anything else you’d like to share about your motivations to become a professional counselor that we haven’t discussed to this point?

Thank you for participating in this interview. Your insights are valuable. What you can expect now is for our research team to transcribe this interview, de-identify it, and send it to you for your review to confirm its accuracy. Our team will then begin our analysis and send you updates on our interpretations of what participants have shared. If you have any questions, please do not hesitate to be in touch with Dr. Hannon at hannonmi@montclair.edu.

Michael D. Hannon, PhD, NCC, BC-TMH, LAC (NJ), is an associate professor at Montclair State University. LaShawn M. Adams, MA, NCC, LPC (NJ), is a doctoral candidate at Montclair State University. Natalie Nieves, MA, NCC, LPC (NJ), is an instructor at Molloy University. Estefanie Ceballo, MSED, NCC, CCMHC, ACS, LMHC (NY), LPC (NJ), C-TFCBT, CCTP, is a doctoral candidate at Montclair State University. David Julius Ford, Jr., PhD, NCC, ACS, LCMHC (NC), LPC (NJ, VA), is an associate professor at Monmouth University. Linwood G. Vereen, PhD, LPC, is a clinical associate professor at Oregon State University. Correspondence may be addressed to Michael D. Hannon, 2114 University Hall, Department of Counseling, College for Community Health, Montclair State University, 1 Normal Avenue, Montclair, NJ 07043, hannonmi@montclair.edu.

A Phenomenological Exploration of Counselors’ Experiences in Personal Therapy

Dax Bevly, Elizabeth A. Prosek

Professional counselors may choose to increase self-awareness and/or engage in self-care through the use of personal therapy. Some counselors may feel reluctant to pursue personal therapy due to stigma related to their professional identity. To date, researchers have paid limited attention to the unique concerns of counselors in personal therapy. The purpose of this descriptive phenomenological study was to explore counselors’ experiences and decision-making in seeking personal therapy. Participants included 13 licensed professional counselors who had attended personal therapy with a licensed mental health professional within the previous 3 years. We identified six emergent themes through adapted classic phenomenological analysis: presenting concerns, therapist attributes, intrapersonal growth, interpersonal growth, therapeutic factors, and challenges. Findings inform mental health professionals and the field about the personal and professional needs of counselors. Limitations and future research directions are discussed.

Keywords: professional counselors, self-awareness, self-care, personal therapy, phenomenological

Self-awareness is a fundamental part of the counseling profession. Not only do professional counselors seek to increase the self-awareness and personal growth of their clients, but counselor educators call upon counselor trainees to increase their own self-awareness before entering the field (Council for the Accreditation of Counseling and Related Educational Programs [CACREP], 2023, Section 3A11). Additionally, counselor educators often recommend self-growth experiences such as personal counseling to increase counselor trainees’ self-awareness in preparation for professional practice (Remley & Herlihy, 2020). Several scholars define counselor self-awareness as the mindfulness of thoughts, feelings, and behaviors in the self and in the counseling relationship (Fulton & Cashwell, 2015; Merriman, 2015; Rosin, 2015). Pompeo and Levitt (2014) asserted that self-awareness parallels awareness of personal values and enables counselors to explore best practices in counseling. However, after training, it becomes less clear how, if at all, counselors access their own counseling for self-growth and self-awareness; therefore, we designed the current study to explore how practicing counselors utilize personal therapy.

Correlates of Self-Awareness Among Counselors
     Counselor self-awareness relates to awareness of the counseling relationship, which is helpful to client satisfaction and growth (Pompeo & Levitt, 2014); as such, several researchers have examined the clinical implications of counselor self-awareness, including professional competence, client treatment outcomes, and wellness. For example, Rake and Paley (2009) found that the therapists in their study reported modeling themselves after their own therapist as well as learning about technical aspects of a therapeutic approach. In regard to wellness, Gleason and Hays (2019) found that counselor self-awareness helped identify stressors and needs regarding personal wellness in doctoral-level counselor trainees. Similarly, Merriman (2015) discussed how self-awareness can help prevent burnout or compassion fatigue. Many researchers have investigated the importance of self-awareness as a characteristic of counselors who can competently work with culturally diverse clients (Ivers et al., 2016; Sue et al., 2022). Thus, some evidence of the clinical impact of counselor self-awareness already exists in the literature.

Expanding upon the impacts of self-awareness on the therapeutic relationship, Anderson and Levitt (2015) articulated the importance of self-awareness in how counselors’ social influence impacts the working alliance. Additionally, Tufekcioglu and Muran (2015) described how the working alliance provides a laboratory wherein the client can focus on and more clearly delineate their experience in relation to the therapist’s experience. Thus, the counseling goal of cultivating mindfulness in clients with respect to the details of their own experience involves counselors becoming mindful of the corresponding details of their own experience. Tufekcioglu and Muran argued that every encounter with a client demands the counselor’s self-reflection in the form of greater self-awareness in relation to the working alliance, and maintained that the therapeutic process should involve change for both participants.

Counselors Seeking Mental Health Care
     Counselors can gain self-awareness in a variety of ways, including personal therapy. Mearns and Cooper (2017) stated that the term therapy loosely signifies the receiving of mental health services from any mental health professional who holds a license to practice. We use the word therapist in reference to researchers who did not specify the type of mental health professional (e.g., counselor, psychologist, social worker) who provided therapy to the participants in their study. Several scholars have suggested that therapists who participated in their own personal therapy experienced increased professional development as well as positive client outcomes. For example, VanderWal (2015) found that clients of counselor trainees with personal therapy experience demonstrated reduced rates of distress more quickly than clients of counselor trainees without personal therapy experience. Other researchers have noted the impact of therapy on therapists’ personal growth. Although not specific to professional counselors, Moe and Thimm (2021) conducted a systematic review of the literature regarding mental health professionals’ experiences in personal therapy and discovered benefits related to genuineness, empathy, and creation of a working alliance. Outcomes of this previous research support the positive impact of personal therapy for therapists.

Some counselors may seek personal therapy due to mental health concerns. Therefore, it is worth exploring the needs of this unique population. In one study, Orlinsky (2013) reported that therapists’ most frequently cited presenting concerns were resolving personal problems. Additionally, Moore et al. (2020) reported that counselors experienced interpersonal stress as a response to threatening situations in their clinical work and, in order to cope, neglected their own personal needs. Other investigators found a relationship between higher rates of ethical dilemmas in clinical practice and increased stress and burnout among counselors (Mullen et al., 2017). Robino (2019) introduced the concept of global compassion fatigue, a phenomenon wherein counselors experience “extreme preoccupation and tension as a result of concern for those affected by global events without direct exposure to their traumas through clinical intervention” (p. 274). In this conceptual piece, Robino summarized the literature findings on how indirect exposure of distressing events impact the mental well-being of professional helpers and advocated for the role of self-awareness as an important coping skill. Furthermore, Prosek et al. (2013) found that counselor trainees presented with elevated levels of anxiety and depression, providing further evidence that counselors are at risk for mental health concerns related to occupational and personal stressors.

Purpose of the Study
     The psychological needs of counselors coupled with the emphasis on gaining self-awareness highlight the necessity for counselors’ personal therapy. Self-awareness is an important component of counselor development due to the personal nature of the profession (Pompeo & Levitt, 2014; Remley & Herlihy, 2020). Personal therapy is one way to enhance counselor self-awareness (Mearns & Cooper, 2017). Additionally, counselors may experience a variety of mental health concerns, including compassion fatigue, interpersonal conflict, depression, and anxiety (Moore et al., 2020; Mullen et al., 2017; Orlinsky, 2013; Prosek et al., 2013; Robino, 2019). Researchers have primarily focused on the perceived outcomes of personal therapy, including personal growth, professional development, and positive client outcomes (Moe & Thimm, 2021; VanderWal, 2015). However, scarce research exists regarding counselors’ decision-making processes in seeking personal therapy. Thus, if counselors could benefit from personal therapy, and if little knowledge exists regarding how counselors decide to seek personal therapy, professional counselors, counselor educators, counselor supervisors, and other mental health providers have limited information regarding how to facilitate that decision-making process.

Researchers employing qualitative investigation typically seek to holistically understand meaning. More specifically, the goal of a phenomenological approach is to capture the experiences and meaning-making from the participants’ perspectives (Creswell & Creswell, 2017). We want to illuminate how professional counselors make meaning of their experiences in personal therapy, as much of the existing literature focuses on trainees, clinical outcomes, or quantitative data. We believe describing the lived experiences, or essence (Moustakas, 1994), of counselors receiving personal therapy may lead to a deeper body of research regarding the perceptions, emotions, and behaviors of this population. The following questions guided our inquiry:

  1. What contributes to counselors’ decisions to seek personal therapy?
  2. How do professional counselors make meaning of their experiences in utilizing
    personal therapy?

Method

Phenomenologists seek to understand the distinctive characteristics of human behavior and first-person experience (Hays & Singh, 2023). Based on an existentialist research paradigm, we wanted to understand how counselors make meaning of their experiences in personal therapy. Because we aimed to describe the lived experiences of counselors receiving personal therapy, descriptive phenomenology answers the research questions appropriately (Prosek & Gibson, 2021). Consistent with descriptive phenomenology, we used Miles et al.’s (2019) adaptation of classic data analysis, an inductive–deductive approach.

Research Team and Reflexivity
     At the time of data collection (pre–COVID pandemic), Dax Bevly, who identifies as a White, Latina cisgender woman in her late 20s, was completing a doctoral degree in counseling. Elizabeth A. Prosek, who identifies as a White, cisgender woman, brought experience in conducting, teaching, and mentoring qualitative research studies. Bevly utilized a research team for data analysis that included four women in their early 20s completing master’s degrees in counseling; three identified as White and one identified as Asian. As instruments in the research themselves, the team needed to embrace their potential influence and impact (Hays & Singh, 2023); therefore, Bevly and Prosek participated in research reflexivity meetings several times during data collection and analysis, where they discussed thoughts and emotions evoked through their participation in the study. Descriptive phenomenology requires researchers to establish epoche, an exchange of assumptions that can be held accountable to bracket or identify throughout the process. Our research team demonstrated epoche by journaling and discussing biases and assumptions regarding the present study throughout the data analysis process. Bevly in particular was especially aware of her own personal biases due to long-term participation in personal therapy, believing it to have highly influenced her personal and professional development in a positive way. Bevly consulted with the research team as we examined experiences, reactions, and any assumptions or biases that could interfere with the coding process during data analysis. The research team members held Bevly accountable for her responses to the research process (Creswell & Creswell, 2017). The four other members of the research team also engaged in the examination of their experiences, reactions, and assumptions or biases during analysis, reporting assumed benefits including increased awareness, higher functioning in relationships, and increased self-esteem. Bevly also utilized the research team for the purpose of engaging in critical discussion during the analysis process in order to develop a trustworthy study. Furthermore, Bevly and Prosek kept a journal in order to document the research team members’ bracketing throughout the study. The journal also noted the connection and validation that Bevly experienced in interviewing participants and the care and mindfulness to not insert her personal experiences, especially regarding the overlapping roles of client and counselor as well as feelings of vulnerability.

Procedure
     We obtained IRB approval before participant recruitment. Eligibility for the study included identifying as a licensed professional counselor (LPC) aged 18 or older who utilized counseling services with a licensed mental health therapist either currently or within the previous 3 years (similar criteria to Yaites, 2015). We used purposive sampling to select participants for this phenomenological study (Hays & Singh, 2023), recruiting participants through email, word of mouth, and networking with LPCs in a 50-mile radius of our institution, which is located in a large state in the Southwestern United States. This radius allowed us to intentionally reach more diverse areas of the geographical region. We also recruited participants through personal contacts and professional counseling organizations. Potential participants completed an eligibility online survey via Qualtrics. We contacted them via phone or email to explain the study and confirm their eligibility. We excluded participants who reported holding expired LPC licenses, experienced therapy more than 3 years ago, or described personal therapy from an individual without a license in a mental health profession. We scheduled face-to-face meetings with participants in their professional counseling office at their convenience. Although participants read and acknowledged the informed consent before meeting face-to-face, we readdressed informed consent before proceeding. Bevly conducted and audio recorded 60-minute interviews with each participant. At the conclusion of each interview, Bevly also facilitated a sand tray activity with the participant.

Participants
     We recruited participants based on gaining depth with adequate sampling (Prosek & Gibson, 2021). Participants (N = 13) identified mostly as White, cisgender women with an average age of 37.23; see Table 1 for complete demographics. Although we sought to recruit participants with diverse social identities, geographic limitations presented a challenge. Thus, our findings should be interpreted with caution, as the external validity, or generalizability, of the findings to other populations or different contexts is impacted by the limited diversity among our participant demographics. Lastly, we asked participants to choose pseudonyms in an effort to protect their anonymity and confidentiality.

Data Sources
Demographic Form
     In order to determine eligibility and collect demographic information, we asked potential participants to complete a Qualtrics survey, an online initial screening tool that included questions about age, gender, racial and ethnic identification, sexual orientation, religious/spiritual identity, number of personal therapy sessions completed, length of time since termination of personal therapy (if applicable), number of years as an LPC, disability status, licensure of therapist, therapist demographic information, and whether or not their counseling training program required personal therapy. The online demographic survey also included information about informed consent and confidentiality. Although it was not required for the study, all participants reported that therapy took place face-to-face. 

Table 1
Participants of the Study

Participant Age Race/Ethnicity Gender Religious/Spiritual Affiliation Sexual Orientation
Alma 37 Latina Woman Christian Heterosexual
Amy 30 Latina Woman Christian Heterosexual
Ashley 29 Multiracial Woman Spiritual Heterosexual
Betty 55 White Woman None Heterosexual
Elenore 30 Multiracial Woman Christian Queer
Felicity 44 White Woman Christian Heterosexual
Jennifer 40 White Woman Christian Heterosexual
Liz 35 White Woman Pagan Bisexual
Lynn 48 White Woman Christian Heterosexual
Michelle 37 White Woman Christian Heterosexual
Rose 30 White Woman Christian Heterosexual
Sophia 35 White Woman None Heterosexual
Thomas 34 White Man None Heterosexual


Semi-Structured Interview Protocol
     We developed a semi-structured interview protocol to guide the interviews. We drafted the questions based on existing literature concerning counselors and personal therapy. The protocol consisted of six open-ended questions and follow-up prompts to understand the experiences of professional counselors who have engaged in personal therapy (see Table 2).

Table 2
Interview Protocol

Grand tour question:
Please tell me about your experience in personal therapy in as much detail as you feel comfortable sharing.
            Follow-up:

What motivated you to seek personal therapy?

What was happening in your life at the time?

How did you go about selecting a therapist?

Can you tell me about what your internal process (thoughts/feelings) was like leading up to your decision to seek personal therapy?

What outcomes did you experience as a result of personal therapy?
How, if at all, has personal therapy affected your personal growth?
How, if at all, has personal therapy affected your own clinical work?
Describe the experience of being both a client and a counselor.

Some literature suggests that counselors feel stigmatized when seeking personal therapy. What do you make of this? How is that similar or different for you?

Is there anything else that you would like to share?

 

Sand Tray Activity
     Hays and Singh (2023) stated that “visual methods in general provide participants the opportunity to express themselves in a nonverbal manner that may access deeper aspects of their understanding and/or experience of a phenomenon” (p. 332). After the semi-structured interview, Bevly invited participants to create their personal therapy experience in a sand tray using the figures and materials provided. This method is consistent with Measham and Rousseau (2010), who used sand trays as a method of data collection for understanding the experiences of children with trauma. The sand trays were documented by digital photos (see Appendix), and participants’ discussions about their creations are part of the audio recordings.

Data Analysis
     We sent the audio recordings to a professional transcriptionist for transcription of each interview and sand tray session. We reviewed transcripts while listening to the recordings for participants’ tone and to verify accuracy. Consistent with phenomenological procedures, the research team conducted data analysis according to an adaptation of classic analysis (Miles et al., 2019), in which three main activities take place: data reduction, data presentation, and conclusion or verification.

Prior to initial coding, the research team completed several tasks in order to develop the preliminary coding manual: taking notes, summarizing notes, playing with words, and making comparisons (Miles et al., 2019). Taking notes involved the research team as well as Bevly’s own independent analysis of a subset of the first three interviews and sand tray explanation transcripts. We divided the transcripts into 10-line segments and wrote notes in the margins. The research team noted our initial reactions to the material.

Summarizing notes involved discussion between the team regarding our reactions to the interview material. We compared and contrasted our margin notes and highlighted shared perspectives and inconsistent viewpoints in a summary sheet. To play with words, we generated metaphors based on our summary sheet. We developed phrases that represented our interpretation of the participants’ interview responses.

During the making comparisons task, we compared and contrasted the key phrases developed in the previous step and grouped them into categories. The team then facilitated reduction of the data as we combined similar phrases and merged overlapping categories. Hays and Singh (2023) asserted the importance of sieving the data to eliminate redundancy. We continued to merge categories and reformat the category headings. From this process, we developed preliminary themes based on the data. To develop initial codes, we established agreement by independently applying the preliminary codes to a subset of three interviews. The research team met weekly to discuss inconsistencies and points of agreement, adjust the preliminary codes, and reapply them to the data subset. We continued to discuss any remaining discrepancies and concerns until we reached a mean agreement of 86% to 90% (Creswell & Creswell, 2017). We reached a mean agreement of 95.1% and then finalized the codes to use in our coding manual.

It is important to note that the research team sensed that we had reached saturation during the final coding process once we began to read the same comments repeatedly in the participant transcripts. In final coding, we applied the final coding manual to each of the interviews and sand tray explanations. We used the same coding manual for both the interviews and the sand tray explanations. The same research team member coded both the interview and sand tray explanation for the same participant. Bevly coded all 13 interviews and sand tray explanations; all four research team members coded the first three interviews and sand tray explanations. Two research team members coded interviews and sand tray explanations 4 through 8, and the other two research team members coded interviews and sand tray explanations 9 through 13. The research team’s finalized codes included the meaning and depth of participants’ experiences in personal therapy. However, if necessary, researchers could still recode during final coding to maintain consistency with the revised definitions (Creswell & Creswell, 2017). When recoding occurred, we reviewed previously analyzed transcripts with the updated codebook on four occasions. Once we completed final coding, Bevly performed member checks with the participants.

Establishing Trustworthiness
     To develop trustworthiness in qualitative research, Lincoln and Guba (1985) presented four criteria: credibility, transferability, dependability, and confirmability. We established credibility in this study through the use of research partners in debriefing, researcher reflexivity, and participant checks. Participant checks occurred after we completed final coding. In this process, we emailed all participants a summary of the identified themes and inquired if the summary portrayed an accurate representation of the experience. Nine out of 13 participants responded and informed Bevly that no adjustments were necessary because the summary adequately captured their experiences. The remaining four participants did not respond to the follow-up email. Additionally, we utilized researcher partners in debriefing and data analysis steps to strengthen the development of the coding manual. In relation to researcher reflexivity, we bracketed our experiences by reflecting on biases and assumptions as counselors who experienced personal therapy through journaling and discussing assumptions with each other, particularly those related to positive personal experience in our own counseling. We demonstrated transferability by openly and honestly providing information about the researchers, the proposed study’s context, the participants, and study methods. This transparency allows readers to have a sense of the context when interpreting findings. We achieved dependability through documenting each task that we completed for the study by keeping an audit trail, allowing for replication. Additionally, the use of multiple data sources, including the demographic survey, interviews, and sand trays, increased the complexity of analysis (i.e., dependability). Also, we provided an in-depth description of our methodology to increase dependability of the study, including information about sample size, data collection, and data analysis that the research team used. Lastly, confirmability was based on an acknowledgement that we, as the primary researchers, cannot be truly objective (Cope, 2014). However, we triangulated the findings using participant checks, consultation with colleagues, and research team consensus to facilitate confirmability.

Findings

The research team identified six major themes and 11 subthemes (see Table 3). The six major themes were: (a) presenting concerns, (b) therapist attributes, (c) intrapersonal growth, (d) interpersonal growth, (e) therapeutic factors, and (f) challenges. We present the subthemes in more detail in the following sections using participant data as supporting evidence.

Table 3
Themes and Subthemes 

Themes Subthemes
Theme 1: Presenting concerns Subtheme 1a: Mental health

Subtheme 2a: Life transitions

Theme 2: Therapist attributes Subtheme 2a: Practicality

Subtheme 2b: Quality

Theme 3: Intrapersonal growth Subtheme 3a: Cognitive

Subtheme 3b: Emotional

Theme 4: Interpersonal growth Subtheme 4a: Personal

Subtheme 4b: Professional

Theme 5: Therapeutic factors Subtheme 5a: Nurturing

Subtheme 5b: Normalization

Subtheme 5c: Vulnerability

Subtheme 5d: Transference

Theme 6: Challenges Subtheme 6a: Finances

Subtheme 6b: Stigma

Subtheme 6c: Role adjustment

 

Theme 1: Presenting Concerns
     Presenting concerns included participants’ thoughts and feelings prior to engaging in personal therapy. Participants shared their decision-making processes and motivations leading to the initiation of personal therapy. Participants described two subthemes that captured their motivation to engage: mental health concerns and life transitions. Mental health concerns represented grief, trauma, anxiety, depression, emotional dysregulation, and relational stressors. For example, Michelle shared:

I would say those were the times when it was like I was pulled to my end, and so the depression, it was like I needed something else more than just the regular support from family and friends and then the miscarriages. It was like I felt so isolated, and then with my dad dying it was like I, gosh, this is . . . it was like both of them dying so close together.

     Participants also described life transitions that served as motivation to engage in personal therapy, such as changes in relationships, careers, and living arrangements. As Lynn represented,

some of that was related to like, as a result of the divorce. I’ve moved three times in the past, like sold a house and moved out of it or kind of moved into storage while in that house in order to be able to stage it and sell it. Then out of the house into an apartment, out the apartment into a rent house. And so there’s been a lot of upheaval for me and for my child.

     Presenting concerns may also be interactional in nature. For some participants (n = 10), life transitions overlapped with their mental health concerns, such as a career change triggering anxiety. However, the remaining three participants cited either mental health concerns or life transitions as a reason for initiating personal therapy. All participants differentiated their experience of internal mental health distress and external life stressors.

Theme 2: Therapist Attributes
     As participants reflected on the different feelings and thought processes they experienced during the initiation of personal therapy, they also shared different attributes they looked for in a therapist. Two subthemes emerged: practicality and quality. Practicality involved factors such as location and affordability. Quality consisted of therapist credentials, training, experience, and specialty areas. All participants shared factors related to both subthemes, including Liz and Alma:

So I was like, “Okay. Well I know this person, I know this person, I know this one. Oh. I don’t know this person, okay. Let’s see if they have an opening.” I wanted someone that was close to my work because it’s easier for me just to go straight from work considering working at a hospital, I can work ridiculously long hours. Sometimes, you know, 12-hour days . . . so I needed someone in [city withheld], and I needed someone I didn’t know. (Laughs) And they took my insurance. (Liz)

I really wanted somebody who was not an intern and not a grad student. I need somebody who was fully licensed. I was looking for somebody who’d done their own work. I wouldn’t really know, but I can kind of tell. I was looking for somebody who had done their own work, their own process, and somebody who’d work with therapists. And so the first therapist that I found, she’d been a therapist for about 12 years. She had a successful private practice on her own. (Alma)

     Some participants (n = 8) prioritized affordability and location over other attributes, while other participants (n = 5) emphasized education, specialty area, and recommendations as their way of selecting therapists. Each participant highlighted their need for accessibility and a good fit into their hectic schedules and personal lives. Participants described these factors as a method of narrowing down the pool of possible therapists.

Theme 3: Intrapersonal Growth
     All participants expressed changes in thoughts related to self that were associated with increased perspective represented by the theme of intrapersonal growth and narrowed into subthemes of cognitive and emotional. Participants specifically reported cognitive intrapersonal growth through internal changes such as awareness, mindfulness, and a sense of purpose as outcomes of receiving personal therapy. Twelve participants described these cognitive changes as a positive experience. Jennifer described the experience as distressing due to the increased awareness of unpleasant knowledge of self and others:

I think a lot of self-awareness in the sense of why I function the way I function and an understanding of why, not only the why, but what I was needing and what I was seeking. And so, just a greater understanding of those pieces that I really had no awareness of before that. . . . I had a little awareness of it, I should say. I probably knew a little bit, but I don’t think I trusted myself in seeing that, trust in myself, trust in my intuition, and trust in my decision-making.

     All participants described emotional intrapersonal growth within themselves related to regulation, stability, and expression as a result of personal therapy. Participants reported a decrease in distressing emotion, increased attunement to their emotional well-being, and an increased ability to express emotions in a healthier manner. Additionally, participants experienced fewer negative feelings toward themselves, including Thomas, who shared, “Back then I was just hiding from a lot of pain. I was hiding a lot of pain. So now I’ve been able to work through that in therapy, I’m just more emotionally attuned in general.”

All participants expressed the overlap between cognitive and emotional intrapersonal growth; furthermore, participants explained how this intrapersonal growth that occurred as a result of personal therapy carried over into other relationships. Participants shared that these internal benefits influenced external factors in their lives. Thus, the theme of intrapersonal growth led directly into the fourth theme, interpersonal growth.

Theme 4: Interpersonal Growth
     All participants shared interpersonal growth, changes in relationships, and depth of social connection, both in their personal relationships and their professional relationships with clients. Participants reflected on how their growth affected relationships with romantic partners, family, friends, and clients. As a result, the two subthemes of personal relationships and professional relationships arose in the data, as expressed by Betty and Thomas:

I believe that it helped me connect with people on a deeper level. Because it’s hard to empathize or connect with someone if you can’t feel yourself. ‘Cause if you can’t feel yourself, you can’t feel what they’re feeling either. So, with my kids, I would be able to first of all, set firmer boundaries with them. And they would take me more seriously. And I’ll then also be able to connect more. And in another area, I was able to learn to ask for help. . . . instead of trying to always take care of things and handle things by myself, and to actually feel safe enough to ask for help. (Betty)

I could empathize. I could play the role of counselor and do my job, but I wasn’t doing it, like “for real for real” . . . I was falling out of what I really needed to be doing, and now I’m able to sit with clients, and every now and then my mind wanders to “oh, I gotta do this or that,” but I’m quick, I become aware of it more quickly, and I’m able to feel deeply with clients. . . . I have sessions all the time now where I’m tearing up with my clients and just feeling so moved by them. And also, I cry more in my personal life and professional life. (Thomas)

     Twelve participants experienced their interpersonal growth as helpful in alleviating their presenting concerns. The remaining participant described the interpersonal growth as tense and uncomfortable. All participants explained that their interpersonal growth in personal relationships was connected to interpersonal growth in professional relationships with their clients. For example, increased boundaries with family extended to increased boundaries with clients. Participants shared that the relationship with their therapist acted as a surrogate for relationships with other people in their lives, which emerged in the therapeutic factors theme.

Theme 5: Therapeutic Factors
     All participants reported avenues of healing within the context of the therapeutic alliance that led to the changes in self and in relationships. Participants reflected on how engaging in the relationship with their therapist facilitated their intrapersonal and interpersonal growth. This theme included four subthemes: nurturing, normalization, vulnerability, and transference. Seven participants described their therapist as nurturing or felt nurtured throughout the process of personal therapy. Participants reported that nurturing meant feeling safe with, trusting of, and cared for by their therapist. This atmosphere of nurturing helped participants foster the courage to take risks without fear of judgment or criticism, as expressed by Jennifer:

I felt prized, and loved, and 100% accepted. And nothing was abnormal or weird, like, what I shared. . . . her response was always super supportive. . . . My schedule was really odd, and so she made it work for my schedule. So, sometimes we met at 7:30 in the morning. Which I really appreciate. Sometimes we met at 8:00, sometimes we met at 2:00 in the afternoon . . . and I never felt like that was a burden . . . she never made it sound like I was burdening her . . . and I’m super appreciative for that.

     All participants reported that their therapist, in different ways, normalized their experience. Many participants (n = 12) believed something was atypical or flawed about their personhood for needing personal therapy. Receiving help triggered feelings of stigma, self-rejection, or self-criticism. Thus, a large part of participants’ healing process was feeling normalized by the therapist. Thomas shared:

There’s even been times when I’ve asked her, like, “do I fit a diagnosis? Like, what’s wrong with me?” You know, there’s even been times when I’ve kind of demanded from her, like “what, what’s the deal? I’ve been seeing you for 2 years, tell me what’s wrong with me.” And she won’t do it. She will not do it, and she’s just like, “No, that’s not what I do.” And so that’s helped me immensely. She’s like “everything you’ve told me, every, everything fits.” And it’s helped me to see it that way.

     Participants also reported feeling vulnerable as the client and described the feeling of opening themselves to the presence and feedback of another as uncomfortable but also inducing growth. Participants described this level of vulnerability as it related to their counselor identity; they explained that they were most accustomed to structuring the session and managing the time and felt more comfortable in the therapeutic relationship in the role of counselor. As the client, participants experienced a new kind of vulnerability that led to intrapersonal and interpersonal growth due to the reversed power differential, as described by Betty:

When I’m the client, it’s like, “I don’t know where we’re going, I don’t know what’s gonna come up.” It’s kind of scary sometimes. Like you know? He’s the guy with the flashlight, and I don’t know where he’s, what’s gonna happen sometimes. Like what’s going to get uncovered, [what] I’m suddenly gonna become aware of or feel, or something. So it’s a little scary.

     Several participants (n = 9) shared that healing occurred as a result of therapeutic transference in the relationship with their therapist. Participants reported perceiving the therapist as a significant relationship in their life, sometimes describing their therapists as a parental presence. At times, the therapists themselves were the healing catalyst, acting as a substitute for redirecting emotional wounds. This subtheme also encompassed feelings of attachment. In many cases, participants’ early attachment figures were either emotionally or physically unavailable or harmful. Participants explained that their therapists acted as a healthy attachment figure and described this aspect of the relationship as reparative. Some participants shared feeling re-parented by their therapist, like Michelle:

She probably was the age of my mom at the time, and so I felt very nurtured by her in a way that, like I always wanted to be nurtured by mom but it hadn’t happened like that. . . . I mean, there was that transference kind of feeling that was happening, but it was very positive and she was very warm, and I feel like that relationship was so healing and allowed me to process through more things, feeling supported and encouraged by someone who is kinda like my mom but not my mom, almost like it was like a reparative thing within the relationship.

Theme 6: Challenges
     Two participants shared that personal therapy was a purely positive experience without negative or uncomfortable feelings. However, 11 participants reported challenges during the course of therapy that inhibited their healing processes. These challenges included three subthemes: finances, stigma, and role adjustment, as explained by Felicity, Michelle, and Rose:

Um and then I kind of thought I was done and then I realized it was like, okay I have to add the money aspect, because every time I’m just like ugh, because I am perpetually broke. And so, I added the money like off to the side just like it’s not really part of the process but it’s this thing that exists that I can’t erase. (Felicity)

There is a stigma like that if you need to go see someone that you’re somehow like inadequate to deal with your own stuff, or that you’re crazy or that you’re really far gone, like only people who are really far gone need to do that, but I still think it’s a pride thing, you know? (Michelle)

It’s weird and it’s distracting as a client because . . . I know what she’s doing. Why is she doing that? Huh. Like it’s a good place to run to if you don’t want to go where they’re trying to take you; you can go into your analytical, left brain, logical mode. Oh, I know exactly, and you feel like an expert. You know what they’re doing. They’re not pulling it over on you. (Rose)

     Five participants discussed the idea of stigma related to their counselor status. The remaining participants (n = 9) explained that they did not personally feel stigmatized, but were aware of the stigma that existed with regard to counselors who receive personal therapy. All participants shared that they would attend personal therapy longer or more frequently if not for financial barriers. Additionally, each participant described the difficulty of experiencing the identity of both client and counselor.

Discussion

We aimed to answer two overarching research questions: 1) What contributes to counselors’ decisions to seek personal therapy? and 2) How do professional counselors make meaning of their experiences in utilizing personal therapy? The results of the current study are both similar and contradictory to previous literature. For example, many researchers have demonstrated evidence of counselor burnout and compassion fatigue (Moore et al., 2020; Robino, 2019; Thompson et al., 2014). Participants described feeling burned out and lacking in empathy as motivations to seek personal therapy. Additionally, Day and colleagues (2017) outlined behavioral symptoms of burnout and compassion fatigue, including mood changes, sleep disturbances, becoming easily distracted, and increased difficulty concentrating. Many participants shared similar symptoms when discussing thoughts and feelings in their decision-making processes to initiate personal therapy, as well as when describing their mental health concerns. Therefore, it is important to assess counselors for levels of burnout and compassion fatigue in addition to raising awareness of their signs and symptoms.

The subtheme of stigma in participant voices within the current study is consistent with the existing literature. Kalkbrenner et al. (2019) found that stigma was one of three primary barriers to counseling among practicing counselors and human service professionals. Participants in our study described the general stigma and personal shame in seeking mental health treatment. Furthermore, participants differentiated between general stigma regarding mental health and stigma specific to counselors. Based on this finding, counselors may experience greater stigma than the general population when seeking personal therapy due to their professional identity. We would also like to note the research team’s personal reactions of feeling affirmed and normalized, as we had all experienced some level of stigma in seeking our own therapy—hearing and reading the participants’ experience of stigma created increased feelings of universality among our team.

With regard to theories about the working alliance, Mearns and Cooper (2017) described the notion of working at the intimate edge of the ever-shifting interface between client and counselor, referring to both the boundary between self and other and the boundary of self-awareness. Most notably in our study, the subtheme of professional interpersonal growth illuminates how the self-awareness gained in therapy impacted participants’ clinical work, supporting the working alliance theory, outlined by Mearns and Cooper (2017), which posits that expanding self-discovery and becoming more intimate with one’s own experience through the evolving relationship with the other increases intimacy in interpersonal relationships as one becomes more attuned to the self.

Aligned with the concept of professional growth, many researchers have emphasized that personal therapy was an educational or training experience for therapists and added to their professional repertoire of knowledge and skills (Anderson & Levitt, 2015; Moe & Thimm, 2021). However, these findings are not congruent with the experiences of participants in the present study. Although participants reported enhanced professional growth in terms of boundaries with clients and professional advocacy outside of the therapeutic relationship, participants shared that the intellectual aspect of personal therapy within the relationship served as a barrier to the healing process. All participants expressed a desire or intent to release themselves of their counselor identity while experiencing the client role. Thus, some counselors may not see personal therapy as a means for education or professional role modeling and instead find those aspects as distracting to the experience. It is also interesting to note that our research team’s perspectives mirrored this varied experience; through our journaling and discussion, we acknowledged that some research team members shared the experience of participants in our study, while other members felt more similarly to the preexisting literature’s conclusions.

Limitations and Future Research
     The current study includes many strengths, such as the rigor we followed and trustworthiness we demonstrated. However, some limitations exist. Firstly, we collected data prior to the pandemic; a replication study post–COVID-19 could shed light on specific factors related to how the pandemic has impacted counselors’ experiences in personal therapy. Additionally, we used a single interview design, which limits the amount of extended field experience with participants. Participants may have offered more intimate and sensitive information after spending more time in the interviewing process. Due to the sensitive nature of the topic of the study, we worked to establish trust and build rapport with the participants by using introductory questions at the beginning of the interview. Researchers may collect richer data through the use of longitudinal studies that examine participants’ experiences in personal therapy over time and with other data sources. Despite plans to recruit a sample that was diverse in terms of age, gender, ethnic identification, sexual orientation, and religious/spiritual orientation, participants in this study were similar to each other. Only one participant identified as a man, and the majority of participants (n = 9) were White. We attempted to rectify the above limitations through networking with licensed professional counselors who worked in a variety of counseling settings. However, future researchers could examine the experience of counselors who identify as men or non-binary, as well as counselors of color.

Implications for Counselors
     The knowledge gained from our study offers both suggestions for how clinicians can approach counselors in personal therapy and broader advocacy for the profession to increase engagement in counseling. In terms of clinical practice, participants often emphasized the struggle in assuming the client role, as they were most comfortable with the typical power differential in their professional work. This phenomenon was especially salient in the participant voices of this study; vulnerability and role adjustment were crucial themes of their experience. Therefore, it may behoove clinicians to maintain awareness of this possibility or discuss it within personal therapy. For example, Moore et al. (2020) suggested engaging in conversations about interpersonal stress, self-care, and burnout within the supervision relationship; however, we purport that clinicians of clients who are also counselors could facilitate intentional space to address these issues in counseling. That being said, mental health professionals may find benefit in balancing attending to the person of the counselor with focus on professional identity due to the barrier of role adjustment presented in this study. Neswald-Potter and colleagues (2013) suggested the use of the Wheel of Wellness Model developed by Witmer and Sweeney (1992) to facilitate an integrated approach in promoting wellness in counselors: spirituality, self-direction, work and leisure, friendship, and love. Finding meaning in all life tasks could assist clinicians in balancing professional and personal concerns in working with counselors as clients. Wellness is often associated with self-care practices in counseling.

Self-care is not a novel topic of discussion in counselor training or professional practice. However, in light of this study’s findings, we aim to describe therapeutic interventions for mental health professionals who may have counselors as clients. Coaston (2017) summarized much of the literature on self-care for counselors and recommended several strategies for interventions in three main areas: mind, body, and spirit. Concretely, interventions may include mindfulness, boundary setting, time management, cognitive reappraisal writing activities, stretching, moral inventory, and listing life principles (Coaston, 2017; Posluns & Gall, 2020). Finally, Bradley et al. (2013) outlined a variety of creative approaches to counselor self-care, as well as facilitative questions that may lend well to opening dialogue in a therapy session. Example questions include: (a) What are the indications that you are doing well and healthy? (b) Which things in the environment can be changed to help you continue to grow? and (c) Do you experience this emotion or pattern of emotions frequently? How did you respond? These suggested self-care interventions are only useful if counselors attend personal therapy, and in the results of our study, participants described how stigma remained a barrier.

Clinicians may consider normalizing thoughts and feelings related to stigma in order to encourage engagement in counseling. Sommers-Flanagan and Sommers-Flanagan (2018) defined normalization as the therapist’s use of indirect or direct statements that reframe client problems as contextual responses to the difficulties of life. Therapists use normalization to depathologize client concerns and convey implicit acceptance of the person of the client. Varying degrees of normalization skills include psychoeducation, reframing, and self-disclosure (Sommers-Flanagan & Sommers-Flanagan, 2018). Reducing the stigma of accessing counseling as a counselor may need to begin with normalizing it during training. Knaak et al. (2014) reported that the most effective anti-stigma interventions incorporate social contact, education, personal testimonies, teaching skills, and myth-busting. Therefore, creating space for anti-stigma interventions in professional development activities (e.g., conference presentations, continuing education sessions) as well as incorporating these strategies into counselor training (e.g., class or group supervision) may advocate for engagement in counseling across the counselor profession spectrum. Additionally, a follow-up study examining counselors seeking therapy to improve their own clinical efficacy with clients may also serve as a way to decrease stigma.

Lastly, we believe that the findings of our study support the need for and advocacy of personal therapy after graduate training. Unlike counselor trainee program requirements that often mandate a certain number of hours in personal therapy, fully licensed professional counselors are not regulated by licensing boards with regard to continuing personal therapy. Policy changes that include a personal therapy requirement in a similar vein as continuing education credits may positively impact counselor stigma and wellness.

Conclusion

Counselors face many challenges in their clinical work, including occupational stressors and the need for self-awareness (Moore et al., 2020; Mullen et al., 2017; Prosek et al., 2013; Robino, 2019; Thompson et al., 2014). The current descriptive phenomenological study serves to provide an understanding of the lived experiences of counselors who utilize personal therapy, including their motives to engage and meaning made while engaged. We offer clinical suggestions within the counseling relationship, steps to reduce stigma, and recommendations for facilitating self-care strategies among counselor trainees and professional counselors directly from voices of counselors who have accessed personal therapy.

 

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

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Appendix



 

Dax Bevly, PhD, is core faculty at Antioch University Seattle. Elizabeth A. Prosek, PhD, NCC, LPC, is an associate professor at The Pennsylvania State University. Correspondence may be addressed to Dax Bevly, Antioch University Seattle, School of Applied Psychology, Counseling, and Family Therapy, 2400 3rd Ave #200, Seattle, WA 98121, dbevly@antioch.edu.

Factorial Invariance of Scores on the Inner Wealth Inventory: A Nationwide Sample of Adults in the United States

Michael T. Kalkbrenner, Stephanie L. Zackery, Yuxuan Zhao

The Inner Wealth Inventory (IWI) is a screening tool for measuring inner wealth (IW), a wellness-based construct centered on empowering clients to inherently value themselves for being who they are. The initial IWI score validation study was conducted with samples of child welfare professionals. If the IWI’s psychometric properties are confirmed with a normative sample of U.S. adults, it has potential to offer professional counselors a tool for measuring IW. The purpose of the present study was to test the factorial invariance and convergent validity evidence of scores on the IWI with a national sample (N = 840) of U.S. adults, stratified by the census data for gender, ethnoracial identity, geographic location, and age. The results of factorial invariance and convergent validity testing revealed strong support for the psychometric properties of a sample of U.S. adults’ scores on the unidimensional IWI, including equivalence in the meaning of IW across gender, ethnoracial identity, help-seeking history, education, and income in our sample. 

Keywords: Inner Wealth Inventory, professional counselors, U.S. adults, psychometric properties, equivalence

Promoting wellness with an emphasis on development and prevention is a core focus in the discipline of professional counseling (Long et al., 2022; Myers, 1992; Myers & Sweeney, 2014). Measuring and promoting wellness is an especially important issue when considering the ubiquitous and comorbid nature of mental and physical health issues among adults living in the United States (World Health Organization [WHO], n.d., 2021). Wellness-based screening tools with rigorously validated scores have a lot of utility in professional counseling settings for monitoring clients’ health and wellness (Mason et al., 2023).

Consistent with the wellness orientation of the counseling profession, The Inner Wealth Inventory (IWI) is a wellness-based screening tool for measuring inner wealth, which is defined as:

A growing, accruing, and deepening sense of internal enrichment, which can be enhanced by external or internal self-narrated recognitions, that empowers a person to navigate the world in relation to one’s unfolding of who they really are as a person who is meaningful, valued, and who has great things to contribute by being simply true to oneself. (Bennett et al., 2023, p. 123)

     The initial IWI score validation study was conducted with two large samples of child welfare professionals (Bennett et al., 2023). The psychometric properties of screening tools can fluctuate over time or with different normative samples (American Educational Research Association [AERA] et al., 2014). Professional counselors have an ethical duty to make sure that screening tools have valid and reliable scores with untested samples to confirm that they are used properly (Lenz et al., 2022; National Board for Certified Counselors, 2023). Accordingly, the primary aim of the present investigation was to test the factorial invariance (equivalence in meaning) of IWI scores with a national sample of U.S. adults. Pending evidence of factorial validity, we will test the convergent validity of IWI scores with established measures.

The State of Mental and Physical Health Among U.S. Adults
     The comorbid nature of mental and physical health issues among U.S. adults has increased in severity and complexity since the COVID-19 pandemic (Clarke et al., 2020). Anxiety and depression are two of the most prevalent mental health issues among U.S. adults (National Alliance on Mental Illness [NAMI], 2022). Anxiety and depressive disorders tend to co-occur with a number of physical health issues, including heart disease and pain disorders (Winkler et al., 2015). In fact, heart diseases were the number one killer of adults over 18 in the United States from 1999–2020, with intentional self-harm (including suicide), and essential hypertension also in the top 15 (Centers for Disease Control and Prevention [CDC], n.d.). The pervasive and concurrent nature of anxiety, depression, and non-communicable physical diseases is further exacerbated by sociodemographic factors.

Sociodemographic Factors
     Past investigators documented a number of sociodemographic health disparities among adults in the United States by gender identity, ethnoracial identity, help-seeking history, income, and education (Kalkbrenner, 2022; Kobayashi et al., 2021; Patrick et al., 2020). Specifically, differences in power, privilege, and biological factors between females and males contribute to inequitable health outcomes (Pan American Health Organization & WHO, n.d.). Specifically, women reported higher rates of negative health outcomes and reduced health care access than men (Connor et al., 2020; Talevi et al., 2020). In terms of ethnoracial differences, U.S. adults who identified as racial minorities/non-White reported higher rates of both mental health concerns (i.e., any mental, behavioral, or emotional disorder) and physical concerns (e.g., heart disease, hypertension, asthma or emphysema) in comparison with their White counterparts (National Institute of Mental Health, 2023; Ramraj et al., 2016). Similarly, lower levels of education are a risk factor for poorer health conditions (van der Heide et al., 2013). In comparison to individuals with less than a high school degree, those with a degree higher than a high school degree reported better health conditions (Johnson-Lawrence et al., 2017). Moreover, individuals with college degrees reported better health in general in comparison to their counterparts with less education (Lawrence, 2017). Income is another sociodemographic factor that impacts wellness in a multifaceted manner (Beech et al., 2021). For instance, adults living under the poverty line are at risk for food insecurities and exposure to hazardous working environments (Laska et al., 2021; Mikati et al., 2018). Additionally, individuals living with a lower socioeconomic status are more at risk for COVID-19 and its aftermath (J. A. Patel et al., 2020).

Help-seeking history is a relatively new demographic variable in the extant literature that is related to attitudes about counseling and utilization of counseling services (Kalkbrenner, 2023; Cheng et al., 2018). In the context of a demographic variable, help-seeking history is not intended to quantify a latent trait representing a comprehensive representation of one’s engagement in counseling. Rather in terms of a demographic variable, help-seeking history is quantified categorically as either 1 (attended at least one session of personal counseling) or 2 (never attended counseling; Cheng et al., 2018). A help-seeking history is a predictor of more positive attitudes about accessing mental health support services (Cheng et al., 2018). However, Kalkbrenner (2023) found that adults in the United States with a help-seeking history reported lower levels of mental and physical health than those without a help-seeking history. Accordingly, help-seeking history and other sociodemographic variables are important considerations when calibrating wellness-based screening tools (e.g., the IWI).

The initial IWI score validation study (Bennett et al., 2023) established the IWI’s overall internal structure (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]) and validity based on relations with other variables. Factorial invariance testing is an extension of CFA and a method for enhancing the precision of internal structure validity. Factorial invariance testing (psychometric equivalence across subgroups of the larger sample) is an especially important next step in this line of research, as findings in the extant literature (e.g., Kalkbrenner, 2022; Kobayashi et al., 2021; Patrick et al., 2020) have evidenced differences in wellness by sociodemographic variables.

Inner Wealth and the Inner Wealth Inventory
     Inner wealth (IW) is a latent construct consisting of internal enrichment and empowerment (Bennett et al., 2023; Glasser & Lowenstein, 2016). This internal enrichment can be furthered by external factors such as meaningful social connections. This enrichment acts by empowering individuals to view themselves as a meaningful and valued person who contributes things to the world by being their true self (Bennett et al., 2023). The Nurtured Heart Approach (NHA) is a framework used to help individuals in growing their IW (Glasser & Lowenstein, 2016). The NHA and IW have been implemented for decades (Glasser & Easley, 1998); however, there is a dearth of empirical NHA studies in the extant literature, as a screening tool for measuring IW (the primary outcome variable in NHA) did not exist until recently. Bennett et al. (2023) developed and validated scores on the IWI with two large samples of child welfare professionals. Bennett et al. (2023) also found that IWI scores were significant negative predictors (with large effect size estimates) of lower levels of burnout and compassion fatigue as well as significantly higher levels of resilience. One of the next steps in this line of research is to test the generalizability of IWI scores with a national sample of U.S. adults, as professional counselors need wellness-based inventories with valid scores.

Purpose Statement and Research Questions
     The purpose of the current study was to test the factorial invariance and convergent validity evidence of IWI scores with a national sample of adults in the United States. If scores are validated, the IWI has potential to contribute a wellness-based screening tool with utility for appraising IW in clinical and in research settings. The following research questions (RQs) guided the present study:

Research Question 1:  Is the dimensionality of scores on the IWI confirmed with a national sample of adults in the United States?

Research Question 2:  Are scores on the IWI from a national sample of adults in the United States invariant across extant sociodemographic variables?

Research Question 3:  What is the convergence of scores on the IWI with established measures among a national sample of adults in the United States?

Method

A quantitative cross-sectional research design was employed to answer the research questions. Specifically, we used a psychometric design based on internal structure validity, convergent validity, and internal consistency reliability. This study is part of a larger grant-funded project with an aim to increase the generalizability of scores on wellness-based measures.

Participants and Procedures
     Following IRB approval, grant funding was used to hire Qualtrics Sample Services (2023), an online research panel and sampling pool for survey research. Mike Kalkbrenner, the first author, entered the instrumentation into the Qualtrics secure online survey tool and sent the distribution link to the Qualtrics Research Services Account Executive. Working with a team of analysts, the Research Services Account Executive launched a national sampling procedure (stratified by the U.S. Census Bureau [2022] data for gender, age, ethnoracial identity, and geographic location) among adults living in the United States. The present study included two eligibility criteria. First, prospective participants had to be 18 years old or older. Second, they had to be permanent residents of the United States at the time of data collection. The team of Qualtrics analysts completed a quality check on the data by identifying and removing random response patterns, speeders, and unrealistic answers.

A raw sample of N = 850 responses was collected. Seven cases were removed due to > 20% missing data. Little’s Missing Completely at Random (MCAR) test revealed that the data could be treated as MCAR (X2 [428] = 454.736, p = .179); expectation maximization was used to impute missing values. Skewness and kurtosis values were consistent with a normal distribution, standardized z-scores showed zero univariate outliers (z > 3.29), and Mahalanobis distances exhibited zero multivariate outliers, yielding a final sample of N = 840.

Participants (N = 840) ranged in age from 18 to 90 (M = 48; SD = 18). For gender identity, 52.0% (n = 437) self-identified as female, 46.7% (n = 392) male, 0.5% (n = 4) transgender, 0.4% (n = 3) non-binary, and 0.5% (n = 4) preferred not to answer. For ethnoracial identity, 1.0% (n = 8) self-identified as American Indian or Alaska Native; 10.0% (n = 88) Asian or Asian American; 11.5% (n = 97) Black or African American; 14.2% (n = 119) Hispanic, Latinx, or Spanish origin; 1.4% (n = 12) Multiethnic; 0.1% (n = 1) Native Hawaiian or Other Pacific Islander; 58.2% (n = 489) White or European American; 1.1% (n = 9) another race, ethnicity, or origin; 1.8% (n = 15) preferred not to answer; and 0.2% (n = 2) did not specify their ethnicity. For highest level of education, 37.5% (n = 315) reported high school degree, 16.8% (n = 141) associate degree, 27.3% (n = 229) bachelor’s degree, 12.9% (n = 108) master’s degree, 2.6% (n = 22) doctoral degree, 2.3% (n = 19) preferred not to answer, and 0.7% (n = 6) did not specify their level of education. For help-seeking history, 67.3% (n = 565) reported help-seeking history, 31.1% (n = 267) had no help-seeking history, and 1.7% (n = 14) did not specify their help-seeking history. For income, 27.7% (n = 233) self-identified as below the poverty line, 63.5% (n = 533) above the poverty line, and 8.8% (n = 74) did not specify their income.

Measures
     Participants indicated their voluntary informed consent and confirmed that they met the inclusion criteria for participation, at least 18 years old and living in the United States. Next, respondents completed a demographic questionnaire, which included self-report items on age, gender identity, ethnoracial identity, help-seeking history, geographic location, income, and the number of people living in their household. Lastly, participants completed a battery of four screening tools.

Inner Wealth Inventory
     The IWI is a screening tool for measuring IW,

a growing, accruing, and deepening sense of internal enrichment, which can be enhanced by external recognitions, that empowers a person to navigate the world in relation to one’s unfolding of who they really are as a person who is meaningful, valued, and who has great things to contribute by being simply true to oneself. (Bennett et al., 2023, p. 123)

Participants respond to declarative statements on the following Likert scale: 1 = Strongly Disagree, 2 = Disagree, 3 = Not Sure, 4 = Agree, or 5 = Strongly Agree. Bennett et al. (2023) validated scores on both a unidimensional and a two-dimensional IWI model via internal structure validity (EFA and CFA) and convergent validity testing with two large samples of child welfare professionals.

The unidimensional version of the IWI is comprised of 13 items, which collectively measure general IW (example item: “I believe I have the power to make positive changes in my day to day life.”). The two-factor version of the IWI includes the 13 items from the unidimensional version plus seven additional items. The first subscale of the two-dimensional model, Internal IW, is comprised of 15 items that appraise intrapersonal elements of IW (example item: “I know how to calm myself down when I am upset.”). The second subscale, External IW, consists of five items, which measure interpersonal components of IW (example item: “I feel comfortable in social situations.”).

Bennett et al. (2023) found strong internal consistency reliability evidence for child welfare professionals’ IWI scores on the unidimensional version (α = .90, ω = .90) and the Internal IWI scale (α = .91, ω = .91) of the two-dimensional model. Questionable-to-acceptable internal consistency reliability evidence of scores emerged for the External IWI scale (α = .67, ω = .65). Consistent with the results of Bennett et al. (2023), we found strong internal consistency reliability evidence of scores with the current sample of adults in the United States on the unidimensional IWI version (α = .942, 95%
CI [.935, .948]; ω =. 942, 95% CI [.935, .949]) and the Inner IW subscale (α = .947, 95% CI [.940, .953]; ω =. 947, 95% CI [.941, .953]) and questionable-to-acceptable internal consistency reliability evidence of scores on the External IWI subscale (α = .684, 95% CI [.640, .722]; ω =. 645, 95% CI [.571, .701]).

Mental Health Inventory-5
     The Mental Health Inventory-5 (MHI-5) is a screening tool for measuring general mental health in adults (Berwick et al., 1991). Participants respond to five different items concerning their mental health in the past month on the following scale: none of the time, a little of the time, some of the time, a good bit of the time, most of the time, and all of the time (Berwick et al., 1991). Past investigators found both internal structure (Rivera-Riquelme et al., 2019) and criterion validity evidence (Yamazaki et al., 2005) of MHI-5 scores. Multiple researchers also found satisfactory internal consistency reliability of MHI-5 scores including Rivera-Riquelme et al. (2019; α = .71, ω = .78) as well as Marques et al. (2011; α = .82). In the present study, we found acceptable internal consistency reliability evidence of MHI-5 scores (α = .841, 95% CI [.819, .860]; ω =. 833, 95% CI [.805, .856]).

Generalized Anxiety Disorder-7
     The Generalized Anxiety Disorder-7 (GAD-7) is a self-report instrument used for measuring the severity of generalized anxiety disorder symptoms (Spitzer et al., 2006). Each of the seven items ask how often in the last two weeks were participants bothered by different symptoms of anxiety, for example, “feeling nervous, anxious, or on edge” and “being so restless that it is hard to sit still.” Participants respond to each item on a response scale ranging from 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day). A number of past investigators (e.g., Dhira et al., 2021; Omani-Samani et al., 2018) found construct validity evidence for GAD-7 scores. Scores on the GAD-7 displayed moderate to strong internal consistency reliability estimates, including α = .91 (Seo & Park, 2015), α = .89 (Dhira et al., 2021), and α = .85 (Rutter & Brown, 2017). Among the sample of U.S. adults in the present study, strong internal consistency reliability estimates of GAD-7 scores emerged (α = .933, 95% CI [.925, .941]; ω = .933, 95% CI [.924, .940]).

Patient Health Questionnaire-9
     The Patient Health Questionnaire-9 (PHQ-9) is a self-report instrument used to assess various depressive symptoms and their severity (Kroenke et al., 2001). Within the PHQ-9, individuals respond to the following prompt: “Over the last 2 weeks, how often have you been bothered by any of the following problems” with order responses ranging from 0 = not at all, 1= several days, 2 = more than half the days, or 3 = nearly every day (Kroenke et al., 2001). The PHQ-9 consists of nine items (example item: “Feeling down, depressed, or hopeless”; Kalkbrenner, 2022). Maroufizadeh et al. (2019) demonstrated convergent validity evidence of PHQ-9 scores through moderate to strong correlations with measures assessing similar constructs. Internal structure validity of PHQ-9 scores were found through factorial invariance testing by J. S. Patel et al. (2019). Scores on the PHQ-9 have demonstrated moderate to strong internal consistency reliability scores when investigated by a variety of researchers including α = .90 (Dosovitsky et al., 2021), α = .85 (Maroufizadeh et al., 2019), and α = .78 (Dajpratham et al., 2020). Similarly, we found strong internal consistency reliability evidence of PHQ-9 scores with the present sample of U.S. adults (α = .926, 95% CI [.917, .934]; ω = .927, 95% CI [.917, .935]).

Data Analysis
     Two single-order CFAs were computed to test the dimensionality of a national sample of U.S. adults’ scores on the unidimensional and two-dimensional IWI models. We referred to Dimitrov (2012) and Schreiber et al. (2006) for cutoff scores to interpret model fit, including chi-square absolute fit index (CMIN, non-significant p-value or χ2 to df < 3), the comparative fit index (CFI, .90 to .95 = acceptable fit and > .95 = strong fit), standardized root mean square residual (SRMR < .08 = acceptable fit and < .06 = strong fit), and root mean square error of approximation (RMSEA < .08 = acceptable fit and < .06 = strong fit;). Pending acceptable fit, one or both models will be tested for factorial invariance of scores. Based on our review of the extant literature, the following sociodemographic variables were tested for factorial invariance: gender, help-seeking history, ethnoracial identity, income, and education (Kalkbrenner, 2022; Kobayashi et al., 2021; Patrick et al., 2020).

Meade and Kroustalis (2006) recommended that comparison groups for multiple-group confirmatory factor analysis (MCFA) should be comprised of at least 200 participants. Accordingly, the levels of the gender and ethnoracial identity variables were coded into the following levels in order to meet the sample size requirements for MCFA: gender identity (n = 437 female or n = 391 male) and ethnoracial identity (n = 489 White or n = 334 non-White). The levels of the help-seeking history (n = 565 with a help-seeking history or n = 261, without a help-seeking history), education (n = 315 high school diploma or n = 501 undergraduate degree or beyond), and income (n = 533 above the poverty line or n = 233 below the poverty line) variables met the minimum sample size requirement for MCFA.

Pending at least acceptable internal structure validity evidence of IWI scores (RQs 1 and 2), we will test convergent validity evidence by computing Pearson product moment correlations (r) between the IWI and the following well-established screening tools: the PHQ-9, GAD-7, and MHI-5. Strong negative correlations between the IWI and both the GAD-7 and PHQ-9 would prove convergent validity evidence of scores. A strong positive correlation between the IWI and MHI-5 would support convergent validity. A threshold of r > +/− .50 was used to evidence convergent validity of scores (Drummond et al., 2016).

Results

The unidimensional and two-dimensional IWI models were entered into two separate CFAs to test the dimensionality of scores on each model with adults in the United States (RQ 1). Pending acceptable model fit, the IWI items will be entered into an MCFA for invariance testing (RQ 2). The CFAs and MCFA were computed in IBM SPSS Amos version 26 with a maximum likelihood estimation method.

Single-Order Confirmatory Factor Analysis
     The unidimensional IWI items were entered into the first CFA, and all the incremental fit indices displayed an acceptable model fit: CFI = .94, NFI = .93, IFI = .94. For the absolute fit indices, the SRMR indicated a strong model fit (SRMR = .04); however, the CMIN (χ2 [65] = 498.61, p < .001, X2/df = 7.67) and RMSEA (.09, 90% CI [.08, .10]) displayed a questionable-to-poor fit. The CMIN tends to underestimate model fit with large samples (Dimitrov, 2012) and the RMSEA tends to underestimate model fit for shorter screening tools (Shi et al., 2019). Accordingly, the collective results of the CFI, NFI, IFI, and SRMR supported satisfactory fit for scores on the unidimensional model. Thus, we proceeded with the MCFA for the unidimensional model.

The two-dimensional IWI model items were entered into another CFA to test the fit of the baseline model. The CFA results revealed poor model fit: CMIN (χ2 [169] = 876.11, p < .001, X2/df = 5.18); CFI = .84; NFI = .81; IFI = .84; RMSEA = .11, 90% CI (.09, .11); and SRMR = .16. We decided not to proceed with factorial invariance testing for the two-dimensional IWI model due to both the poor internal structure validity evidence and questionable internal consistency reliability evidence of scores on the External IWI subscale (α = .684, 95% CI [.640, .722]; ω =. 645, 95% CI [.571, .701]).

Factorial Invariance Testing: Multiple-Group Confirmatory Factor Analysis
     The unidimensional IWI items were entered into an MCFA (RQ2). To establish invariance of scores, we used the following recommendations from Chen (2007): < ∆ 0.015 in the RMSEA, < ∆ 0.030 in the SRMR for metric invariance or < ∆ 0.015 in SRMR for scalar invariance, and < ∆ 0.010 in the CFI. Results revealed strong measurement invariance (metric and scalar) for all sociodemographic variables (see Table 1). In other words, the MCFA provided strong evidence that IW had the same meaning among adults in the United States across gender identity, ethnoracial identity, help-seeking history, income, and education.

Table 1
Multiple-Group Confirmatory Factor Analysis: Inner Wealth Inventory

Invariance Forms CFI ∆CFI RMSEA ∆RMSEA RMSEA CIs SRMR ∆SRMR Model Comparison

                             Gender Identity: Male vs. Female

Configural .930 .067 .061, .072 .042
Metric .928  .002 .065 .002 .060, .070 .046  .004 Configural
Scalar .925  .003 .063 .002 .058, .068 .046 < .0001 Metric

Ethnoracial Identity: White vs. Non-White

Configural .930 .067 .061, .072 .043
Metric .929  .001 .064 .003 .059, .070 .043 < .0001 Configural
Scalar .928  .001 .062 .002 .057, .067 .043 < .0001 Metric

Help-Seeking History vs. No Help-Seeking History

Configural .934 .064 .059, .070 .038
Metric .935  .001 .061 .003 .056, .067 .039  .001 Configural
Scalar .932  .003 .060 .001 .055, .065 .039 < .0001 Metric

Income: Below the Poverty Line vs. Above the Poverty Line

Configural .922 .071 .066, .077 .041
Metric .922 < .0001 .068 .003 .063, .074 .044  .003 Configural
Scalar .921  .001 .066 .002 .061, .071 .044 < .0001 Metric

Education: High School vs. Undergraduate and Beyond

Configural .928 .068 .062, .073 .045
Metric .928 < .0001 .065 .003 .060, .070 .046  .001 Configural
Scalar .928 < .0001 .062 .003 .057, .067 .046 < .0001 Metric


Convergent Validity Testing
     Scores of a national sample of U.S. adults on the IWI were correlated with the following established measures to investigate convergent validity of scores: the MHI-5, PHQ-9, and GAD-7. A threshold of r > +/− .50 was used to evidence convergent validity of scores (Drummond et al., 2016). The IWI displayed a strong correlation with scores on the MHI-5 (r = .66, r2 = .44, p < .001, 2-tailed). A strong correlation also emerged between scores on the IWI and PHQ-9 (r = −.56, r2 = .31, p < .001, 2-tailed). Finally, we found a strong correlation between the IWI and GAD-7 (r = −.52, r2 = .27, p < .001, 2-tailed).

Discussion

The primary aims of this study were to test the factorial invariance and convergent validity evidence of IWI scores with a national sample of adults in the United States. IW is a wellness-based construct that dovetails with the wellness orientation of the counseling profession (Bennett et al., 2023; Myers, 1992; Myers & Sweeney, 2014). Bennett et al. (2023) developed and validated IWI scores with samples of child welfare professionals; however, a score validation study was necessary to ensure that the measure was appropriately calibrated with a sample of U.S. adults. Collectively our results supported the psychometric properties of the unidimensional IWI model but not the two-dimensional model. The findings will be discussed accordingly.

Unidimensional IWI Model
     The CFA and MCFA results were promising for the unidimensional IWI model. Unidimensional IWI scores demonstrated strong invariance (metric and scalar) for all sociodemographic variables, which is particularly noteworthy, as it is not uncommon for at least one fit index to evidence metric invariance only. These results supported the generalizability of a sample of U.S. adults’ scores on the unidimensional IWI. Collectively, the MCFA results revealed that IW had the same meaning among U.S. adults between the following sociodemographic variables: income, gender, ethnoracial identity, help-seeking history, and education. These sociodemographic variables are associated with differences in terms of wellness (Kalkbrenner, 2022; Kobayashi et al., 2021; Patrick et al., 2020). This finding is encouraging, as professional counselors need wellness-based screening tools now more than ever considering the complex and comorbid nature of mental and physical health issues among U.S. adults (Clarke et al., 2020; NAMI, 2022). In particular, the IWI offers professional counselors a brief tool for measuring a wellness-based construct (IW) that is invariant among U.S. adults.

The results of convergent validity testing were also favorable, as the strength and direction of all correlations were in the expected directions. The effect size estimates (practical significance) for all correlations were in the strong range (Sink & Mvududu, 2010). The strength of the effect size estimate for the co-variance between IWI scores and MHI-5 scores was particularly noteworthy and evidenced 44% shared variance. Also as expected, IWI scores of a sample of U.S. adults demonstrated strong negative correlations with the GAD-7 (anxiety severity) and the PHQ-9 (depression severity). This finding is promising for a couple of reasons. First, it supports the convergent validity evidence of IWI scores, as wellness-based constructs tend to display negative correlations with both anxiety and depression severity (Kalkbrenner, 2022). In other words, the results of convergent validity testing supported that the IWI measured the intended construct of measurement. Second, these findings are promising when considering the prevalence of anxiety and depressive disorders among U.S. adults (Clarke et al., 2020; NAMI, 2022). Future outcome research is needed to establish causality between latent traits. However, the findings of the present study provide tentative evidence surrounding a notable proportion of co-variation between a sample of U.S. adults’ IWI scores and lower anxiety and depression scores.

Two-Dimensional IWI Model
     In the initial instrument development and score validation study, Bennett et al. (2023) found support for the internal structure validity of scores on both unidimensional and two-dimensional IWI models. However, in the present study, we found questionable internal consistency reliability and poor internal structure validity evidence of scores on the two-dimensional IWI model. Differences in the normative samples might account for the discrepant findings between Bennett et al. (2023) and the current study. The present study was comprised of a non-clinical sample of U.S. adults, and Bennett et al. (2023) sampled child welfare professionals, who were defined as mental health professionals who were working “directly and indirectly in public child welfare agencies to ensure the safety, protection, and well-being of children” (p. 122). Mental health professionals have training in providing mental (and sometimes physical) health care to clients in need of support services. Perhaps mental health professionals’ clinical training and work experience is what led to them understanding IW as a two-dimensional construct. In other words, mental health professionals’ training in interpersonal communication might have contributed to their recognizing both internal and external dimensions of IW (the two-dimensional model), whereas IW might have a unidimensional meaning among a non-clinical sample of adults living in the United States. Future research is needed to test this possible explanation for this finding.

Implications for Practice
     The results of this study show strong psychometric support for the unidimensional IWI model with a sample of U.S. adults, which has a number of implications for counseling practitioners. The National Board for Certified Counselors (2023) encourages professional counselors to use screening tools with validated scores as one way to enhance clinical practice. In fact, professional counselors have an ethical duty to make sure that screening tools have valid and reliable scores with representative client samples to ensure their proper use (AERA et al., 2014; Lenz et al., 2022; National Board for Certified Counselors, 2023). CFA and MCFA are rigorous tests of construct validity and evidenced that the IWI accurately appraised the intended construct of measurement (IW). The results of the present study extend the generalizability of IWI scores from child welfare professionals (Bennett et al., 2023) to adults in the United States. Accordingly, as one implication for practice, professional counselors can use the IWI to measure their clients’ IW. This is a particularly salient implication for practice, as demonstrating measurable treatment outcomes is becoming increasingly important in professional counseling and related health care settings (de Ossorno Garcia et al., 2021). In particular, professional counselors are expected to provide evidence of measurable client goals and outcomes. The IWI has potential to help professional counselors demonstrate such goals and outcomes. Suppose, for example, that a professional counselor is working with a client who is struggling with IW, which can manifest in a number of ways, such as struggles with self-efficacy and/or one’s sense of self-worth being dependent on external validation from others (Bennett et al., 2023; Glasser & Lowenstein, 2016). The counselor can use the IWI to track their client’s IW throughout treatment. The client’s test scores might serve as one way to quantify their progress throughout therapy.

The NHA has been implemented for decades to help individuals grow their IW and reduce workplace stressors (e.g., burnout) as well as increase resilience (Bennett et al., 2023; Glasser & Lowenstein, 2016). However, to date, there is a dearth of empirical NHA studies in the extant literature, as a screening tool for measuring IW (the primary outcome variable in NHA) did not exist until recently. The results of the present study build on the initial score validation study by Bennett et al. (2023). Specifically, the MCFA in the present study took construct validity testing to another level by demonstrating that IWI scores have the same meaning across important demographic factors among a national sample of U.S. adults. Collectively, the results of CFA, MCFA, and convergent validity testing suggest that the IWI is particularly well calibrated for measuring IWI among adults in the United States. Accordingly, professional counselors and professionals in related fields can use the IWI as one way to measure the utility of NHA interventions.

Practicality of the IWI and Consistency With the Counseling Profession
     Practicality is a cornerstone of test-worthiness and involves the degree to which a screening tool is logistically feasible for use in clinical practice (Neukrug & Fawcett, 2019). Brief screening tools with validated scores enhance the practicality of screening tools, as they provide practitioners with a quick and feasible method for measuring their clients’ scores on latent variables (Shields et al., 2021). The IWI has potential to be a highly practical screening tool in professional counseling settings, as it is comprised of reasonably few items (13 items in the unidimensional model), which has implications for reducing respondent fatigue. The IWI is also available in the public domain, free to use, and can be scored in minutes. Accordingly, the IWI has potential to be a practical screening tool that professional counselors can use in the intake process to establish baseline IW scores. The brevity and feasibility of the IWI makes it practical for professional counselors to administer the IWI to their clients as one way to monitor their progress in treatment.

Consistent with the underlying strengths-based principles of the counseling profession (Long et al., 2022; Myers, 1992), the IWI’s construct of measurement, IW, is a strengths-based latent characteristic (Glasser & Lowenstein, 2016). Accordingly, professional counselors are encouraged to use strengths-based assessment tools to measure well-being and keep track of treatment effectiveness (Fullen, 2016; Young et al., 2015) rather than focusing solely on measures of symptomatic distress or psychopathology. NHA and IW emphasize empowerment, strength, and resilience. The IWI is a strengths-based screening tool for measuring a growing, accruing, and deepening sense of inner enrichment (Bennett et al., 2023). Considering the promising psychometric support for the unidimensional IWI model in the present study, practitioners can use the IWI to measure IW when working with adults in the United States. In addition, the current results revealed strong correlations between IWI and MHI-5, which further supports that IW is a form of mental wellness.

Inner Wealth, Anxiety, and Depression
     Anxiety and depression are the two most common mental health conditions among adults living in the United States (NAMI, 2022). The PHQ-9 and GAD-7 are screening tools with rigorously validated scores for measuring depression and anxiety severity with normative samples of adults in the United States (e.g., J. S. Patel et al., 2019). Accordingly, the results of convergent validity testing between the IWI and the GAD-7 and PHQ-9 in the present study support the IWI’s psychometric properties and have implications for counselors who are working with U.S. adults living with anxiety or depression. Specifically, the IWI’s strong correlations with the PHQ-9 and GAD-7 suggest that the IWI might have utility for tracking treatment outcomes related to potential protective factors against depression and anxiety. Future research is needed; however, the results of the present study tentatively suggest that higher levels of IW might have utility for predicting lower levels of anxiety and depression among U.S. adults. To this end, it might be helpful for professional counselors to include the IWI in assessment batteries for clients who are living with anxiety and depression. Treatment plan goals can reflect both aiming to reduce negative symptoms (anxiety or depression) and increase wellness-based symptoms (e.g., IW). In addition, counselors and their clients can refer to the content of IWI items as semi-structured discussion prompts. Suppose, for example, that a client scores high on the following IWI item: “When I receive a compliment, I think it is likely untrue.” The client and counselor can use this information to discuss how and in what ways the client can work on giving themselves credit when they receive a compliment.

Two-Dimensional IWI Model
     At this stage of development, we recommend that clinicians and researchers use the two-dimensional IWI tentatively, if at all, to measure IW among U.S. adults due to the questionable-to-poor validity evidence of scores that we found for this model. Future researchers or practitioners who are seeking to use the two-dimensional model with adults in the United States should test for reliability and validity evidence of IWI scores with their sample before interpreting the meaning of scores.

Limitations and Future Research
     The findings of this study present limitations and implications for future research. We hired a data collection contracting company to employ a rigorous data collection procedure to recruit a national sample of U.S. adults stratified by the census data (U.S. Census Bureau, 2022). However, the statistical aggregation procedure that we used to dummy code variables into subsamples that were substantial enough for invariance testing may have limited the external validity of the findings. In particular, the results might not have detected differences in the meaning of IW among U.S. adults with (a) gender identities besides female or male, (b) ethnoracial identities beyond White or non-White, and/or (c) levels of education that were more specific than having a college degree or not. To these ends, we recommend that future investigators examine the factorial invariance of IWI scores with more ethnoracially, educationally, and gender-diverse samples. In addition, future researchers can extend the existing line of research on the IWI by testing for temporal internal structure validity via a time series factor analysis. Results might reveal insights into the time series psychometric properties of the IWI.

The results of convergent validity testing revealed strong co-variation (i.e., both statistical and practical significance) between IWI scores of a sample of U.S. adults and their depression and anxiety severity scores. However, causal directionality between variables cannot be inferred from the results of any cross-sectional study. Accordingly, future outcome research on the potential utility of IW in a possible treatment for anxiety and depressive disorders is recommended. For example, future researchers can test for changes in anxiety and depression severity before and after the NHA training (Glasser & Lowenstein, 2016), which is geared toward increasing IW. In addition, the results of the present study are based on a non-clinical sample of adults in the United States. There might be utility in future researchers testing the psychometric properties of the IWI with samples of participants who are living with mental and/or physical health conditions.

Summary and Conclusion

Consistent with the wellness orientation of the counseling profession, IW is a strengths-based construct that emphasizes internal enrichment and empowerment (Glasser & Lowenstein, 2016). The IWI is a screening tool for appraising IW, which was normed with two large samples of child welfare professionals (Bennett et al., 2023). The purpose of the present study was to extend the generalizability of IWI scores to a normative national sample of U.S. adults (stratified by the U.S. Census Bureau [2022] data for gender identity, age, ethnoracial identity, and geographic location). We found support for the psychometric properties of the unidimensional IWI model but not the two-dimensional IWI model with U.S. adults. Specifically, the results of factorial invariance (MCFA) and convergent validity testing evidenced strong support for the psychometric equivalence in the meaning of IW across gender, ethnoracial identity, help-seeking history, education, and income for U.S. adults’ scores on the unidimensional IWI model. When working with adults in the United States, professional counselors can use the unidimensional IWI as one way to measure and track their clients’ IW throughout treatment. The IWI offers a number of practical advantages to professional counselors, including brevity, simple scoring instructions, and free availability in the public domain.

Conflict of Interest, Funding Disclosure, and Author Note
The authors reported no conflict of interest in the development of this manuscript. This research was supported by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number P20GM103451. The authors would like to thank Dr. Howard Glasser for developing the Nurtured Heart Approach and Inner Wealth. This research would not have been possible without Dr. Glasser’s innovations.

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Michael T. Kalkbrenner, PhD, NCC, is a full professor at New Mexico State University. Stephanie L. Zackery is a doctoral student at New Mexico State University. Yuxuan Zhao, MEd, is a doctoral candidate at New Mexico State University. Correspondence may be addressed to Michael T. Kalkbrenner, Department of Counseling and Educational Psychology, New Mexico State University, 1780 E. University Ave., Las Cruces, NM 88003, mkalk001@nmsu.edu.

Enhancing Counselor Trainee Preparedness for Treating Eating Disorders: Recommendations for Counselor Educators

Taylor J. Irvine, Adriana C. Labarta

Eating disorders (EDs) are increasingly prevalent and pose significant public health challenges. Yet, deficits exist in counselor education programs regarding ED assessment, conceptualization, and treatment. Consequently, counselors report feeling incompetent and distressed when working with ED clients. We propose a conceptual framework, the 3 Cs of ED Education and Training, to enhance trainee development. The 3 Cs are: (a) cultivating trainee self-awareness through reflexivity and deliberate skill practice, (b) capturing contextual and sociocultural factors with culturally responsive approaches, and (c) collaborating with interdisciplinary ED professionals while strengthening counselor professional identity. Implications for counselor educators include incorporating activities aligned with this framework into curriculum and experiential training in order to facilitate trainee competence in ED assessment and treatment.

Keywords: eating disorders, 3 Cs of ED Education and Training, framework, counselor education, trainee development

Eating disorders (EDs) remain one of the most lethal mental health illnesses, contributing to roughly 3 million deaths globally each year (van Hoeken & Hoek, 2020) and impacting 29 million or 9% of Americans over their lifetime (Deloitte Consumer Report, 2020). In the United States alone, EDs directly result in 10,200 deaths annually, averaging one death every hour (Deloitte Access Economics, 2020). The steady rise of EDs across genders and countries is of increasing concern, with scholars noting in their systematic literature review that rates have doubled from 3.5% in 2000–2006 to 7.8% in 2013–2018 (Galmiche et al., 2019). EDs also exact a significant economic toll in the United States. In the 2018–2019 fiscal year, Streatfeild et al. (2021) found that EDs generated financial costs of nearly $65 billion, averaging about $11,000 per affected individual. Moreover, their study estimated an additional $326.5 billion in non-financial costs due to reduced well-being among those with EDs. Given their associated comorbidities with other mental health illnesses (Ulfvebrand et al., 2015), enduring somatic issues (Galmiche et al., 2019), and facilitation of psychological distress (Kärkkäinen et al., 2018), EDs pose significant public health and economic threats that necessitate further consideration. However, the literature lacks meaningful attention to ED prevention and treatment (van Hoeken & Hoek, 2020), an oversight that needs to be redressed within counselor education (CE) graduate training programs. A failure to examine this clinical issue threatens the maintenance of quality assurance and ethical standards within the profession, enabling short- and long-term client harm.

Challenges and Gaps in ED Education and Training
     Given the steady rise in the prevalence of EDs and their associated consequences, counseling trainees must be equipped with comprehensive training in order to effectively conceptualize and treat these complex conditions. However, across the decades, research has illuminated ED education and training deficits, particularly in graduate programs (Biang et al., 2024; Labarta et al., 2023; Levitt, 2006; Thompson-Brenner et al., 2012). For instance, Labarta et al.’s (2023) recent study examined clinician attitudes toward treating EDs, revealing challenges related to the lack of specialized graduate training. Among surveyed respondents, only 25.7% reported that their programs offered a specialized course on EDs, while approximately half of the sample (41.3%) divulged that their program dedicated only 1–5 hours of ED-related instruction throughout the curricula. Furthermore, one participant indicated that ED education is “rarely more than one lecture at the master’s level” (Labarta et al., 2023, p. 21). This is particularly concerning as research shows that trainees are not only very likely to encounter a client battling an ED at some point in their professional career (Levitt, 2006) but are also going to be less prepared and effective in treating such clients without specialized ED training in graduate programs (Biang et al., 2024; Labarta et al., 2023).

As a result of this lack of ED education, scholars have noted negative implications for helping professions, contributing to clinician incompetence, increased burnout, and diminished self-efficacy when working with ED clients (Labarta et al., 2023; Levitt, 2006; Thompson-Brenner et al., 2012). Clinician competence is a necessary vehicle to not only promote individual accountability but to also ensure the integrity of the broader counseling profession. However, holistic competency development is threatened without adequate, targeted ED training, increasing the likelihood that counselors-in-training (CITs) will encounter recurring treatment failures when working with clients struggling with an ED (Williams & Haverkamp, 2010). Williams and Haverkamp (2010) echoed this sentiment, stating that the field risks the occurrence of “iatrogenesis . . . particularly when the practitioner has a poor understanding of EDs, the negative reactions that eating disordered clients can evoke in the clinician are not managed, and/or there are specific types of process and relationship errors made in therapy” (p. 92). For example, although a school counselor may not serve as the primary treatment provider for an adolescent with bulimia nervosa, their understanding of warning signs and symptoms, supportive collaboration with students and families, and knowledge of specialized community referrals are invaluable to the counseling process (Carney & Scott, 2012). As such, counselor educators must assist CITs with developing essential competencies for treating EDs during graduate training programs, ultimately working toward bridging this gap and improving the quality of care.

Addressing the deficit of multicultural research in the field of EDs is of paramount importance, as it directly impacts the practice and education of counselors. Accrediting and professional bodies expect counselor educators to impart multicultural knowledge and skills to CITs, including a focus on diverse cultural and social identities (American Counseling Association [ACA], 2014; Council for the Accreditation of Counseling and Related Educational Programs [CACREP], 2023). Furthermore, Levitt (2006) emphasized that the significant consequences and growing prevalence of EDs across diverse cultural groups necessitate that clinicians “gain exposure to the etiology, manifestation, and treatment of eating disorders within multiple contexts” (p. 95). This assertion underscores the critical need for a more inclusive and culturally competent approach to assessing, treating, and educating about EDs, emphasizing the urgency of addressing the existing gaps in research. Ultimately, the absence of targeted ED research and training, notably conceptualization and assessment strategies, poses ethical concerns for safeguarding clients’ welfare, rendering trainees ill-equipped to address milder presentations of these disorders, let alone complex cases with more severe symptoms, such as heightened suicidality, enduring medical complications, and acute psychological distress (Kärkkäinen et al., 2018).

Research concerning client experiences is also imperative when assessing education and training needs for effective ED treatment. Babb et al. (2022) conducted a meta-synthesis of qualitative research on ED clients’ experiences in ED treatment, illuminating important themes on clinicians’ roles in supporting clients. Several clients reported that some staff perpetuated stereotypes about EDs (e.g., viewing the client as an illness versus a person) and tried to fit clients into specific theoretical frameworks. Clients attributed this lack of awareness and sensitivity to the providers’ lack of specialized training in EDs. Conversely, clients in this study felt empowered when providers were empathic and provided individualized approaches to treatment. These participants noted that “being seen as an individual” facilitated motivation for treatment, with the therapeutic alliance as an essential factor in this process (Babb et al., 2022, p. 1289). These client perspectives provide valuable insights that should inform the development of CE training programs to better prepare CITs for working with individuals with EDs.

Training Recommendations for Counselor Education Programs

Collectively, the findings cited above underscore the importance of comprehensive ED training for counselors to be able to effectively and compassionately serve diverse clients with EDs. However, accessibility to such education and training remains a challenge to both the graduate students and practitioners (Biang et al., 2024; Labarta et al., 2023). Furthermore, despite the efficiency of manualized approaches, Babb et al.’s (2022) study emphasized the need for both flexibility and avoiding a one-size-fits-all approach to ED treatment, particularly given the diversity of clients with EDs, including those from traditionally underrepresented backgrounds (Schaumberg et al., 2017). Clients’ lived experiences corroborate these gaps, reporting instances of stereotyping, rigid adherence to theoretical frameworks, and a lack of empathy stemming from inadequate specialized training (Babb et al., 2022). These findings highlight the pressing need for training strategies that ensure competence and uphold ethical standards within the treatment of EDs, including ongoing education for new practitioners entering the field.

The following section offers competency-based recommendations for CE programs to incorporate into their curricula and experiential training. We propose a conceptual model that we call the 3 Cs of ED Education and Training. The 3 Cs are: (a) cultivating trainee self-awareness, (b) capturing contextual and sociocultural factors, and (c) collaborating with interdisciplinary professionals (see Figure 1). We also provide an overview of recommended activities and associated reflective prompts that can be used in a special topics course on EDs (see Appendix A), as well as suggested adaptations for integration across counseling curricula. By integrating these teaching strategies, CE programs can enhance competency-based education for EDs (Williams & Haverkamp, 2010), which may empower CITs to provide compassionate, empirically supported services to this vulnerable population.

Figure 1
The 3 Cs of ED Education and Training
 


Cultivating Trainee Self-Awareness
     Cultivating trainee self-awareness is essential to ethical and multiculturally competent ED treatment. As espoused in our ethical codes (ACA, 2014), counselors are expected to examine their own beliefs, attitudes, and emotional responses when working with clients. Without such conscious examination, clinicians risk projecting their personal biases onto their clients or responding in ways that might inadvertently cause harm. For instance, the pervasive weight stigma embedded in our society can unconsciously influence counselors and may result in microaggressions, victim blaming, or the dismissal of symptoms, particularly when working with clients in larger bodies (Veillette et al., 2018). Counselors may also experience countertransference reactions triggered by ED behaviors or other challenging treatment components, such as high relapse rates, resistance to treatment, or insurance coverage issues (Labarta et al., 2023; Warren et al., 2013), negatively influencing the therapeutic relationship (Graham et al., 2020). Reflexive exercises, paired with targeted deliberate skill practice, are valuable mechanisms for facilitating conscious self-examination and building relevant knowledge and skills for effective ED treatment. 

Encouraging Reflexivity and Deliberate Practice
     Reflexivity, defined as “a practice of observing and locating one’s self as a knower within certain cultural and socio-historical contexts,” allows CITs to engage with courses on cognitive, affective, and experiential levels (Sinacore et al., 1999, p. 267). The integration of reflexive exercises and critical discussions into ED curricula is essential for cultivating self-awareness and, in effect, mitigating potential client harm. Such practices create opportunities for trainees to identify and address any unconscious biases or beliefs, which, if unaddressed, can undermine the quality of care provided. By establishing a habit of mindful self-inquiry, educators can take the first critical step in preparing ethically conscientious counselors attuned to ED clients’ diverse needs (Labarta et al., 2023).

This intentional practice of reflexivity should be paired with deliberate practice strategies focused specifically on promoting skill development for treating EDs. Deliberate practice is a systematic and intentional training method that targets skill development in order to attain expert performance in a given area or domain (Ericsson, 2006; Irvine et al., 2021). Research shows that integrating deliberate practice strategies early in CE training promotes competency development (Chow et al., 2015). Ericsson (2006) developed five crucial tasks of deliberate practice: self-assessment, skill repetition, formative feedback, stretch goals, and progress monitoring. The first task is a necessary step in increasing trainee self-awareness, which is particularly crucial when working with vulnerable populations, such as those struggling with EDs. Deliberate practice empowers trainees to refine their skills and continuously evolve as competent, empathic, and effective counselors. Thus, deliberate self-reflection on personal assumptions is key, as examining one’s relationship with food and body is imperative to prevent issues like value imposition and orient the focus of treatment to the client’s healing process.

Integrating reflexivity and deliberate skill practice early in CE training is vital to promoting lasting competency. CITs often overestimate their competence at the end of their training, necessitating that CE programs systematically monitor the congruence between CITs’ self-assessments and counselor educators’ assessments of CITs’ competency and skill development (Gonsalvez et al., 2023). Routine reflexive exercises can illuminate areas for growth, while deliberate practice strategies provide structured mechanisms for targeted skill refinement. As trainees embark on their professional journeys, ongoing and intentional efforts to self-reflect and evolve through skill refinement will empower them to provide safe, ethical, and effective ED treatment.

Capturing Contextual and Sociocultural Factors
     It has been well-documented that EDs impact individuals across social and cultural identities despite the misconception that only thin, White, affluent, cisgender women are affected (Schaumberg et al., 2017). Indeed, scholars have pointed to the need for intersectional, social justice–informed research that addresses the unique ways that context and culture influence EDs and body image concerns (Burke et al., 2020; Halbeisen et al., 2022). The prevalence of EDs and pervasive body image issues is alarming in today’s sociocultural landscape. For instance, the recent increase in gender-affirming care bans and anti-LGBTQ+ legislation poses profound and detrimental effects on individuals battling an ED (Arcelus et al., 2017), as these restrictive policies exacerbate the mental and emotional distress already experienced by LGBTQ+ individuals, further isolating them and undermining their access to critical health care services (Canady, 2023). As a result, members of this community are more apt to experience intensified body dysphoria, heightening the risk of developing or worsening an ED in an attempt to conform to societal norms (Arcelus et al., 2017).

In the wake of the COVID-19 pandemic, the world has experienced a collective trauma that triggered a series of physical and mental health consequences that will linger for years to come, including rising rates of disordered eating and body-related concerns. Termorshuizen et al. (2020) surveyed 1,021 individuals across the United States and the Netherlands, revealing that ED diagnoses increased at a rate of roughly 60%, with respondents noting increased binge episodes (30%) and restriction behaviors (62%) during this time. Scholars have also shown the deleterious effects of the pandemic on body image perception. For instance, in one study of 7,878 respondents, 61% of surveyed adults and 66% of surveyed children (17 and under) disclosed frequent negative feelings regarding their body image, with 53% of adults and 58% of children reporting that the pandemic has significantly exacerbated these feelings (House of Commons, 2021). Unfortunately, weight stigma was also pervasive in the media, with concerns regarding quarantine weight gain (e.g., “Quarantine-15”) contributing to eating and body image challenges (Schneider et al., 2023). Amidst the multifaceted challenges presented by recent sociopolitical events and the intersecting struggles faced by diverse individuals with EDs, it is essential that counselors implement culturally responsive approaches to treatment and advocacy efforts.

Centering Culturally Responsive Approaches
     Given the diversity of clients who struggle with eating and body image concerns (Schaumberg et al., 2017), CE programs must integrate culturally sensitive theories into the curriculum to ensure that CITs possess the necessary competencies to explore relevant cultural factors and effectively treat diverse clients with EDs (Williams & Haverkamp, 2010). Two theories that fostered the development of the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) are intersectionality theory and relational–cultural theory (Singh et al., 2020). Intersectionality is a framework for comprehensively understanding the interaction of systemic inequalities and oppression that significantly affect marginalized community members (Burke et al., 2020; Crenshaw, 1991). This theoretical paradigm deepens our understanding of factors such as age, race, ethnicity, sexual orientation, ability status, body size, and gender identity and how these factors influence an individual’s lived experience. Intersectionality is vital for promoting social justice and culturally responsive treatment while also serving as a tool to dismantle oppression and colonizing practices within the profession (Chan et al., 2018; Singh et al., 2020). Intersectionality-informed practice may assist researchers and counselors with considering risk and protective factors for EDs; however, the lack of attention to the intersecting roles and identities of ED clients (e.g., a Catholic, bisexual, Latina) remains a concern, which is crucial for informing culturally competent counseling and training practices (Burke et al., 2020).

Relational–cultural therapy (RCT; Jordan, 2009) is another promising theory that may decolonize dominant counseling approaches (Singh et al., 2020). Due to its emphasis on relational connection, social justice, and empowerment, RCT has been applied to the treatment of EDs (Labarta & Bendit, 2024; Trepal et al., 2015). Infusing RCT into practice may help counselors understand sociocultural influences that maintain ED (e.g., diet culture, weight stigma, acculturation) and perpetuate feelings of disconnection for individuals who do not conform to prevailing body or appearance standards. RCT also aligns well with counseling’s wellness orientation due to its relational and strengths-based focus, emphasizing resilience over pathology in the treatment of ED (Labarta & Bendit, 2024). Counselor educators can expand beyond traditional ED treatment approaches by integrating culturally responsive theories like intersectionality and RCT into course curricula, thus highlighting the intrapersonal, interpersonal, and systemic components that impact clients with EDs.

Collaborating With Interdisciplinary Professionals
     The counseling profession has recognized the importance of interdisciplinary practice, encouraging counselors to participate in “decisions that affect the well-being of clients by drawing on the perspectives, values, and experiences of the counseling profession and those of colleagues from other disciplines” (ACA, 2014, Code D.1.c, p. 10). The CACREP Standards (2023) also emphasize the need for counseling students to learn about collaboration, consultation, and community outreach as part of interprofessional teams (Section 3.A.3). Indeed, interdisciplinary collaboration provides an opportunity for individual and systems-level advocacy (Myers et al., 2002). The challenge remains in how counselors can balance establishing a distinct professional identity while simultaneously fostering a sense of community among various helping professions (Klein & Beeson, 2022). Researchers have underscored common experiences of counselors within interdisciplinary teams, including challenges with building legitimacy and credibility, especially among more well-established helping professions such as psychiatry or psychology (Klein & Beeson, 2022; Ng et al., 2023). Given that multidisciplinary collaboration is also crucial to ED treatment (Crone et al., 2023; Williams & Haverkamp, 2010), counselor educators must prepare CITs to effectively work within interdisciplinary treatment teams while utilizing their counseling values and training to best serve their clients and advocate for the inclusion of counselors across ED treatment settings (Labarta et al., 2023).

Strengthening Counselor Professional Identity
     Given that EDs are biopsychosocial in nature, effective treatment commonly involves collaboration among various health professions (e.g., medicine, psychiatry, counseling, psychology, dietetics) to ensure holistic, comprehensive client care (Crone et al., 2023). Counselors’ developmental, preventive, and wellness-based perspectives can help provide a strengths-based approach to interdisciplinary collaborations (Labarta et al., 2023). For example, a psychiatrist at a residential facility may focus on assessing a client’s pathology, comorbidity, and changes in symptoms throughout treatment. Although counselors can also focus on assessing client symptoms, their training allows them to provide insight into protective factors that foster client resilience in their recovery process (e.g., social support and cognitive flexibility). Both professionals bring unique expertise, knowledge, and skill sets that provide a distinct conceptualization of the client’s concerns with food or with their body. However, the ultimate goal of the treatment team is to ensure ethical and competent care for the client.

Outside of intensive ED treatment, counselors in school settings and community agencies can offer prevention-based approaches to mitigate risk factors leading to the development of EDs. Prevention-based efforts, such as community programs and workshops, are essential to the field of ED, given the alarmingly low rates of help-seeking in adults with lifetime EDs (34.5% for anorexia nervosa, 62.6% for bulimia nervosa, and 49.0% for binge eating disorder), which are even more pronounced among marginalized communities (Coffino et al., 2019). As such, counselors and other helping professionals can collaborate on ways to increase accessibility to mental health services for underserved groups with increased risk of eating or body image concerns (e.g., LGBTQ+; Nagata et al., 2020). Regardless of the settings within which CITs will work, students can benefit from developing teamwork, leadership, and advocacy skills, as well as a systemic conceptualization of client care (Ng et al., 2023). Ultimately, counselor educators can encourage the exploration of shared goals across helping professions and the utilization of counseling values and training to enhance interdisciplinary work for diverse clients and communities recovering from EDs (Klein & Beeson, 2022; Labarta et al., 2023; Ng et al., 2023).

Implications for Counselor Educators

The 3 Cs for ED Education and Training pose several implications for counselor educators and counseling programs. Although intended for ED treatment, this framework captures essential competencies across counseling specialties, such as counselor self-awareness, cultural and diversity issues, and interdisciplinary practice (CACREP, 2023). As such, integrating these foci into the counseling curriculum can help reinforce competencies regardless of the settings within which students will work. Counselor educators teaching about EDs should also consider ways to incorporate other ED counseling competencies, such as relevant ethical issues, assessment and screening, and evidence-based treatments into coursework (Williams & Haverkamp, 2010). These topics can be integrated into the 3 Cs for ED Education and Training in several ways. For instance, ethical issues and scenarios, such as determining when a client may need a higher level of care, can be presented to students as a standard component of collaborating with interdisciplinary professionals. Counselor educators can also review common ED assessments and encourage students to critically evaluate gaps in the diagnostic process that impact underrepresented populations (e.g., men with EDs), capturing contextual and sociocultural factors and enhancing culturally responsive care (see Appendix B for more examples.)

We also recognize the potential challenges of implementing the 3 Cs of ED Education and Training, as a stand-alone, special topics course on EDs may not be possible for all counseling programs. However, counselor educators can adapt and incorporate the suggested activities in Appendix A into various CACREP core courses to enhance ED education across the curriculum. CE programs can also utilize their Chi Sigma Iota chapters to host events on EDs, such as an interdisciplinary panel discussion followed by a group discussion on professional counseling identity and advocacy (Labarta et al., 2023). Opening these events to the local community could encourage continuing education, collaboration, and advocacy.

Directions for Future Research
     Given that the 3 Cs of ED Education and Training is a conceptual framework, there are several directions for future research. Counselor educators and researchers may consider developing a stand-alone course to test the effects of this framework on CITs’ competence in treating EDs. To our knowledge, limited ED competency measures exist, especially for counselors. As such, researchers could explore developing an instrument that measures ED competency areas that include the 3 Cs of ED Education and Training. Such a tool would be helpful for research, clinical, and teaching purposes. An ED competency tool may also enhance CITs’ and counselors’ deliberate practice efforts, promoting quality care for clients across ED treatment settings. Additionally, one theoretical framework educators can modify to help enhance trainees’ clinical competencies in treating EDs is Irvine and colleagues’ (2021) Deliberate Practice Coaching Framework (DPCF), given its structured guidance for skill refinement through individualized coaching and feedback. The development and future testing of an adapted DPCF for EDs may further enhance reflexive and deliberate practice efforts for CITs and counselors working with this population.

Conclusion

In this article, we have proposed our 3 Cs of ED Education and Training to address current gaps in ED education and enhance trainee preparedness across CE programs. Informed by existing literature, this framework incorporates essential elements of comprehensive ED treatment, including counselor self-awareness, cultural and contextual factors, and interdisciplinary practice. The flexibility of this framework allows educators to adapt current curricula to strengthen ED training in CE programs and to meet the needs of their students. Further research that tests a stand-alone course incorporating this framework is needed. The 3 Cs of ED Education and Training offer a path forward in remedying the salient gaps in ED education, ultimately advocating for more compassionate, ethical, and inclusive care across counseling settings.

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

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Appendix A

The 3 Cs of ED Education and Training: Suggested Activities and Reflective Prompts

 

3 Cs of ED Education & Training Suggested

Activities

Activity Sample

Reflective Prompts

Adaptations for Integration Across Counseling Curricula
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cultivating Trainee

Self-Awareness

Reflexive Journaling:

Have CITs maintain a journal, reflecting on their experiences (e.g., biases, assumptions, insights, challenges) throughout the course.

Instructors can provide suggested weekly prompts based on the content or topic area discussed.

Deliberate Practice:

During the first week, CITs will read Williams and Haverkamp’s (2010) article on ED counseling competencies.

CITs then write a reflection paper identifying 2–3 targeted, actionable areas for development and growth.

Revisit these competencies at the end of the course to assess CIT growth and ongoing development areas.

Reflexive Journaling Prompts:

Reflect on your beliefs, values, and attitudes about counseling ED clients. What would you like to learn? What challenges do you anticipate?

How might cultural factors impact how counselors work with ED clients? Consider how your cultural and social identities shape your relationship with food and body image.

Complete the Anti-fat Attitudes Questionnaire (Crandall, 1994) and interpret your score. What insights did you gain? Why might self-assessment in this domain be an important tool for counselors? (Kerl-McClain et al., 2022)

Deliberate Practice Prompts:

Using a Likert scale of 1 (not confident) to 5 (very confident), how confident do you feel to treat clients with EDs?

Using a Likert scale of 1 (not prepared) to 5 (very prepared), how prepared do you feel to treat clients with EDs?

Identify 2–3 areas of personal or professional development and growth.

Identify 2–3 actionable steps for this semester and beyond.

 

Psychopathology and Diagnosis Courses:

Before teaching ED diagnoses, facilitate a brief activity to promote reflexive practice (see suggested prompts).

Follow up with a class discussion on CITs’ reflections, reactions, insights, and the possible impact of biases or assumptions on the diagnosis and treatment process for ED clients.

Practicum and Internship Courses:

CITs working in ED treatment settings can use the deliberate practice prompts to continually assess strengths and growth areas.

Encourage CITs to complete the self-assessment on ED knowledge and skills. Based on the identified gaps, campus instructors can invite guest lecturers to discuss topics of interest.

3 Cs of ED Education & Training Suggested

Activities

Activity Sample

Reflective Prompts

Adaptations for Integration Across Counseling Curricula
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Capturing Contextual

and

Sociocultural Factors

Media Critique:

Have CITs select and analyze a form of media (e.g., movies, TV series, social media).

CITs can then consider the messages conveyed about EDs and body image.

Class Discussion:

Engage in a class discussion on CITs’ observations, noted themes, and implications for counseling practice.

Educators may also initiate a discussion on media literacy and how to broach similar discussions with clients and colleagues.

 

Individual Reflection Prompts:

How were EDs and/or body image concerns portrayed explicitly and implicitly?

How do sociocultural factors (e.g., race, ethnicity, gender, etc.) influence media portrayals and messages about EDs/body image?

How might these portrayals or messages influence one’s beliefs about EDs?

Class Discussion Prompts:

What were the overarching themes or messages across the various media?

How can culturally responsive theories (e.g., RCT, intersectionality) inform how we conceptualize the impact of media on EDs and body image concerns?

How can counselors work with clients impacted by harmful media ideals?

How can counselors advocate for more culturally inclusive and responsible ED portrayals in media?

Social and Cultural Diversity Course:

Facilitate a discussion on CITs’ observations of ED media portrayals, considering the impact of limited representation on mental health access.

Provide a case study of a client with intersecting minoritized identities and encourage CITs to identify culturally responsive treatment approaches and theories that can benefit the client’s recovery.

3 Cs of ED Education & Training Suggested

Activities

Activity Sample

Reflective Prompts

Adaptations for Integration Across Counseling Curricula
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collaborating with Interdisciplinary Professionals

ED Expert Panel:

Invite professionals across disciplines specializing in treating EDs (e.g., M.D., psychiatrist, psychologist, dietician).

Engage the panelists in a discussion on their respective training, roles, responsibilities, and experiences working in interdisciplinary treatment teams.

Reserve Q&A time for CITs to share any thoughts, questions, and insights (Labarta et al., 2023).


Professional Identity Reflection Paper:

After the ED expert panel discussion, have CITs write a reflection paper on what they learned from the panelists.

CITs can reflect on how counselors contribute to interdisciplinary teams using their developmental, prevention-focused, and wellness-based training.

Facilitate a broader discussion with CITs during the subsequent class meeting.

Expert Panel Discussion Prompts:

Briefly discuss your ED treatment experiences and describe your main roles and responsibilities.

Discuss the benefits and challenges of working in interdisciplinary treatment teams.

What would you say are the most prevalent issues faced by ED professionals today?

What words of wisdom can you share with CITs considering working with ED clients?

Professional Identity
Paper Prompts:

·      What challenges and opportunities do you foresee as a counselor working in an interdisciplinary treatment team?

·      How can counseling values inform an interdisciplinary perspective on ED treatment?

·      What personal strengths could you contribute as an interdisciplinary treatment team member?

·      Reflect on the MJSCC (Ratts et al., 2016), discussing how they can inform a counselor’s work with diverse clients struggling with eating and/or body image concerns.

Introduction to Mental Health Counseling Course:

If coordinating an ED expert panel is not feasible, consider inviting other professionals across specialty areas (e.g., EDs, addictions, integrated behavioral health) to share their experiences

CITs can complete a reflection paper on their insights and reactions to the guest panelists using the professional identity paper prompts as a guide.

 


Appendix B

Educator Checklist for Integrating the 3 Cs of Eating Disorder (ED) Education and Training Into Counselor Education Curricula

Cultivating Trainee Self-Awareness
Increase trainee awareness by incorporating ED warning signs, risk factors, and conceptualization strategies into assessment and treatment approaches.
Routinely assess student competency on ED-related knowledge and skills, evaluating for any incongruence between the students’ and educators’ scores. Additionally, assess multicultural counseling competencies related to EDs during student evaluations. Provide feedback for growth.
Encourage student attendance at ED-focused workshops, webinars, and conferences to enhance deliberate practice efforts, promoting professional growth and development.
Promote student exploration of their own cultural identities, values, and biases related to appearance, health, and eating behaviors.
Capturing Contextual and Sociocultural Factors
Incorporate diverse ED case examples and vignettes that reflect a range of intersecting cultural identities and experiences.
Provide training on culturally responsive ED treatment approaches like RCT and intersectionality. Be sure to cover strategies for adapting evidence-based ED treatment approaches to be culturally relevant for diverse clients.
Emphasize the importance of cultivating cultural humility and client empowerment, particularly when working with ED clients from diverse or marginalized backgrounds.
Collaborating With Interdisciplinary Professionals
Critically examine course syllabi to identify where ED content and scholarship could be incorporated or expanded (e.g., textbooks, media, articles). Include resources from interdisciplinary helping professionals.
Compile a list of interdisciplinary community referrals and resources to support students working with ED clients.
Provide opportunities (e.g., guest lecture, course assignment) for students to learn from ED experts in various helping disciplines. Encourage students to reflect on ways to utilize their counseling values and training within interdisciplinary treatment collaborations.

Note. This checklist is a framework for integrating ED education into CE graduate training. Consider modifying components to align with your specific curriculum, resources, and student population. The goal is to integrate ED education in a way that provides students with foundational knowledge, skills, and practical experience to effectively support clients struggling with EDs and body image issues in their future counseling practice.

Taylor J. Irvine, PhD, NCC, ACS, LMHC, is an assistant professor at Nova Southeastern University. Adriana C. Labarta, PhD, NCC, ACS, LMHC, is an assistant professor at Florida Atlantic University. Correspondence may be addressed to Taylor J. Irvine, Department of Counseling, Nova Southeastern University, 3300 S. University Dr., Maltz Bldg., Rm. 2041, Fort Lauderdale, FL 33328-2004, ti48@nova.edu.

2024 Dissertation Excellence Awards

In the eleventh year of TPC‘s Dissertation Excellence Award program, awards were presented to the authors of two winning dissertations, one in qualitative research and one in quantitative research. After an extensive review of submissions from across the United States, the committee selected Drs. Patti Lindsey and April Brown to receive the 2024 Dissertation Excellence Awards. Dr. Lindsey received the award in quantitative research for her dissertation entitled Training School Counselors to Close the Gap in College and Career Readiness: A Brief Intervention Study, and Dr. Brown received the award in qualitative research for her dissertation entitled Lived Experiences of Black Women Counselor Educators Mitigating Experiences of Racial Trauma in the Workplace.

Patricia “Patti” Lindsey, PhD, NCC, LSC, LPC (MN), is a licensed school counselor and a licensed professional counselor and holds the National Certified Counselor certification. Dr. Lindsey has served 7th–12th grade students in rural Southern Minnesota public schools for the past 16 years. Dr. Lindsey co-led the ASCA Affinity Group for rural school counselors over the past 2 years and was a member of the MN ACT Council for 9 years, helping plan and host an annual professional conference for educational stakeholders. Her passion for school counseling and college and career readiness led her to pursue her PhD in counselor education and supervision and research these topics for her dissertation. She earned her PhD from the University of the Cumberlands in December 2023 and is ready to use her knowledge, experience, and expertise to make a difference in our profession.

April Brown, PhD, NCC, CPCS, LPC, is a licensed professional counselor, wellness expert, business consultant, Kaiser Permanente awardee, and founder of The Wellness Room, LLC and The Wellness Room Coaching & Consulting, LLC. Dr. Brown combines 10 years of training and experience in counseling and education to deliver evidence-based practices and a solution-focused approach to help people and businesses prioritize mental health, elevate wellness, and embrace self-care. Dr. Brown was awarded the Thriving Schools Honor Roll Award from Kaiser Permanente in 2018 for her work in designing a wellness room for teachers and staff to improve employee wellness.

A firm believer in mental health awareness and self-care, Dr. Brown is passionate about teaching people how to prioritize self-care to reduce stress, obtain mental health resources, find work–life balance, and improve their overall well-being. Dr. Brown is on a mission to help people and businesses achieve optimal wellness by providing individual therapy, wellness coaching, business consulting, and wellness event planning and hosting wellness retreats. Dr. Brown plans to continue her research journey, develop innovative ways for more people to access mental health resources, create corporate wellness programs for businesses, and engage in advocacy to promote policy change around safety in the workplace.

Aside from her professional pursuits, Dr. Brown is passionate about faith, family, food, and fitness. She is a devoted wife, sister, aunt, friend, and avid plant mom. When she is not working, Dr. Brown enjoys traveling with her husband, spending time with family, reading books, and cooking vegan-friendly recipes. To learn more about Dr. Brown and her work, visit www.trythewellnessroom.com. Also, keep up with Dr. Brown on social media @thewellnessroomatl.

TPC looks forward to recognizing outstanding dissertations like those of Drs. Lindsey and Brown for many years to come.

Read more about the TPC scholarship awards here.