Nov 25, 2019 | Volume 9 - Issue 4
Alwin E. Wagener, Laura K. Jones, J. Scott Hinkle
The global burden of disease related to mental health is astronomical and growing, with underprivileged countries being disproportionately affected. The Mental Health Facilitator (MHF) program was designed by the National Board for Certified Counselors (NBCC) to address the need for greater mental health support within international communities lacking adequate mental health practitioners to provide services. The MHF program trains individuals within communities to provide support and necessary referrals for those struggling with mental health challenges. This study assesses the effectiveness of MHF trainings conducted in a diverse subset of countries and communities. Initial findings from the analyses found significant gains in participants’ knowledge of mental health and mental health facilitation skills across training populations.
Keywords: Mental Health Facilitator, MHF, mental health, NBCC, global
Over 450 million individuals around the world struggle with mental health concerns with 300 million people alone suffering from depression (World Health Organization [WHO], 2018). Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2014a, para. 1). Mental disorders account for nearly 30% of the global burden of disease (i.e., what kills, injures, and disables people around the world) in terms of years lived with disability (Kessler et al., 2009; Vigo, Thornicroft, & Atun, 2016). In addition to the hardships that mental disorders place on an individual’s social relationships, occupational opportunities, and physical health, nearly 800,000 people a year die by suicide, with 75% of those individuals residing in developing countries (WHO, 2014b). Such staggering statistics include the rank of suicide as the second most common cause of death among young people globally (WHO, 2014b).
In addition to personal struggles, communities also face economic hardships related to mental disorders. The global cost of mental health was estimated at $2.5 trillion in 2010, with estimates of costs expected to reach as high as $6 trillion by 2030 (Bloom et al., 2011). Such costs can be devastating for individuals and communities alike, especially where resources are limited.
Despite the exorbitant number of individuals around the world struggling with mental health concerns and the associated individual, societal, and economic costs, only a small portion of people receive the support they need (Hinkle, 2014; Kohn, Saxena, Levav, & Saraceno, 2004; Wang et al., 2007). It is important to note that only one third to one half of individuals in high-income countries receive mental health care. This gap is even more pervasive in low- to middle-income countries, with a mere 15%–24% of individuals receiving any form of mental health support (Demyttenaere, 2004). Furthermore, according to WHO (2015), most of the world’s population live in areas where there is an average of less than one psychiatrist per 200,000 people and even fewer individuals trained in psychosocial interventions.
This gap in service provision and treatment stems from both attitudinal (e.g., misinformation about mental health such as low perceived need, stigma, and discrimination) and structural-level (e.g., availability of services, financial considerations, and transportation problems) barriers (Andrade et al., 2014; Hinkle, 2014). Although attitudinal barriers appeared to be more pervasive, overall individuals with more severe mental health conditions and those in low- or lower–middle- income countries cited financial and service availability barriers as being especially problematic. In 2011, WHO detailed the scarcity of resources available to treat and promote mental health across the spectrum of high- to low-income countries, which leads to a gap in the provision of treatment as well as the quality of treatment when it is available. For example, within high-income countries, approximately $44.84 USD is spent per person on annual mental health expenditures, a value which drops to $0.20 USD per person in low-income countries (WHO, 2011). Clearly, a strategy to lessen this gap in global mental health service provision is needed.
A Call to Action
Given the pervasiveness and deleterious consequences of mental health disorders paired with the dearth of individuals receiving treatment, there is a global imperative that countries begin prioritizing mental health awareness, education, and treatment and combatting the noted barriers to individuals seeking and receiving adequate care. Enhancing the awareness and education of not only individuals struggling with mental health difficulties, but also members of the community, would be beneficial in addressing attitudinal barriers, while providing additional resources through increasing the number of both service providers and service centers can help to eliminate structural barriers to services. Such solutions are reflected in the WHO’s (2013) Mental Health Action Plan, which outlines the following four objectives:
(1) to strengthen effective leadership and governance for mental health; (2) to provide comprehensive, integrated and responsive mental health and social care services in community-based settings; (3) to implement strategies for promotion and prevention in mental health; and (4) to strengthen information systems, evidence and research for mental health. (p. 10)
Several approaches exist to address these objectives, yet one program in particular is unique in creatively addressing multiple objectives at once. Developed by the National Board for Certified Counselors (NBCC) and initially endorsed by WHO, the Mental Health Facilitator (MHF) program aims to reduce disparities in mental health care by facilitating access to support individuals and mental health services in underserved populations (Hinkle, 2006, 2014; Hinkle & Saxena, 2006). Specifically, the MHF program trains diverse community members (i.e., mental health laypersons) in the knowledge and skills necessary to identify mental health needs, support those in need of care, work with existing care resources, and make referrals to mental health professionals as needed (Hinkle & Henderson, 2007). The program focuses on creating a culturally appropriate curriculum adaptive to community needs and contexts while also providing fundamental information concerning mental health and basic psychosocial interventions. Also, unlike many other programs, the MHF program is only tailored and implemented into specific communities at the community’s request. In this way, the MHF program content aligns with WHO’s Mental Health Action Plan by working to strengthen culturally appropriate information systems, implementing strategies for promoting mental health and decreasing the severity and pervasiveness of disorders, and enhancing responsive and integrated service provision within community-based settings tailored to the needs of that community (Hinkle, 2014).
Content of the MHF Program
The mission of the MHF program is to provide skilled, responsible access to quality mental health interventions. This is usually accomplished through basic first-contact help and referrals to mental health professionals with respect for human dignity and meeting population needs by balancing globally accepted mental health practices within local norms and conditions (Hinkle, 2014). Cross-disciplinary in nature, the MHF program includes competencies from psychiatry, psychology, social work, psychiatric nursing, and counseling, covering topics such as helping skills, diversity, violence and trauma, suicide prevention, and referral and consultation skills. The design of the training emphasizes important considerations and approaches in addressing mental health concerns while allowing for flexibility in implementation. This flexibility is a key strength of the training program and is necessary given the breadth of cultural and contextual factors affecting mental health and mental health care around the globe. Such flexibility allows local stakeholders to identify and adapt the training to local needs and the knowledge gained from the MHF training program to be implemented within existing care settings or to provide a foundation for care in areas where no established system is present. The information contained within the training and flexibility of implementation constitute a population-based mental health care approach to addressing health care needs across a broad range of social, political, economic, and cultural environments (Hinkle, 2014), and one that is growing in its evidence base.
History and Implementation of the MHF Program
The MHF program is a three-tiered, train-the-trainer implementation model that consists of MHF master trainers, MHF trainers, and mental health facilitators. MHF master trainers are selected by NBCC based on specific criteria, most notably the completion of considerable training and experience in mental health and education. MHF trainers are often professionals or paraprofessionals with mental health and teaching experience located in the community who can train community groups. MHF trainees are typically laypersons with an interest in mental health who then become the first line of support for community members with mental health needs. Following training at each of the levels, individuals are registered in the international MHF registry. Currently there are over 4,774 registered MHF master trainers, MHF trainers, and mental health facilitators located around the world.
The MHF program was first established in 2005, when NBCC worked in collaboration with WHO to establish a panel of experts, including mental health professionals from the United States, Canada, Malaysia, Trinidad, St. Lucia, Turkey, Romania, India, Mexico, Botswana, and Venezuela, who would contribute to the development of the MHF training manual, curriculum, and implementation plans. This approach led to content and delivery plans that represented diverse cultures and thus diverse perspectives on mental health, mental health care, and the role of MHF master trainers, MHF trainers, and mental health facilitators. The curriculum and master training guide were completed and piloted in Mexico City in 2007 and 2008. Later in 2008, the first train-the-trainer program was delivered in Lilongwe, Malawi. To date, NBCC has partnered with 26 countries, including eight countries in Africa, five in Asia, four in the Middle East, and eight in Europe, as well as programs in Mexico and the United States. Furthermore, the MHF curriculum has been translated into Arabic, Chinese, Dzongkha (the language of Bhutan), Estonian, German, Greek, Japanese, Malay, Portuguese, Romanian, Russian, Spanish, and Swahili (Hinkle, 2014).
The MHF Curriculum
When developing a partnership with NBCC, communities can choose one of five MHF curricula to best suit their needs, namely the original MHF training, an abridged MHF training, a training for educators (MHF-EE), an abridged MHF-EE, or a version for first responders (i.e., fire, rescue, and police). The five MHF curricula share core content aimed at helping professionals and paraprofessionals improve communication and helping skills, identify local mental health resources, understand important ethical considerations, and connect health providers with individuals within their community who are in need of mental health services (Hinkle, 2014). In addition to the core content, the curricula directed toward educators and emergency personnel contain tailored modules to best support those populations. With trainings ranging from 6 to 30 hours, the curricula can be delivered over consecutive days or divided into its modules and taught over several weeks, depending on community needs (Hinkle & Henderson, 2007).
The foundation of the MHF curriculum underscores the shared experiences of stress, distress, and disorder (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Hinkle, 2014; Hinkle & Henderson, 2007). Given these theoretical underpinnings, the core modules cover topics such as basic helping skills, coping with stress, community mental health services, and community advocacy skills, and also introduce trainees to considerations around ethical practice and specifics about interventions such as suicide mitigation and trauma responses (Hinkle, 2014). Participants learn the benefits of investing in mental health, barriers to mental health care, cost-effective interventions, how mental health disorders impact families, confidentiality and privacy, and the broad mission of the MHF program (Hinkle, 2014).
In the basic helping skills section of the training, trainees cover development; diversity; verbal and nonverbal communication; facilitative skills such as listening, asking questions, and providing reflections; assessing for mental health concerns; empathy and understanding human feelings; and how to make referrals and effectively terminate relationships (Hinkle, 2014; Hinkle & Henderson, 2007). This information is followed by a discussion of how to understand problems, coping styles, and ways of effectively managing problems. The training then delves into recognizing stress, distress, and various disorders, including risk factors and mental health in children. The core modules conclude with discussions of suicide and trauma. Being the leading cause of death among young people in low- and middle-income countries, suicide is a pressing concern within all communities (WHO, 2006). Similarly, the pervasiveness of natural and human-born disasters and crises, such as war, forced displacement, human trafficking, typhoons, and wildfires, affects individuals of all demographics around the world and often goes untreated (Hinkle, 2014). A final topic covered in the core MHF training is the importance of self-awareness and self-care for mental health facilitators.
Moreover, the content in any of the five MHF curricula can be adapted to best fit the social, cultural, economic, and political realities and needs of any community, country, or region. For example, countries have chosen to add additional modules on child maltreatment in the Syrian region.
Past and Ongoing MHF Research
Building a strong evidence base is imperative to the development of a sustainable program that addresses the staggering gap that exists in mental health service provision. With limited resources spent on mental health, countries and communities cannot afford to implement programs that lack evidence supporting their projected outcomes and benefits. To this end, NBCC has and will continue to emphasize building a solid evidence base for the MHF program. Qualitative studies published to date (Luke, Hinkle, Schweiger, & Henderson, 2016; Van Leeuwen, Adkins, Mirassou-Wolf, Schweiger, & Grundy, 2016) support the perceived value and effectiveness of the program. Luke et al. (2016) reported that among the value and benefits, participants commented on how the program was culturally congruent and beneficially adapted to the needs of their community as well as how the program filled a need in terms of limited mental health resources. Participants further noted the considerable negative implications if the MHF program were to be discontinued (Luke et al., 2016). Van Leeuwen et al. (2016) also found notable positive perceptions of the MHF program. Participants reported that they gained skills in communication and referral. They also noted how they received important education on mental health and causes of mental health problems, and an enhanced awareness of mental health in communication. Finally, participants reported that there were both personal and community benefits to the program, such as an ability to better understand their own mental health and the mental health of family members as well as a reduction in community mental health stigma (Van Leeuwen et al., 2016).
However, to date no study has reported the quantitative outcomes of MHF trainings. Most trainings include pre- and post-training assessments of participants using a true-false, pencil-and-paper–based assessment. The assessment for the original MHF curriculum had three small adaptations involving changing the wording on several questions in 2009, 2011, and 2013. The adaptations were minimal, so all years were included in this study. This study fills the gap in the MHF literature by reporting on the objective data gathered from the pre- and post-training assessments of the original MHF curriculum.
Methods
This study uses a quasi-experimental research design to evaluate whether participants in 88 MHF original trainings demonstrated increased knowledge of mental health issues and approaches to address community mental health concerns. The trainings spanned from 2009–2017 and included all MHF trainings conducted outside of the European Union and the United States. For each MHF training, pre- and post-training assessments were completed by all participants in an effort to evaluate the effectiveness of training. The pre- and post-training assessments contained 50 true-false questions with the pretest administered on the first day of training and the posttest administered at the final training day, 5 days later. The present study analyzed the pretest and posttest evaluations using paired t-tests and a one-way ANOVA.
Participants
Participants who completed all items on both the pretests and posttests were included in the study, resulting in 1,392 participants from 15 countries. Of the 1,392 participants, only 735 provided descriptive information. For those participants, 431 were female (59%) and 304 were male (41%). The age range of participants was 17 to 75 years with a mean age of 36 years. The education of participants ranged from elementary school to doctoral (PhD) and professional degrees (MD and JD). There were 14 participants reporting only an elementary school level of education (2%), 150 with high school (20%), 151 with a 2-year degree (21%), 310 with a 4-year degree (42%), 99 with a master’s degree (13%), and 11 with a PhD or professional degree (1%). Given that trainings were conducted in countries within North America, Africa, Asia, and the Middle East, the data included a diverse range of participants in terms of nationality.
Research Questions
There were two primary questions investigated in this study. The questions were prompted by a desire to better understand the effectiveness of the MHF trainings: (1) Does the MHF program training significantly increase overall knowledge of mental health facilitation from pretest to posttest evaluation for participants? and (2) How does performance on the pretest, or initial mental health knowledge, affect possible training gains made between pretest and posttest scores for the participants?
Data Preparation
Prior to formal data analyses, the authors examined the data to ensure it satisfied the assumptions of the relevant statistical tests. Upon initial data examination, the authors determined that 77 participants of an initial 1,392 were outliers. The outliers were those with scores 1.5 times the interquartile range, either above the third quartile or below the first quartile. Based on this, the data analyses presented in the following sections were run with and without the outliers removed, and it was determined that the outliers did not significantly affect the results (the only exception to the outliers affecting the results is described in the results section). As such, the data analyses presented are using the remaining 1,315 participants after the removal of the outliers.
As the data set is too large for statistical normality tests to be accurate, skewness and kurtosis values were examined. The data set without the outliers had skewness (.208) and kurtosis (-.018), both values within the normal range. A visual inspection of the descriptive q-q line further supported the conclusion that the data is normally distributed.
Results
Overall Mental Health Knowledge Gain
The first research question, asking whether the MHF program training significantly increased overall knowledge of mental health and mental health facilitation, was assessed using a paired sample t-test. The result of this analysis showed that there was a significant difference (t = -35.90, p = 0.000) between pretest (M = 37.64, SD = 5.58) and posttest (M = 41.17, SD = 5.24) scores. This analysis confirms the hypothesis that the MHF program training significantly increases the scores of participants from pretest to posttest evaluation.
Initial Mental Health Knowledge and Training Gains
The second research question investigated whether the starting knowledge of participants, as measured in the pretest, affected the training gains made between the pretest and posttest. To address this research question, four categories based on pretest scores were generated. A descriptive analysis was conducted to determine the quartiles of the pretest scores, and the quartiles were used to define the categories. The authors determined that quartiles are an effective means of dividing the pretest scores into four groups given that the relationships between the groups are clearly linked to the overall distribution of pretest scores. The pretest scores ranged from 15–50 (the range of possible scores was 0–50), and quartiles were generated in order to better understand the effects of MHF training on participants with low, medium-low, medium-high, and high MHF knowledge going into the training. The quartile scores were as follows: low < 34 (N = 317, M = 5.34, SD = 4.23), medium-low = 34 to 38 (N = 369, M = 4.13, SD = 3.62), medium-high = 39 to 42 (N = 340, M = 3.06, SD = 2.69), and high > 42 (N = 289, M = 1.35, SD = 2.04).
To compare the four groups and answer the second research question, a one-way ANOVA was used. The analysis showed that the differences between the scores of the four categories are significant (F[3, 1311] = 81.05, p = 0.000). A post-hoc Tukey HSD test allowed for a more detailed understanding of the difference between the four groups. The Tukey HSD test results indicated significant differences between all four groups. The details of the differences between means in the post-hoc test are as follows. The low score group showed a significant difference between pretest and posttest scores compared to the medium-low test score group (mean difference = 1.21, p = 0.000), the medium-high test score group (mean difference = 2.28, p = 0.000), and the high test score group (mean difference = 3.99, p = 0.00). The medium-low test score group was significantly different from the medium-high (mean difference = 1.07, p = 0.000) and high (mean difference = 2.78, p = 0.000) test score groups, and the medium-high test score group was significantly different from the high test group (mean difference = 1.71, p = 0.000). When running the one-way ANOVA with the outliers included, the only difference in significance found in the results for any of the analyses occurred between the medium-low and medium-high groups. With the outliers included in the analysis, there was no significant difference between those two groups, although all the other significant differences remained, and the overall trend of pretest to posttest score differences decreasing as the pretest score rose remained unchanged. The results of the analyses confirm that the lower the pretest scores, the larger the gain in knowledge from the training.
Post-Hoc Data Analysis
After considering the significant pretest to posttest gains, the authors became curious about whether the content of the pretest and posttest questions might be separated into subscales to better evaluate MHF training effectiveness. The observation that the questions on the MHF pretests and posttests naturally related to either knowledge or skills prompted the authors to separate the questions into the two subscale categories, MHF knowledge and MHF skills.
To generate the two subscales, one author went through the questions independently and categorized them for each of the three test iterations. Then, the second author went through the questions to confirm they fit the subscales. A paired t-test was used to determine whether participants demonstrated equivalent gains in both knowledge and skills.
The results of the analyses showed significant gains on both subscales. The mean gain on MHF knowledge was 1.41 (N = 1315, t = -22.86, p = 0.000), and the mean gain on MHF skills was 2.12 (N = 1315, t = -29.67, p = 0.000). The results of this post-hoc analysis confirm the hypothesis that the MHF program training leads to significant increases in both MHF knowledge and skills.
Discussion
The results of the present study provide further evidence of the effectiveness of the MHF program. Previous studies have examined qualitative accounts of trainees’ experiences and impressions of the program (Luke et al., 2016; Van Leeuwen et al., 2016). The present data, however, provide objective evidence that the program is indeed enhancing trainee knowledge of mental health and MHF skills. This finding suggests that individuals who complete the MHF program have the requisite knowledge and skills to provide frontline interventions and needed referrals for community members struggling with their mental health.
Interestingly, the results also demonstrate that the documented growth in knowledge and skills is relative to the existing knowledge of the participant prior to training, whereby those with less initial training (i.e., lower scores on the pretest) showed greater gains in knowledge and skill from participation in the MHF training. Although somewhat intuitive, this provides evidence that the program is successful at enhancing the knowledge and skills of participants despite previous training in mental health. It brings all participants up to a similar, requisite baseline level of knowledge to perform mental health facilitation. Participants with little to no information regarding mental health can gain the needed knowledge and skills necessary to support the mental health of others in their community, while those with considerable information and training can refine their skills and knowledge for their new role.
Post-hoc analyses assessed whether the MHF program is equally adept at enhancing knowledge related to mental health and mental health struggles as well as the skills needed in mental health facilitation. Findings revealed that participants demonstrated a significant growth in both knowledge and skills. As such, the MHF program not only provides mental health literacy, but also the skills needed to support those in need. This is notable given the significant disparity of mental health literacy in both the developed and developing world (Ganasen et al., 2008; Jorm, 2000). Among professionals and laypersons alike, the lack of knowledge and understanding of mental health not only contributes to the treatment gap, but also the considerable stigma faced by those who struggle with mental health issues.
Taken together, the results suggest that the researchers and program developers can confidently endorse this program as one that leads to an increase in mental health knowledge and skills associated with mental health facilitation among both professionals and laypersons. In this way, the MHF program furthers the WHO’s (2013) Mental Health Action Plan goals of strengthening information systems surrounding mental health and clearly establishing a requisite foundation for the implementation of strategies and services. In its proposed actions for member states, WHO emphasized the importance of human resource development by “build[ing] the knowledge and skills of general and specialized health workers to deliver evidence-based, culturally appropriate and human rights-oriented mental health and social care services” (WHO, 2013, p. 15).
Our findings also complement the positive evaluation feedback of participants. In particular, Van Leeuwen et al. (2016) found that participants appreciated the increased knowledge they gained, noting that it was beneficial to themselves as well as their community. Participants noted that they had an enhanced ability to better understand their personal and family members’ mental health and that the MHF training helped reduce community stigma. Examined in conjunction with the present data, this suggests that not only are participants objectively gaining knowledge about mental health, they are aware of what they learned and actively and intentionally applying that knowledge to help themselves, other individuals, and their overall community better understand mental health. Given that the present study also demonstrated that participants are gaining an enhanced understanding of MHF-related skills, the researchers are hopeful that with their knowledge of mental health, participants are likewise intentionally putting their facilitation skills into action to support those in need within their communities.
Limitations and Future Research
The present study provides a notable step in further documenting the effectiveness of the MHF program, yet the limitations of this research must be taken into consideration and used for ongoing program planning and research development. Using true-false repeated measures pre- and post-training assessment could lend itself to bias. Within such situations, the trainee may recall, implicitly or explicitly, the questions asked in the pre-training assessment and may be primed for remembering the information needed to respond to those questions. Similarly, although the findings were statistically significant, probability suggests that true-false questions are more accessible to educated guesses rather than a depiction of accurate knowledge. In this way, having a multiple-choice format test with possible case scenarios to assess application in greater depth might provide a richer depiction of the knowledge gained. The present means of assessment also are vulnerable to a ceiling effect, whereby those with the most knowledge around mental health would earn the maximum number of points on both the pre- and post-training assessment. Although the present testing level is the most adaptive to all knowledge levels, perhaps a greater breadth of questioning to assess more nuanced components of the MHF skillset might be more helpful in accurately assessing the knowledge and skills gained by those coming into the MHF program with more extensive mental health training. An additional limitation of the assessments specifically was the post-hoc distinction between the skills and knowledge components assessed in the MHF training. In the future, greater attention to developing questions specifically geared toward these two necessary areas will be more effective in discriminating such gains. One final limitation of the present study and an area well positioned for future research is the lack of specific data regarding how the knowledge and skills are being used following the training.
Prior to this study, there was no formal quantitative data analysis to substantiate the reach of the MHF program. In addition to this research assessing the knowledge and skills gained through participation in the MHF program, there is the equally important next step of assessing how that knowledge is being used to address the goals of the program. Research examining the extent to which the MHF program aides in increasing mental health access for individuals in need of support and thereby decreasing the treatment gap among individuals struggling with their mental health would be especially important in addressing the over 70% of individuals in developing countries who do not receive the mental health care they so desperately need (Demyttenaere, 2004).
Conclusion
The growing number of individuals around the world with mental health challenges, coupled with the lack of knowledge, services, access, and fiscal resources to address the growing need, drives mental health to the forefront of worldwide public health challenges. Countries and communities in both developed and developing countries alike must embrace creative, economical, and culturally appropriate population-based solutions. The MHF program developed by NBCC (Hinkle & Henderson, 2007), initially in coordination with WHO and mental health experts from around the world, provides one such solution. Extant research on the MHF program validates the cultural appropriateness of the tailored programs as well as the extent to which community members believe they have benefited from the trainings (Luke et al., 2016; Van Leeuwen et al., 2016). The present findings further this research by providing quantitative data speaking to the effectiveness of the program at enriching participants’ knowledge and skills in relation to mental health. This burgeoning evidence base moves the MHF program one step closer to becoming a global best practice in addressing the notable and growing gap in mental health care around the world.
Conflict of Interest and Funding Disclosure
The first two authors were reimbursed by NBCC
for expenses related to this manuscript.
The third author is an employee of NBCC who
has developed and conducted MHF trainings.
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Alwin E. Wagener, NCC, is an assistant professor at Fairleigh Dickinson University. Laura K. Jones is an assistant professor at the University of North Carolina Asheville. J. Scott Hinkle is the editor of The Professional Counselor. Correspondence can be addressed to Alwin Wagener, 285 Madison Ave., M-AB2-01, Madison, NJ 07940, awagener@fdu.edu.
Nov 24, 2019 | Volume 9 - Issue 4
Bethany A. Lanier, Jamie S. Carney
The purpose of this study was to gain an understanding of the relationship between vicarious trauma (VT) symptoms and subthreshold post-traumatic stress disorder (PTSD) symptoms among practicing counselors. The researchers determined the frequency of VT symptoms and subthreshold PTSD symptoms experienced among practicing counselors and common contributing factors that participants felt contributed to the development of VT symptoms. Implications are presented for counselor educators to determine how they best can prepare students.
Keywords: vicarious trauma, subthreshold post-traumatic stress disorder, PTSD, practicing counselors, counselor educators
Most counselors will likely work with clients addressing trauma (Sommer, 2008; Trippany, White Kress, & Wilcoxon, 2004). Thus, it is important for professional counselors to have an understanding of the dynamics of trauma and interventions to use with clients. Additionally, counselors should be educated on the impact that working with clients can potentially have on them, both personally and professionally. For instance, counselors who work with clients addressing trauma might themselves experience emotional and psychological symptoms, or vicarious trauma (VT). VT has been defined as a disruption in schemas and worldview because of chronic empathic engagement with clients. It is often accompanied by symptoms similar to those of post-traumatic stress disorder (PTSD), which occur as a result of secondary exposure to traumatic material that can result in a cognitive shift in the way the therapist experiences self, others, and the world (Jordan, 2010; Michalopoulos & Aparicio, 2012). Although estimates differ, it has been reported that as many as 50% of counselors are at risk of developing VT (National Child Traumatic Stress Network, 2011).
Counseling requires an immense amount of empathetic acceptance on the part of the counselor, which increases the counselor’s vulnerability to taking on their clients’ traumatic experiences (Finklestein, Stein, Greene, Bronstein, & Solomon, 2015). Empathic acceptance and increased vulnerability on the part of the counselor may increase the counselor’s likelihood of developing VT symptoms (Sommer, 2008). VT can have a detrimental effect on all aspects of the counseling process, including both the counselor’s professional and personal life. Practicing counselors experiencing VT have been found to leave the profession early and may also experience emotional and physical disorders, suicidal ideation, strained relationships, increased or continuous burnout, anger, and possible substance abuse (Bergman, Kline, Feeny, & Zoellner, 2015; Keim, Olguin, Marley, & Thieman, 2008). VT is highly detrimental to the counseling process and the care provided to clients. A counselor experiencing VT is more likely to make clinical errors, and VT can negatively impact the counseling relationship (Trippany et al., 2004). The negative implications associated with VT make it imperative that counselors and those who work with them (e.g., supervisors and counselor educators) understand all the factors that lead to the development of VT. This can include recognizing factors that decrease vulnerability, assessing VT, and intervening (Sommer, 2008). One of the initial components to this process is understanding how VT and related symptoms of subthreshold PTSD develop and the variables or experiences that can contribute to higher levels of vulnerability to VT symptoms. Subthreshold PTSD has been defined as the presence of clinically significant PTSD symptoms that fall short of the full Diagnostic and Statistical Manual of Mental Disorders PTSD diagnostic criteria (Bergman et al., 2015).
VT and Subthreshold PTSD
As noted, VT can have a detrimental impact on all aspects of the counseling process. A counselor experiencing VT can report many of the symptoms associated with both VT and subthreshold PTSD. VT and subthreshold PTSD have been identified as closely related phenomena. Many counselors who experience VT also meet the criteria for subthreshold PTSD and share similar symptoms (Keim et al., 2008). Counselors who experience VT are in essence experiencing post-traumatic stress symptoms in response to hearing and processing the trauma experienced by their clients (Bercier & Maynard, 2015). Common similar symptoms of VT and subthreshold PTSD include experiencing recurring intrusive thoughts about clients or work, numbing of feelings, hypervigilance or increased anxiety, and a decrease in empathy (Howlett & Collins, 2014; Michalopoulos & Aparicio, 2012; Nelson, 2016).
Although there are limitations in the research on the variables that correspond to the development of VT and subthreshold PTSD among counselors, as well as the factors that address these vulnerabilities, the research has highlighted some areas of concern. Understanding these areas is a critical component of addressing the development, assessment, and intervention for VT and subthreshold PTSD, especially for supervisors and counselor educators who train and work with these counselors. One of these variables is years of experience. Although all practicing counselors are at risk for VT and subthreshold PTSD, novice counselors are at an especially elevated risk (Michalopoulos & Aparicio, 2012; Parker & Henfield, 2012). Novice counselors tend to have limited experience with trauma and often have limited training relevant to working with trauma (Newell & MacNeil, 2010; Parker & Henfield, 2012). Further, novice counselors might have trouble establishing boundaries during the early stages of professional identify development, which can contribute to an increase in vulnerability for developing VT and subthreshold PTSD (Howlett & Collins, 2014). Moreover, beginning counselors’ training and personal experiences may not have adequately prepared them for working with individuals dealing with trauma, so in turn they might not have received training on how to address trauma with their clients or identify the development of VT in themselves (Jordan, 2010; Mailloux, 2014; Trippany et al., 2004). It has been recommended that such training should include the key features of trauma, warning signs and symptoms, and strategies to prevent the development of VT and subthreshold PTSD (Newell & MacNeil, 2010).
An essential element of training counselors on strategies to prevent or address the development of VT and subthreshold PTSD includes increasing awareness of the workplace dynamics that may increase vulnerability. Counselors spend a sizeable amount of their time ensuring that others take care of themselves while potentially neglecting their own personal self-care (Whitfield & Kanter, 2014). Neglecting self-care has been found to correspond to an increased rate for developing the negative effects of VT and subthreshold PTSD symptoms (Mailloux, 2014). In an effort to decrease VT and subthreshold PTSD practicing counselors must ensure they are incorporating various types of self-care on a regular basis. Counselors can incorporate self-care activities, such as adequate sleep, social interaction, exercise, a healthy diet, reading, and journaling, into their routine, but all too often practicing counselors let these activities slip (Jordan, 2010; Nelson, 2016).
Related to self-care is helping counselors to understand the importance of seeking support from peers and supervisors. Collaboration and consultation with peers and supervisors at the workplace are vital to minimize the adverse effects of VT and subthreshold PTSD (Jordan, 2010). To address possible VT and subthreshold PTSD, practicing counselors require support from colleagues in relation to case conceptualization and identification of impairment (Newell & MacNeil, 2010; Parker & Henfield, 2012; Whitfield & Kanter, 2014). Additionally, counselors should seek supervision specific to trauma to ensure they are not developing VT symptoms and subthreshold PTSD symptoms (Whitfield & Kanter, 2014). One of the concerns, however, is that for many counselors working at counseling sites with high caseloads related to trauma, there are often low levels of clinical supervision (O’Neill, 2010). These sites also can link to another variable that corresponds to higher levels of VT: the caseload of the counselor. For example, counselors with large caseloads are at increased risk of developing VT or subthreshold PTSD because the counselor may not be able to spend adequate amounts of time on each case and might overextend their time addressing case needs (Whitfield & Kanter, 2014). In addition, counselors with caseloads that deal primarily with trauma are at an increased risk of developing VT and subthreshold PTSD, especially if they have limited clinical experience (Bercier & Maynard, 2015; Newell & MacNeil, 2010; Trippany et al., 2004). Recognizing and understanding the contributors to VT and subthreshold PTSD are essential for counselor educators and supervisors to be aware of as they prepare new counselors to enter the field.
Counselor Educator and Supervisor Implications
When looking at the risk factors associated with VT and subthreshold PTSD, it is clear that a critical component to decrease risk is the training and support provided to counselors. Thus, it is imperative that counselor educators and supervisors be aware of the symptoms and factors that impact the development of VT and subthreshold PTSD. Keim et al. (2008) found that 12% of counselors-in-training (CITs) qualified for a PTSD diagnosis, highlighting the fact that counselor educators and supervisors need to be aware of and educate counselors to recognize the symptoms of VT and subthreshold PTSD. The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) reinforces the importance of this training by specifically requiring that programs educate CITs on trauma-related counseling skills and also engage students in methods to assess and address VT and subthreshold PTSD symptoms in themselves as practicing counselors. To meet this goal, counselor educators and supervisors must more fully understand the causes of VT and subthreshold PTSD (Keim et al., 2008).
This study was developed to assess the frequency of VT and subthreshold symptoms among practicing counselors. This included variables that correspond to the development of these symptoms. The data can contribute to our understanding of VT and subthreshold PTSD symptoms among counselors and provide a framework for working with counselors during supervision and in preparing CITs.
Method
Sample
Two hundred and twenty current practicing counselors completed the nationwide survey. Of the 220 participants, 219 participants reported gender; 23 (10.3%) respondents identified as male and 196 (87.9%) respondents identified as female. Of the participants, 217 (98.6%) reported they were over 19 years of age (range 23–65, M = 39). Two hundred and fifteen respondents indicated holding a master’s degree (97.8%). Thus, exclusion criteria removed five respondents from the data set for not meeting degree requirements—participants must have completed a master’s degree in counseling (i.e., school counseling, clinical mental health counseling, rehabilitation counseling, family and marriage counseling). Current work setting was reported by 207 of the respondents; 137 (62.3%) identified as school counselors, 24 (10.9%) reported working in a community mental health center, 17 (7.7%) reported working in a higher education center, 16 (7.35%) reported working in a private practice, and 13 (5.9%) reported “other,” which included settings such as employee assistance programs and crisis centers.
Six respondents (2.7%) reported less than one year of cumulative counseling experience, 50 (22.7%) reported 1–3 years of cumulative counseling experience, 31 (14.1%) reported 4–5 years of cumulative counseling experience, 47 (21.4%) reported 6–10 years of cumulative counseling experience, and 72 (32.7%) reported 10 years or more of cumulative counseling experience. Of the 220 respondents, 12 (5.5%) did not report how many years they have been in their current position, 8 (3.6%) reported being in their current position less than one year, 103 (10.9%) reported 1–3 years, 31 (14.1%) reported 4–5 years, 30 (13.6%) reported 6–10 years, and 36 (16.4%) reported being in their current position 10 or more years.
Instruments
Participants were asked to complete a brief demographic questionnaire and two surveys, the PTSD Checklist for the DSM-5 (PCL-5), developed by Blevins, Weathers, Davis, Witte, and Domino (2015), and the Secondary Trauma Stress Scale (STSS), developed by Bride, Robinson, Yegidis, and Figley (2004). The demographic questionnaire sought to understand the impact that years of experience, number of contributing factors, and preventive measures have on VT and subthreshold PTSD symptoms. Participants in this study also completed a series of measures assessing the rate of VT among practicing counselors, the number of participants who meet the criteria for subthreshold PTSD, and the impact of the types and number of professional supports on practicing counselors.
Demographic measure. A basic demographic survey was developed and utilized to collect data on each respondent’s age, gender, current position, years of counseling experience, primary type of clientele served, and any licenses and credentials. Text entry was utilized to understand the type and number of professional supports respondents identified: supervision, peer support, years of experience, training specific to trauma, caseload size, and self-care implementation. The demographic survey collected basic information related to the participants’ counseling experience and background to gain an understanding of who chose to participate in the study. Further, the information gained was used to assist in developing implications for counselor educators and supervisors in preparing CITs to recognize VT symptoms and identify the types of professional supports needed.
PTSD Checklist for the DSM-5 (PCL-5). The PCL-5 is a revision of the PTSD Checklist (PCL) that specifically assesses self-report measures of PTSD symptoms as outlined in the DSM-5 (Blevins et al., 2015). The PCL is one of the most widely used measures of PTSD symptoms, and the revised PCL-5 is the only instrument that specifically measures criteria defined in the DSM-5 (Blevins et al., 2015). The PCL-5 is a 20-item survey that corresponds to the 20 PTSD symptoms in the DSM-5 (Bovin et al., 2016). Respondents are asked to rank, from 0–4, how much they have been bothered by the presented symptom within the last month (Bovin et al., 2016). Sample topics include: having difficulty sleeping; feeling jumpy or easily startled; and avoiding memories, thoughts, or feelings related to the stressful event. In a validation study of the PCL-5, Blevins et al. (2015) found high internal consistency (.94), and the measure fell within the recommended range of inter-item correlation of .15 to .50. Test-retest reliability was r = .82 with a 95% confidence interval [.71, .89], and paired t-tests were significant (p < .01) for the PCL-5 between two test validations (Blevins et al., 2015). Cronbach’s alpha for this study indicated high internal consistency (.96) and test-retest reliability of r = .84.
Secondary Trauma Stress Scale (STSS). The STSS, developed by Bride et al. (2004), was used to understand the number of VT symptoms among practicing counselors as well as to determine the relationship between VT symptoms and subthreshold PTSD symptoms among practicing counselors. The STSS is a 17-item self-report measure designed to assess helping professionals who may have experienced secondary traumatic stress and the frequency of intrusion, avoidance, and arousal symptoms (Bride et al., 2004; Ting, Jacobson, Sanders, Bride, & Harrington, 2005).
The STSS asks that respondents endorse how frequently an item was true for them in the past 7 days (Bride et al., 2004). Responses range from 1 to 5 in Likert form (1 = never and 5 = very often). Psychometric data for the STSS indicates very good internal consistency reliability with coefficient alpha levels of .93 for the total STSS scale, .80 for the Intrusion subscale, .87 for the Avoidance subscale, and .83 for the Arousal subscale (Bride et al., 2004). Ting et al. (2005) determined in their validation study of the STSS that internal consistency reliability for the 17 total STSS items was very high (.94) and was moderately high for the Intrusion subscale (.79), the Avoidance subscale (.85), and the Arousal subscale (.87), and all three factors were highly correlated with each other (intrusion–avoidance, r = .96; intrusion–arousal, r = .96; avoidance–arousal, r = 1.0), as indicated by a confirmatory factor analysis. Cronbach’s alpha for this study confirmed Ting et al.’s findings, as internal consistency reliability for the 17 total STSS items was very high (.94) and was moderately high for the Intrusion subscale (.80), the Avoidance subscale (.86), and the Arousal subscale (.89). Statements on the Intrusion subscale inquire about respondents’ intrusion symptomology on a Likert scale with statements such as “My heart started pounding when I thought about my work with clients” and “I had disturbing dreams about my work with clients.” The Avoidance subscale asks respondents to respond on a Likert scale to statements such as “I felt emotionally numb” and “I had little interest in being around others.” The final subscale, Arousal, asks respondents to respond on a Likert scale to statements such as “I had trouble sleeping” and “I expected something bad to happen.”
Procedures
Upon Institutional Review Board approval, participants were recruited via email through listserv solicitation that included the Alabama Counseling Association, the American School Counselor Association, the American Counseling Association, and CESNET. Participants were provided a link to an informed consent document and the research surveys in Qualtrics. Participation was restricted to practicing mental health or school counselors who had a master’s degree in counseling and had been a practicing counselor for at least 6 months at the time of the survey.
Design and Statistical Analyses
The purpose of this quantitative study was to investigate the frequency of VT symptoms and subthreshold PTSD symptoms experienced by practicing counselors. This included the relationship of VT symptoms and subthreshold PTSD symptoms with years of experience, work setting and type of clientele, and the number and type of professional supports utilized by practicing counselors. Descriptive analysis was used to determine what symptoms of VT and subthreshold PTSD practicing counselors experience. A linear regression was used to determine the relationship between VT symptoms and subthreshold PTSD symptoms. Linear regressions were utilized to determine the relationship years of experience, work setting and type of clientele, and professional supports have with VT symptoms and subthreshold PTSD symptoms among practicing counselors.
Results
Symptoms of VT and Subthreshold PTSD Experienced by Practicing Counselors
Descriptive statistics based on participants’ responses indicated symptoms of VT and subthreshold PTSD are being experienced by practicing counselors. On the STSS, all symptoms were experienced to some degree by 49.5% of the participants. Symptoms were rated significant if they scored higher than “never” on the STSS, meaning they had experienced the symptom to some degree within the past 7 days.
The most common symptom of VT experienced by participants was thinking about work with clients when not intending to do so (85.5%), as measured by the STSS. Additional symptoms of VT experienced commonly by participants included feeling emotionally numb (80.5%), becoming easily annoyed (79.1%), having difficulty concentrating (75.5%), and feeling discouraged about their future (75.5%). Experiencing disturbing dreams about their clients (49.5%) and feeling jumpy (56.4%) were the least common symptoms experienced by participants, but 49.5% of the participants experienced these symptoms. Table 1 outlines the VT symptoms of participants as measured by the STSS in descending order.
Table 1
STSS Symptom Distribution
| Items in Descending Order |
n (%) |
| I thought about my work with clients when I didn’t intend to. |
188 (85.5%) |
| I felt emotionally numb. |
177 (80.5%) |
| I was easily annoyed. |
174 (79.1%) |
| I felt discouraged about the future. |
166 (75.5%) |
| I had trouble concentrating. |
166 (75.5%) |
| I had trouble sleeping. |
165 (75.0%) |
| I wanted to avoid working with some clients. |
162 (73.6%) |
| I was less active than usual. |
156 (70.9%) |
| Reminders of my work with clients upset me. |
155 (70.5%) |
| My heart started pounding when I thought about my work with clients. |
155 (70.5%) |
| I had little interest in being around others. |
149 (67.6%) |
| It seemed as if I was reliving the trauma(s) experienced by my client(s). |
133 (60.5%) |
| I expected something bad to happen. |
132 (60.0%) |
| I avoided people, places, or things that reminded me of my work with clients. |
126 (57.3%) |
| I noticed gaps in my memory about client sessions. |
126 (57.3%) |
| I felt jumpy. |
124 (56.4%) |
| I had disturbing dreams about my work with clients. |
109 (49.5%) |
Participant responses to the PCL-5, utilized to measure subthreshold PTSD symptoms, suggested practicing counselors are experiencing subthreshold PTSD symptoms. Symptoms were rated as significant if they scored higher than “not at all,” indicating they had experienced the symptom to some degree within the past month. The most common symptom reported to have been experienced by all participants (100%) was repeated, disturbing, or unwarranted memories of the stressful experience. Other symptoms that were reported to have been experienced commonly by practicing counselors included having trouble falling or staying asleep (71.4%), having difficulty concentrating (70.9%), feeling distant or cut off from other people (68.2%), and feeling very upset when something reminded them of the stressful experience (66.8%). Taking too many risks or doing things that could cause personal harm (36.8%); feeling or acting as if the stressful experience were actually happening again (42.7%); and experiencing repeated, disturbing dreams of the stressful experience (49.1%) were experienced least commonly by participants. Table 2 outlines the VT symptoms of participants as measured by the PCL-5 in descending order.
Table 2
PCL-5 Symptom Distribution
| Items in Descending Order |
n (%) |
| Repeated, disturbing, and unwanted memories of the stressful experience? |
220 (100%) |
| Trouble falling or staying asleep? |
157 (71.4%) |
| Having difficulty concentrating? |
156 (70.9%) |
| Feeling distant or cut off from other people? |
150 (68.2%) |
| Feeling very upset when something reminded you of the stressful experience? |
147 (66.8%) |
| Irritable behavior, angry outbursts, or acting aggressively? |
139 (63.2%) |
| Avoiding memories, thoughts, or feelings related to the stressful experience? |
139 (63.2%) |
| Having strong negative feelings such as fear, horror, anger, guilt, or shame? |
134 (60.9%) |
Having strong physical reactions when something reminded you of the stressful experience
(for example, heart pounding, trouble breathing, sweating)? |
130 (59.1%) |
| Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? |
127 (57.7%) |
| Being “superalert” or watchful or on guard? |
125 (56.8%) |
| Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? |
125 (56.8%) |
| Loss of interest in activities that you used to enjoy? |
123 (55.9%) |
| Blaming yourself or someone else for the stressful experience or what happened after it? |
121 (55.0%) |
| Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? |
119 (54.1%) |
| Feeling jumpy or easily startled? |
116 (52.7%) |
| Trouble remembering important parts of the stressful experience? |
113 (51.4%) |
| Repeated, disturbing dreams of the stressful experience? |
108 (49.1%) |
Suddenly feeling or acting as if the stressful experience were actually happening again
(as if you were actually back there reliving it)? |
94 (42.7%) |
| Taking too many risks or doing things that could cause you harm? |
81 (36.8%) |
Relationship Between VT Symptoms and Subthreshold PTSD Symptoms
Linear regression models determined the relationship between VT symptoms and subthreshold PTSD symptoms among practicing counselors. In a backward regression, the PCL-5, measuring subthreshold PTSD symptoms, was entered as the dependent variable, and the subscales of the STSS, measuring VT symptoms, were entered as the independent variables. Results indicated that the more VT symptoms were experienced by practicing counselors, the more subthreshold PTSD symptoms were experienced. There was a significant relationship between results from the PCL-5 and all three STSS subscales. The relationship between subthreshold PTSD symptoms and the Intrusion subscale was significant (r = .676, p < .001). There also was a significant relationship between subthreshold PTSD symptoms and avoidance symptoms (r = .759, p < .001), and between subthreshold PTSD symptoms and arousal symptoms (r = .790, p < .001). Avoidance VT symptoms and arousal VT symptoms were the most predictive variables associated with developing subthreshold PTSD symptoms as evidenced in the restricted model regression summary. In the backward regression model, the Intrusion subscale of the STSS was eliminated as the least significant variable, which indicates the more arousal and avoidance symptoms were experienced as VT, the more subthreshold PTSD symptoms were experienced by the practicing counselors. In the full regression model (R2 Full = .656, F = 103.4, p < .001), results suggested a significant relationship, indicating that the more VT symptoms were experienced by practicing counselors, the more subthreshold PTSD symptoms were experienced. Through the restricted regression model (R2 Restricted = .655, F = 155.75, p < .001) and the F change test, results indicated that the restricted model is not worse than the full model because the observed F (.00000892; p = .647) does not exceed the critical F (df = 1,163), which is 3.94.
Relationship Among Demographics and Type of Professional Supports Among Practicing Counselors on VT
A backward linear regression model was utilized to determine the relationship between VT symptoms and years of experience, work setting and type of clientele, and type of professional supports among practicing counselors. There were two significant relationships within this regression in the restricted model of the regression. There was a significant negative correlation between VT symptoms and having a manageable caseload, indicating the more manageable caseload the counselor has, the fewer VT symptoms they have. In addition, there was a significant negative correlation between VT symptoms and having adequate supervision, indicating the more supervision received, the fewer VT symptoms experienced. Overall, the two variables (caseload and supervision) correlate with the dependent variable, VT symptoms (r = .273, R2 = .074). This overall correlation is unlikely due to chance (F = 8.159, p < .001). The F change test indicated the observed F (2.008; p = .158) does not exceed the critical F (df = 1, 202), which is 3.89. The semi-partial correlation between caseload and VT symptoms was -.173, while the semi-partial correlation between supervision and VT symptoms was -.150. The semi-partial correlation indicates the uniqueness of the relationship. The squared semi-partial correlation for supervision was (-.173)2 = .029, and the squared semi-partial correlation for caseload was (-.150)2 = .02., *p < .05.
Relationship Between Demographics and Type of Professional Supports Among Practicing Counselors on Subthreshold PTSD Symptoms
A backward linear regression model was utilized to determine the relationship between subthreshold PTSD symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports among practicing counselors. With subthreshold PTSD symptoms as the dependent variable and years of experience, work setting and type of clientele, and type of professional supports as the independent variables, a backward linear regression was run to understand the relationship between the variables in the restricted model of the regression. Results indicated a significant relationship between subthreshold PTSD symptoms and those counselors who work primarily with adolescents or with sexual assault/domestic violence survivors. Overall, the two variables (adolescents and sexual assault/domestic violence) correlate with our dependent variable, subthreshold PTSD symptoms (r = .242, R2 = .059). This overall correlation is unlikely due to chance (F = 5.080, p = .007). The F change test indicated the observed F (2.255; p = .135) does not exceed the critical F (df = 1,162), which is 3.94. The semi-partial correlation between adolescents and subthreshold PTSD symptoms was .159, while the semi-partial correlation between sexual assault/domestic violence and subthreshold PTSD symptoms was .187. The semi-partial correlation indicates the uniqueness of the relationship. The squared semi-partial correlation for adolescents was (.159)2 = .025, and the squared semi-partial correlation for sexual assault/domestic violence was (.187)2 = .03. This data indicates that work setting and the type of clientele served by the counselor can influence risk for developing subthreshold PTSD symptoms.
Limitations
One limitation for this study was the high percentage of participating school counselors (62.3%). This could have possibly skewed results as the type of clientele that the practicing counselors primarily worked with exhibited the most influence on symptoms of VT and subthreshold PTSD (i.e., adolescents). Additionally, this large percentage of school counselors could make the implications suggested in this study not as applicable for counselors in higher education settings.
An additional limitation of this study was the lack of demographics available to identify if counselors were in a rural setting or urban setting. Although the implications suggested are applicable to all counselors, demographic location could serve as an additional barrier to implementing the professional supports suggested.
Discussion
The purpose of this study was to develop an understanding of the frequency and characteristics of VT symptoms and subthreshold PTSD symptoms among practicing counselors, which was answered by the first research question. The most common VT symptom experienced by participants (85.5%) was thinking about their work with clients when they did not intend to outside of work. This finding is significant for counselor educators and supervisors as it indicates that VT symptoms are being experienced by the majority of the counselors in this study. All VT symptoms, as measured by the STSS, were experienced by 49.5% of the participants, indicating all 17 VT symptoms measured had been experienced to some degree by the counselors that participated in this study. This study adds to the current literature reported by Bride (2007) that 50% of child welfare counselors experience traumatic stress symptoms within the severe range. In addition, Cornille and Meyers (1999) reported 37% of their sample of child protection service workers reported clinical levels of emotional distress associated with secondary trauma, and Conrad and Kellar-Guenther (2006) reported 50% of child protection workers suffered “high” to “very high” levels of compassion fatigue.
In addition to measuring VT symptoms, the first research question was developed to acquire an understanding of the frequency of subthreshold PTSD symptoms experienced by counselors. Subthreshold PTSD symptoms were measured by the PCL-5 and results suggest practicing counselors are experiencing subthreshold PTSD symptoms. Of the 20 items in the PCL-5, all but three were experienced by at least 50% of the participants. All 220 (100%) of participants reported experiencing repeated, disturbing, and unwanted memories of the stressful experience. This finding is similar to that found by the STSS in that over 85% of participants had unwanted thoughts about experiences with clients outside of work. Furthermore, over 70% of participants reported having trouble sleeping and having difficulty concentrating in both the STSS and PCL-5 as symptoms of VT and subthreshold PTSD. Understanding the symptoms of VT and subthreshold PTSD experienced by participants was important, as previous studies have indicated that those who experience VT symptoms also experience subthreshold PTSD symptoms (Jordan, 2010). Additionally, the literature has reported VT symptoms and subthreshold PTSD symptoms as being one and the same (Finklestein et al., 2015).
The second research question was developed to gain an understanding of the relationship between VT symptoms and subthreshold PTSD symptoms. A linear backward regression with the PCL-5 measuring subthreshold PTSD symptoms was entered as the dependent variable, and the subscales of the STSS, measuring VT symptoms, were entered as the independent variables. Results from this regression model indicated that the more VT symptoms were experienced by practicing counselors, the more subthreshold PTSD symptoms were experienced. In the backward regression model, the Intrusion subscale of the STSS was eliminated as the least significant variable, which indicated that the more arousal and avoidance symptoms were experienced as VT, the more subthreshold PTSD symptoms were experienced by the practicing counselors, with the Intrusion scale not being significant. This finding is consistent with the extant literature that has reported VT symptoms being analogous to PTSD symptoms (Keim et al., 2008). Furthermore, this finding also is consistent with prior literature that reported counselors who experience VT symptoms also experience PTSD symptoms (Bercier & Maynard, 2015), as found in Bride’s (2007) study in which 34% of child welfare workers met the PTSD diagnostic criteria because of VT.
In an effort to answer the second research question, which was interested in the relationship between VT symptoms and subthreshold PTSD symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports, two backward linear regression models were established. The first linear regression model was interested in the relationship between VT symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports among practicing counselors. In this backward linear regression model, the STSS served as the dependent variable with years of experience, work setting and type of clientele, and the number and type of professional supports serving as the independent variables. Results indicate a significant relationship between VT symptoms and having a manageable caseload as well as between VT and utilizing supervision. A negative correlation between VT symptoms and having a manageable caseload indicates that the more manageable a counselor’s caseload, the less likely they were to experience VT symptoms. This finding is consistent with prior studies that indicate a manageable caseload as being a protective factor for counselors that can decrease their chance of developing both VT symptoms and subthreshold PTSD symptoms (Trippany et al., 2004). Additionally, there was a negative correlation between supervision as a professional support and the development of VT symptoms among counselors. Adequate supervision has been identified as a protective factor against the development of VT (Harrison & Westwood, 2009). Both of these findings are important implications for counselor educators and supervisors as they can be initiated in the classroom while CITs are preparing for a career in the counseling profession.
The second linear regression model focused on the relationship between subthreshold PTSD symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports among practicing counselors. In this backward linear regression model, the PCL-5 served as the dependent variable with years of experience, work setting and type of clientele, and the number and type of professional supports serving as the independent variables. Results indicated a significant relationship between subthreshold PTSD symptoms and counselors who primarily work with adolescents and sexual assault/domestic violence survivors. These findings are consistent with prior literature that has indicated sexual assault counselors report more VT symptoms and subthreshold PTSD symptoms. For instance, Bride (2007) reported 65% of domestic violence and sexual assault social workers reported at least one symptom of VT, while Lobel (1997) reported over 20 years ago that 70% of sexual assault counselors experienced VT. Additionally, Schauben and Frazier (1995) reported that counselors who work with a higher percentage of sexual assault survivors report more disrupted beliefs about themselves and others, more subthreshold PTSD symptoms, and more VT than counselors who see fewer sexual assault survivors.
Implications for Counselor Educators and Supervisors
The results of this study provide counselor educators and supervisors with information to prepare CITs to have an increased awareness of VT and subthreshold PTSD symptoms. This study established evidence that practicing counselors are experiencing numerous VT symptoms and subthreshold PTSD symptoms. In fact, this study found that all VT symptoms measured were experienced by 49.5% of the participants, and 17 of the 20 PTSD symptoms measured were experienced by all participants. Further, in an open-ended question in the brief demographic survey, participants provided the researcher with ideas they felt would increase awareness of VT and subthreshold PTSD and decrease VT and subthreshold PTSD symptoms. Over 40% of responses indicated a desire for more education on VT symptoms and subthreshold PTSD symptoms. With 49.5% of participants reporting VT symptoms and subthreshold PTSD symptoms, it is evident that additional education is needed related to these symptoms among practicing counselors. Keim et al. (2008) suggested educational trainings and workshops be provided to CITs proactively to increase awareness of VT and subthreshold PTSD and to decrease VT symptoms and subthreshold PTSD symptoms among practicing counselors. Counselor educators and supervisors can provide trainings on the signs and symptoms of VT and subthreshold PTSD experienced by counselors to raise awareness of these symptoms and ways to recognize and alleviate them before causing harm to the counselor or client.
This study denoted that counselors who work primarily with adolescents and sexual assault/domestic violence survivors are experiencing more subthreshold PTSD symptoms than counselors that do not work specifically with these populations. As counselor educators prepare CITs for practicum, internship, and employment as counselors, it is vital for counselor educators to acknowledge the unique challenges that may stem from working with adolescents and survivors of sexual assault/domestic violence. It is imperative that counselor educators and supervisors integrate specific educational material through coursework related to these populations to best prepare CITs. Evidence-based practices that are effective for counseling these populations should be implemented within counselor education programs, supervision, workshops, and trainings outside of the degree program (e.g., at conferences; Alpert & Paulson, 1990; Mailloux, 2014; Whitfield & Kanter, 2014).
Education on the significance of professional supports, such as adequate supervision and manageable caseloads, is fundamental for CITs to be prepared to lessen the hazard of developing VT symptoms and subthreshold PTSD symptoms. By providing sufficient supervision during practicum and internship, counselor educators and supervisors can prepare CITs for coping with VT symptoms and subthreshold PTSD symptoms should they develop. In addition, through modeling appropriate supervision, CITs will comprehend the supervisory process and seek post-degree supervision.
Directions for Future Research
Future studies on VT symptoms and subthreshold PTSD symptoms need to focus solely on clinical mental health counselors or school counselors to develop implications specific to counseling sites. Further research devoted to the development of workshops and trainings to educate counselors on VT and subthreshold PTSD is needed.
A future study that compares counselors in rural settings and urban settings will be important to understand barriers to coping with and addressing VT symptoms and subthreshold PTSD symptoms. For example, in a rural setting, the counselor may not have adequate supervision and may be overloaded with cases, which can decrease the amount of self-care they are able to implement. It will be important for future research to explore what barriers to professional supports counselors face in these different demographic communities.
Because of this study’s finding that working primarily with adolescents and individuals who have experienced sexual assault or domestic violence increases counselors’ chances of experiencing VT symptoms and subthreshold PTSD symptoms, a qualitative or mixed-methods study focused on VT among counselors working with these populations is desirable. In an effort to best prepare students who will work with these populations, an understanding of exactly which aspects of working with these clients increase VT symptoms and subthreshold PTSD symptoms is essential.
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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Bethany A. Lanier, NCC, is an assistant professor at the University of West Georgia. Jamie S. Carney is a professor at Auburn University. Correspondence can be addressed to Bethany Lanier, 1601 Maple Street, Carrollton, GA 30116, blanier@westga.edu.
Nov 14, 2019 | Volume 9 - Issue 4
Angela K. Tang, Kok-Mun Ng
Based on archival data from an urban school district, this retrospective correlational study examined the extent to which certain types of student–school counselor contacts, based on a student-report high school exit survey, could predict high school students’ postsecondary enrollment in 2- and 4-year colleges within 5 years of graduating from high school. In addition to these variables, information such as ethnicity, grade point average, and free and reduced lunch status were used to identify other trends in the data. Multiple logistic regression analysis showed that counselor contact regarding college planning and attendance and demographic information regarding free and reduced lunch status were significant predictors of postsecondary enrollment. Counselor contact regarding goal setting, concerns about grades, and needing more college information did not significantly predict postsecondary college enrollment. Findings suggest some school counselor duties can serve as sources of social capital, which can help increase student social capital.
Keywords: school counselor, postsecondary college enrollment, reduced lunch, free lunch, social capital
According to the American School Counselor Association (ASCA; 2012), the role of school counselors is to remove barriers to academic success through establishing a comprehensive counseling program and providing appropriate services. This includes, but is not limited to, developing and imparting counseling curriculum based on school need, intentional guidance lessons, connecting with other stakeholders, planning, and counseling students at all levels. Through these various functions, school counselors interact with and impact students they serve. Statewide studies focusing on school counseling programs have found that comprehensive school counseling programs assisted in increasing test scores, improving student grades, lowering suspension rates, and increasing feelings of school connectedness (Carey, Harrington, Martin, & Hoffman, 2012; Carey, Harrington, Martin, & Stevenson, 2012; Lapan, Gysbers, & Petroski, 2001; Lapan, Gysbers, & Sun, 1997).
According to the National Center for Education Statistics (NCES), only 66.2% of graduating high school students enrolled in a 2-year or 4-year college in Fall 2012 (NCES, 2015a, row 52). Recently, there have been increased efforts to matriculate students to higher education after high school as national attention focuses on the United States’ post-industrial society and its effects on enrollment (Clinedinst & Koranteng, 2017; Hill, 2012; NCES, 2015b). Former First Lady Michelle Obama launched the Reach Higher Initiative (n.d.), which introduced the idea of a national signing day to encourage and inspire all students, especially low-income and first-generation students, to attend college. Some key individuals who are primed to support all students in the transition from high school to postsecondary education, especially for lower socioeconomic status and minority populations, are high school counselors (Holcomb-McCoy, 2010). Elementary and middle school counselors play a crucial role in preparing students for high school, yet high school counselors are held the most responsible for ensuring students’ successful transitions to life after high school (Carey & Dimmitt, 2012). Through the present study, we sought to add to the literature by examining the extent to which school counseling contacts predict high school students’ postsecondary enrollment. We believe that such focus will help school counselors self-advocate for duties that support successful postsecondary enrollment.
Roles, Responsibilities, and Challenges of a High School Counselor
High school counselors, while meeting academic, career, personal, and social student needs, also play a crucial role in ensuring their students are on track for high school graduation, assisting in college applications, and filling out financial aid applications, especially for first-generation and marginalized students who rely more heavily on school counselors to complete the process (Lapan, 2012; Martinez, 2013; McDonough, 2005). Though increasing college and career services is a current focus in K–12 education, frequently, the college and career services that school counselors wish to provide are at odds with administration and school districts’ work expectations and emphasis for school counselors (Carey, Harrington, Martin, & Hoffman, 2012; Paolini & Topdemir, 2013). Instead of being able to wholly focus on providing personal, social, and college and career services, school counselors are oftentimes saddled with administrative tasks such as entering transcripts, grade verifications, and test proctoring. This has led to an internal push in the school counseling profession to provide data to support the positive impact school counselors have on their students (Brigman & Campbell, 2003; Hurwitz & Howell, 2014).
Impact of School Counselor Interventions on Postsecondary Outcomes
Most studies related to high school counseling have focused specifically on how school counselor caseload size influences school counseling duty outcomes. Whether it was assisting with college applications (Bryan, Moore-Thomas, Day-Vines, & Holcomb-McCoy, 2011), spending more than half their time on college-related topics (Engberg & Gilbert, 2014), increased opportunity for individual planning (Woods & Domina, 2014), or higher rates of 4-year college enrollment (Hurwitz & Howell, 2014), smaller school counselor caseloads were demonstrated to positively influence students’ postsecondary plans. One study specifically examined first-generation and low-income students. Pham and Keenan (2011) found that the lower the first-generation student–counselor ratio, the higher the likelihood that a qualified first-generation student would enroll in a 4-year university. This finding corroborates existing findings that show first-generation and low-income students tend to rely more heavily on school-provided services, and the degree to which school counselor support can improve student access to higher education. Belasco (2013) highlighted the association between school counselor meetings with students and subsequent postsecondary enrollment; however, the study only examined the first fall after high school graduation and excluded enrollment in 2-year institutions in the analysis.
The abovementioned studies support the argument that school counselors contribute to students accessing postsecondary planning and support. Specifically, findings in the studies indicate that specific contacts with school counselors contribute to students’ 4-year college postsecondary enrollment. With that said, despite the literature that supports school counseling and highlights the extent to which school counselors can positively impact students, there has been a lack of conversation regarding which specific counselor contacts may contribute most to postsecondary enrollment, as well as enrollment in both 2- and 4-year institutions (NCES, 2005). Thus, it is crucial to examine what exact contacts school counselors have with students that potentially influence student postsecondary enrollment in order to advocate for more time to do those activities.
Purpose of the Study
The focus of this study was to examine specific school counseling contacts and their influence on students’ postsecondary enrollment. Specifically, we wanted to know whether students’ contacts with school counselors influence students into matriculating to higher education. We hoped to fill a gap in the research by examining specific counselor contacts that support student achievement, in addition to expanding the examined postsecondary institution enrollment window beyond the fall immediately following graduation. The ultimate goal is that our findings will provide information to the profession and its advocates, such as ASCA, to assist with their advocacy efforts and policy recommendations.
Based on the gaps in the existing research, the primary research question that guided our study was: To what extent do the following student–school counselor contacts, as reported by graduating high school students, predict postsecondary institution enrollment (2- and 4-year inclusive): (1) contact related to attendance, (2) contact related to college planning/scholarship support, (3) contact related to concerns about grades, and (4) contact related to goal setting?
The secondary research question was: To what extent do culminating GPA in high school, free and reduced lunch (FRL) status, and a student’s ethnicity predict enrollment in a postsecondary institution (2- or 4-year inclusive)? In addition to the above student–school counselor contact variables, we included a predictor variable that assessed students’ perception of the college search and application process. This data came from student responses to the survey question: Were there parts of the college search and/or application process you felt you needed more assistance or information?
Method
Design
The present study was a retrospective study that used binary multiple logistic regression to analyze an archival dataset. The central data was high school students’ reported contacts with their school counselors as related to subsequent college enrollment.
Two types of data were collected for each student. The first type was data regarding students’ contacts with counselors while in high school. This data was drawn from a district database, which was comprised of data from 17 high schools. The data came from a Senior Exit Survey (required of all 12th-grade students) and general background information (GPA, FRL status, and ethnicity). The second type was data regarding student enrollment in a postsecondary course of study. This data was drawn from the National Student Clearinghouse (NSCH; n.d.) to ascertain if students enrolled in a 2- or 4-year college in any of the 5 years following graduation.
District Information
The school district studied is a large urban school district in a Western state in the United States. As an urban district, it encompasses both suburban and urban areas and at the time of this study, the total K–12 enrollment was 79,423. The district follows the ASCA National Model (ASCA, 2012) and encourages comprehensive school counseling program implementation at each site.
Participants
The target population studied was the 2,276 12th-grade students who were slated to graduate. We selected this cohort in order to include 5 years of postgraduate data regarding whether they enrolled or did not enroll in 2- or 4-year postsecondary institutions. Of the 2,276 students, 67 were excluded because of missing information necessary for the study. The final 2,209 in the study sample consisted of 0.04% Hawaiian/Pacific Islander, 0.09% Native American, 0.09% two or more races, 3.9% Asian, 20% African American/Black, 30% White, and 47.5% Hispanic/Latinx. This breakdown is representative of the district at large. Of the sample used, 1,181 (53%) students qualified for FRL, while 1,028 (47%) did not qualify.
Because of the small number (n = 19) of Native American, Hawaiian/Pacific Islander, and “two or more race” students, we did not use these ethnicities in our regression model. Representing all students is crucial in school counseling; however, with such small sample sizes, it might make the students personally identifiable (NCES, 2017). The Every Student Succeeds Act (ESSA) also has guidelines regarding minimum numbers of n-size requirements to make statistical inferences in state accountability systems, and 19 did not make the minimum (Alliance for Excellent Education, 2018).
Measures
Senior Exit Survey. This school district administers its Senior Exit Survey to each senior every school year between May 15 and June 15. The purpose of the survey is to assess the types of support services students accessed during their high school careers. The survey includes questions that directly answered the research questions posed for this study: whether students had met with their school counselor about (a) attendance; (b) college planning, applications, essays, and scholarships; (c) concerns about grades; and (d) goal setting (all responses coded as 0 for not met, and 1 for met). The survey also included a question that asked students, “Were there parts of the college search and/or application process you felt you needed more assistance or information?” We incorporated responses to this survey question into the current study as an additional predictor variable because we wanted to examine if the perception of needing more assistance resulted in students not enrolling in either a 2- or 4-year college (all responses coded as 0 for not attended, and 1 for attended).
National Student Clearinghouse data. NSCH data is collected from over 3,600 colleges and universities, both private and public. Membership in the Clearinghouse is open to any postsecondary institution that participates in the Federal Title IV program. The data includes degrees obtained and enrollment in postsecondary institutions (NSCH, n.d.). The specific information used as the outcome variable in our study was if students enrolled in a 2- or 4-year postsecondary institution at least once in the 5 years after graduating from high school (coded as 1 for yes, or 0 for no). We used the 5-year time frame because not all students enroll immediately in college upon graduation, and we wished to capture students who enrolled later (NCES, 2005; Rowan-Kenyon, 2007).
District data. Student data that has been known to reflect achievement and postsecondary enrollment were provided by the district as well. District data included in the data analysis was: (a) ethnicity, (b) GPA, and (c) FRL status.
Data Construction and Analysis
A de-identified dataset was obtained from the school district’s research department after receiving a research proposal. As the dataset was de-identified and had already been collected, the university IRB committee determined that an IRB application for human subjects was not required. A multiple logistic regression was performed, with binary and scale variables, using SPSS Statistics 22.0 to examine whether the set of school counseling duties (dependent variables) are statistically significant in predicting 2- or 4-year institution enrollment (independent variable). In addition to these, background supplemental independent predictor variables were included to assess their relative contribution to the outcome response. School counseling duties, FRL status, and ethnicity were coded as binary variables, and GPA was coded as a scale (A = 4, B = 3, C = 2, D = 1, F = 0).
Some data was recoded in order to condense some of the information. One piece of the dataset that was recoded was the NSCH data. As there were 5 years of postsecondary enrollment data, it was condensed and recoded to create one variable that indicated if the individual had been enrolled (yes or no) in a postsecondary institution, either 2- or 4-year, during those 5 years.
In order to ascertain the number of participants required to make for a robust study, G*Power (Heinrich, 2014) was used. According to the information, 89 individuals are the minimum number of participants required to ensure the results had enough power, and our sample size far exceeded the minimum requirement. In order to reduce the possibility of a Type II error, we used an alpha level of .05 to determine statistical significance.
Results
School Counselor Contacts
Multiple logistic regression was conducted to determine which dependent variables of school counselor contact (i.e., attendance, college planning, concerns about grades, goal setting) and demographic variables (i.e., FRL status, GPA, ethnicity, and perception of needed additional assistance with college topics) were statistically significant predictors of enrollment at least once in a 2- or 4-year postsecondary institution. Regression results indicated the overall model of eight predictors: four dependent variables (meeting with school counselors about college planning, concerns about grades, attendance, and goal setting) and four demographic variables (FRL status, GPA, ethnicity, and perception of needing more assistance with college-related topics). The model of eight predictors was statistically reliable in distinguishing between students who did not enroll in postsecondary institutions and those who did. The Nagelkerke R2 = .262 (p < .0001) indicated that the predictor variables accounted for about 26% of the variability in student outcomes. The Hosmer and Lemeshow test indicated the goodness-of-fit (p = .381, X2 = 8.559). Significance levels and odds ratios are presented in Table 1.
Table 1
Logistic Regression Analysis Predicting Postsecondary Enrollment at Least Once (N = 2,209)
Sig. Exp(B)
Weighted GPA .000 2.222
FRL Status (1) .021 .771
College Planning (1) .000 1.436
Concerns About Grades (1) .659 1.049
Goal Setting (1) .687 .754
Attendance .000 .577
Needing More Assistance? (1) .772 1.029
Ethnicity
White .873 .924
Black .093 2.308
Asian .591 1.354
Hispanic/Latinx .305 .605
Constant .001 .183
Note. FRL = Free and reduced lunch; Needing More Assistance? = Were there parts of the college search and/or application process you felt you needed more assistance or information?; (1) = Student met with school counselor for indicated contact type, qualified for FRL, and/or felt they needed more assistance/information.
Of the variables, four did not have significant group differences: ethnicity, concerns about grades, goal setting, and perceptions of further need regarding postsecondary topics. But, FRL status, GPA, college planning contact, and attendance contact with school counselors all had significant group differences as to whether a student enrolled at least once in a postsecondary institution or not within 5 years of high school graduation. Specifically, students who participated in FRL programs were 22.9% less likely than those who did not participate in those programs to attend either a 2- or 4-year college. Students who met with their school counselor regarding attendance were 24.6% less likely to attend a postsecondary institution during the same time frame. The odds for students with higher GPAs (95% CIs [1.93, 2.55]) to enroll in a postsecondary institution at least once were 122% higher than for those with lower GPAs. The likelihood for students to attend a 2- or 4-year postsecondary institution at least once in the 5 years post-graduation was 43.6% higher for those who met with their school counselor concerning college planning than for those who did not.
Based on the variables, the analysis also predicted if a student would enroll in a postsecondary institution within 5 years of high school graduation. The model classified 69.8% of the cases correctly regarding if a student enrolled at least once in a postsecondary institution based on the variables introduced in our study.
Interesting information regarding postsecondary enrollment and GPA was uncovered during the data analysis portion of this process (see Table 2). There were a significant number of students who did not enroll in postsecondary institutions despite having above a 3.0 GPA. In addition to this, there were significantly more students who had a GPA between 2.0 and 3.0 who did not enroll in a postsecondary institution, even though their grades were more than sufficient to do so. It is possible that the students who had qualifying GPAs but did not appear to attend a college may have attended one that did not participate in National Clearinghouse data collection. It also is possible that students who participated in special education non-college classes artificially inflated the number of students with high GPAs.
Table 2
Variables and Average GPA
Weighted GPA Mean
Attendance Did Not Meet About Attendance 3.07
Met About Attendance 2.34
College Planning Did Not Meet for College Planning 2.63
Met for College Planning 3.06
FRL Status Not FRL 3.24
FRL 2.55
Enrolled at Least Once Not Enrolled 2.45
Enrolled 3.15
Note. FRL = Free and reduced lunch.
Discussion
It is not surprising that findings in this study support extant findings that suggest school counselor interventions positively impact student-related outcomes and constitute a source of student social capital (Bryan et al., 2011). Social capital can be defined as relationships and influencing connections that individuals have with others and the system in which they live (Coleman, 1988). In this context, our findings have important implications for school counselors, school administrators, and legislators. Additionally, the results also contribute much needed data to the existing literature examining strategic school counseling interventions and accountability in assisting students with matriculating to higher education.
This study supported previous findings about the influence of socioeconomic status and school-provided support in assisting students to enroll in postsecondary institutions (Martinez, 2013; Stanton-Salazar & Dornbusch, 1995). Findings indicate that students in this school district who met with their counselors for college planning were 1.4 times more likely to enroll in postsecondary institutions within 5 years of graduating high school compared to students who did not. It is reasonable to think that students who consult with their counselors for college planning have already decided they will attend a postsecondary institution; however, it is also reasonable to think that contact with counselors in relation to college planning might have encouraged some students who were not as motivated or resourceful to pursue postsecondary education. Regardless of students’ postsecondary institution intentions before school counselor contact, the fact that there is opportunity to discuss college-related information is beneficial. Either way, this finding can support the argument that school counselors need sufficient time to provide college-related services for students, which can impact their postsecondary enrollment.
This study further highlights that students who met with their school counselors regarding attendance were 24.6% less likely than their peers to attend a postsecondary institution within 5 years of graduating high school. It is within reason to expect that students who meet with their counselor regarding attendance are generally doing so because attendance is an issue that puts them in the “at-risk” category. This highlights the fact that students who miss school may be less engaged or have other personal and social factors occurring in their lives that hinder school performance and consequently derail them from pursuing a postsecondary college education. This information highlights the topics of prevention and intervention, both of which school counselors can and are expected to provide. However, with large caseloads and assigned duties outside of what ASCA specifies as appropriate for school counselors, they are unlikely to be able to provide adequate attention and intervention for students in need (McKillip, Rawls, & Barry, 2012). As such, this information can be useful in advocating for more time dedicated to the intentional interventions needed.
The other variables examined were goal setting, GPA, concerns about grades, ethnicity, and perceptions of needing more assistance with college-related items. None of these variables statistically predicted postsecondary enrollment. It is possible that because there are many different areas of goal setting, not just postsecondary goal setting, there was no correlation found. The same can be said for contact with school counselors regarding concerns about grades. It was interesting that the perception of needing more assistance with college-related items did not predict postsecondary enrollment. One reason might be that because it is a confusing process, even if students needed more assistance, it is possible they had already completed the correct steps for enrollment. Though ethnicity was not found to be statistically significant during post-hoc analysis, interesting patterns were observed.
Latinx students were much less likely to attend a postsecondary institution at least once, even though they did not meet with their school counselor at different rates than their peers (Stanton-Salazar & Dornbusch, 1995). This leads to discussion regarding specific school counselor interventions with Latinx students and their families. School counselors can be sources of social capital and more information is needed to identify school-based interventions that may successfully assist more Latinx students to enroll in postsecondary institutions.
Curiously, the mean GPAs of students who did not meet with school counselors regarding attendance and college planning, although they were lower than students who did meet, were still high enough to apply to 4-year colleges, and students would thus also have the opportunity to enroll in a 2-year institution. The same pattern was noticed between students who qualified for FRL and those who did not, and those who enrolled and those who did not. Although those who did qualify for FRL and those who did not enroll had an overall lower mean GPA, both groups still would have qualified for a 4-year institution based on mean GPAs. This leads to a discussion regarding successful school counseling interventions that can target students who qualify but do not enroll (Bozick & DeLuca, 2005; Kim, 2012; NCE, 2005; Pham & Keenan, 2011).
Overall, the data and the analyses supported the desired goal of this research study. In examining the variables, we were able to find supporting evidence that certain student–school counselor contacts had a statistically significant relationship to the students’ subsequent enrollment in a 2- or 4-year institution within 5 years of high school graduation. We also inadvertently discovered data that supports further research into tiered intentional interventions for students who qualify for postsecondary options but choose not to attend. Although this study highlights how school counselors are well-positioned to provide postsecondary preparation services and how students can benefit, we also hope it informs professional practice as an advocacy tool and in areas for subsequent research.
Limitations
It must be noted that our results are only representative of the individuals who took the Senior Exit Survey in the study sample. The results from this study cannot be directly generalized to other districts, as this district produces its own required core curriculum lessons in addition to its own exit survey. Though the number of participants is much larger than required by G*Power, there are advantages to this, as the study has the ability to detect smaller differences than if there were fewer participants. Another factor that must be mentioned is the varying degrees to which the ASCA National Model is implemented at each site. Though there were evaluations and a district push for comprehensive counseling programs at each site, some programs in the district were more fully implemented than others. It is uncertain how the level of comprehensive counseling program implementation confounds the results. Further research examining this topic and caseload size would be beneficial.
Additionally, a limitation that must be mentioned is that even though there are 3,600 2- and 4-year postsecondary institutions that participate in providing NSCH enrollment data, there are higher education institutions that do not participate. If institutions choose not to participate or if they do not receive federal financial aid, such as international institutions, students’ postsecondary enrollment data will not appear if they enroll in these institutions. Also, trade schools that help postsecondary students with skills are not included in this data. Hence, some of the students in this cohort who did not show up as having enrolled in postsecondary colleges might have enrolled in these other postsecondary institutions.
Furthermore, because of the limitations of the data collected, it was difficult to ascertain the quality of the contact that students had with their school counselor; for example, who initiated the meeting, how frequently and for how long did they meet, and what was the quality of their encounter? Related to data limitations, closer examination of small n-size student ethnicity groups should be conducted as well, as there may be factors unique to them. Lastly, as this was a correlational study, findings do not show causality. Future investigations should further explore the student–counselor dynamic and what characteristics may lead to more successful student outcomes related to postsecondary enrollment. Also, future studies should examine students’ experiences with counseling during high school as it relates to their persistence in college enrollment, which our study did not address.
Implications for School Counseling
This study has some important implications regarding high school counselors and college counseling. For many students, school counselors serve as bridges to social capital in the college attainment process. Although there are a variety of factors that influence student postsecondary enrollment, two specific contacts with school counselors in this district were significantly related to the likelihood of attending a postsecondary institution. Specifically, contact with school counselors regarding attendance was associated with a decreased likelihood of postsecondary enrollment, while contact with school counselors about college planning was associated with a higher likelihood of postsecondary enrollment. Though the study was exclusive to one particular school district, the demographic makeup is not unique. The findings of this study point to the need for school counselors to meet with their students regarding college-related topics, and a need to pay attention to students who have attendance issues because of the likelihood of them being at risk for not succeeding academically. Also, our findings indicate that attention needs to be given to Latinx students and students from lower socioeconomic backgrounds in order to help improve their access to higher education.
The obstacles school counselors face with regard to caseload size and non-counseling administrative duties severely hinder their ability to meet the needs of their students. The fact that these students who had met with their school counselors for college planning showed a higher likelihood of attending a postsecondary institution clearly supports the fact that school counselors can play a significant role as sources of social capital for students in postsecondary enrollment.
Because this study only examined a limited number of college-related school counselor contacts, future studies should investigate the quality, type, and frequency of school counselor contact that positively influences students’ postsecondary success. Future studies should clearly operationalize each type of contact that goes beyond a binary data type. Researchers also should consider investigating associations among high school counselor–student contacts and college graduation rates and success, as the present study only examined college enrollment and was not explicitly related to college success. Quantitative research on tiered interventions, focused on the students with college-qualifying GPAs who chose not to attend, and qualitative research to examine reasons why, would be practical next steps.
Findings in this study bear implications for school counselor training. We believe that it is important to prepare school counselors-in-training to identify and become skillful in providing the types of school counseling services that contribute to students’ college and career readiness. For example, counselors-in-training should be trained to identify and intervene with students who have attendance issues and are at risk for not succeeding academically, and understand that the likelihood of attending college is significantly lower for those students than their peers. In preparing school counselors to collect data and create comprehensive programs that reach all students, counselor educators are training change agents who can provide evidence to administrators that school counselors positively influence students. An implication for school counselors is that data on their interactions with their students at the school site level are important sources of evidence, which they can use to advocate for themselves and their services to students.
Overall, it seems that school counselors can positively influence their students despite negative environmental factors outside of school. School counselors serve as sources of social capital for students, which helps student outcomes. Lastly, it is imperative that school counselors self-advocate and provide intentional interventions to at-risk populations who do not have as much social capital in the educational system as compared to their more advantaged counterparts.
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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Angela K. Tang, NCC, is an assistant professor at the University of San Francisco. Kok-Mun Ng is a professor at Oregon State University. Correspondence can be addressed to Angela Tang, 2130 Fulton St., San Francisco, CA 94117, atang15@usfca.edu.
Nov 13, 2019 | Volume 9 - Issue 4
Katherine E. Purswell
The purpose of this paper is to explain how humanistic learning theory is applicable to current counselor education practices. A review of humanistic learning theory and the rationale for the application of the learning theory to counselor education provide a framework for application of these concepts to counselor education classrooms. Specifically, a person-centered framework is applied to the seeming incompatibility of external accreditation standards and humanistic learning theory. I propose suggestions for implementing humanistic, person-centered learning theory within counselor education programs and courses, focusing special attention on the attitudes and values of the counselor educator as these principles are applied.
Keywords: humanistic learning theory, person-centered theory, counselor education, accreditation, attitudes
With the philosophical shift in the mental health field from a meaning-making, holistic model of mental health toward a reductionistic, medical model of mental health, counselor preparation programs have adapted by increasing the emphasis on measuring outcomes, sometimes at the expense of focusing on aspects of counseling that are less easy to quantitatively assess (Hansen, 2009). Furthermore, external realities such as university policies and accreditation requirements have put pressure on programs and faculty members to focus more on measurable outcomes. In many counselor education programs, external requirements come in the form of the Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) standards. With the advent of the 2009 standards, the focus in counselor education changed from program-level evaluation to directly assessing student outcomes (Barrio Minton & Gibson, 2012), a trend consistent in higher education (Penn, 2011). Although the admirable intention of accountability measures is to ensure quality programs and competent counselors, these systems do not provide incentives for counselor educators employing pedagogy that emphasizes process and critical thinking over product and knowledge retention.
Many counseling faculty ascribe to a humanistic way of viewing people, including students, and the increasing focus on outcomes over process may create dissonance for these counselor educators. They can feel internal as well as external pressure to adopt a more didactic or reductionistic form of teaching that does not fit with their philosophy of education (Hansen, 2009). This paper is directed at person-centered counselor educators who wish to teach in a more humanistic way but feel constrained by the current system. This paper also may be helpful for other counselor educators who wish to explore humanistic teaching. The purpose of this article is to demonstrate that counseling faculty can apply a person-centered learning philosophy to counselor preparation settings within the reality of external requirements intended to ensure quality in counselor preparation programs. Because the person-centered teaching literature is not sufficiently robust to accomplish this purpose, I will also draw from humanistic learning theory. First, I provide an overview and rationale for humanistic learning theory and then discuss the application of person-centered concepts, within the context of humanistic learning theory, to counselor preparation settings. When a view is specifically person-centered, I will use that term. Otherwise, I will refer to humanistic learning theory, which encompasses person-centered learning theory.
Humanistic Learning Theory
Humanistic learning theory is grounded in the philosophy of humanistic theories of psychology, including person-centered theory (Gould, 2012). Primary contributors to humanistic learning theory include Arthur Combs, Carl Rogers, and Malcolm Knowles, all of whom believed the goal of education is to facilitate students’ development and self-actualization (Combs, 1982; Gould, 2012; Rogers, 1951). Therefore, humanist educators have an unwavering trust in the individual’s growth capacity and view self-directed learning as most facilitative of growth (Combs, 1982; Knowles, 1975; Rogers, 1951). Additionally, humanistic theorists hold a phenomenological view of humans in that they believe each person’s view of the world is reality for that person and that learning is motivated by personal need based on one’s internal frame of reference (Combs, 1986; Rogers, 1951). For example, a student with low self-efficacy might not attempt difficult projects because of a belief that “I am not capable,” whereas a student with a high level of self-trust can go beyond the direct instructions of an assignment to tailor the assignment to fit their learning needs. Highly self-actualized individuals view themselves as dynamic beings who are constantly growing and changing (Knowles, 1975; Tolan, 2017).
In general, humanistic learning theorists define learning as the holistic growth of the person, including cognitive, emotional, and interpersonal domains (Combs, 1986; Dollarhide & Granello, 2012; Rogers, 1957, 1989). They tend to focus less on accumulation of knowledge and more on how the learner’s way of being in the world impacts the integration of skills and knowledge (Combs, 1986; Kleiman, 2007). This view of knowing requires a paradigm shift for the person who tends to describe learning as the acquisition and application of knowledge. In particular, learners who have learned to approach assignments or classes with a grade-based mentality (e.g., “What do I need to do to get an ‘A’?”) may have difficulty changing, or even understanding the rationale for changing, their focus to a learning-based mentality (e.g., “What do I need to learn to positively impact my personal and professional development?”).
Humanistic learning theorists avoid teacher-directed learning, defined as transmission of knowledge, because they believe the most important learning and growth cannot be transmitted directly from person to person (Knowles, 1975; Rogers, 1957, 1989). Rather, they believe knowledge integration is a natural process occurring in a facilitative environment (Rogers & Freiberg, 1994). Because learning requires this environment, humanistic educators focus first on themselves and their ability to provide that environment (Combs, 1982; Rogers & Freiberg, 1994). In this article, the term educator is used in the broadest sense of the word to mean a facilitator of learning.
Rogers’s Conditions in Humanistic Learning Theory
Most humanistic learning theorists base their view of the educator–learner relationship on Rogers’s (1957) three therapist-provided conditions for personality change: congruence, empathic understanding, and unconditional positive regard (Combs, 1986; Mearns, 1997; Rogers & Freiberg, 1994). In an educational setting, empathic understanding, which Rogers (1951) considered a sensitive understanding of a person’s internal frame of reference, involves focusing on the person rather than only on course content (Mearns, 1997). For example, the educator also would value and empathize with learners’ reactions to course content as well as other circumstances in learners’ lives that might impact their experience in the class.
Unconditional positive regard is an experience of accepting and prizing another person regardless of whether one agrees or disagrees with the person’s behaviors or ideology (Rogers, 1957). Rogers and Freiberg (1994) described unconditional positive regard as “a basic trust—a belief that this other person is somehow fundamentally trustworthy” (p. 156). This trust differentiates unconditional positive regard from the common use of the term acceptance. In a classroom setting, unconditional positive regard for students can mean valuing and respecting students wherever they are in their growth processes and trusting they are moving toward growth as they are ready or able (Kunze, 2013). For example, if a student struggles to accept feedback in supervision, the counselor educator will accept the student in that moment and trust that there are valid reasons for the student’s difficulty. This acceptance is an attitude and does not mean educators abandon their professional gatekeeping roles.
Congruence, also called transparency in a classroom setting, involves openness to one’s experience within a relationship, including an acceptance of one’s own feelings or desires at any moment, even if one chooses not to act upon those feelings (Mearns, 1997; Rogers, 1951; Rogers & Freiberg, 1994). Transparency is closely tied to a non-defensiveness that promotes openness rather than debate as well as the formation of respectful, trusting relationships between educators and learners (Mearns, 1997). These trusting relationships form the basis for open dialogue.
The result of the interaction between these conditions can be transformational for students in the classroom. When an educator makes a genuine effort to help a learner feel understood rather than evaluated, the learner is more free to stop judging or evaluating oneself and to creatively explore the learning environment with the security of knowing that any ideas, even those that conflict with the educator’s views, will be respectfully acknowledged and discussed (Combs, 1982; Rogers & Freiberg, 1994). Meaningful learning can occur in an environment in which the contributions and ideas of learners are valued just as much as those of the educator (Kleiman, 2007). Humanistic educators strive to provide some level of Rogers’s (1957) three conditions to all learners.
Rationale for Use of Person-Centered Learning Theory
The goal of facilitating relationships in a learning environment characterized by the person-centered conditions of congruence, unconditional positive regard, and empathy is to provide learners with the opportunity for the growth and development of the whole person (Dollarhide & Granello, 2012; Rogers & Freiberg, 1994). Some of the results of such a learning environment are a deeper understanding and acceptance of oneself, a strong connection and openness to the experiences of others, and the development of skills and knowledge to facilitate the growth of both the individual and society. Because of these outcomes, a person-centered approach to learning is an appropriate match for counseling faculty and supervisors who believe these growth processes are key purposes of training counselors (Combs, 1986; Dollarhide & Granello, 2012).
One of the primary goals of counseling faculty is to develop the counselor-in-training’s (CIT’s) belief system about counseling and about oneself as a counselor (Combs, 1986; Gibson, Dollarhide, & Moss, 2010). From a phenomenological perspective, beliefs influence behavior; therefore, person-centered counseling faculty can focus on helping CITs develop their own beliefs about themselves in the context of counseling relationships (Combs, 1986; Dollarhide & Granello, 2012). When counseling faculty facilitate genuine, accepting, and empathic relationships between themselves and learners and among learners, they create an environment in which CITs are free to examine those beliefs that are both more and less accepted by society and then to modify those beliefs in ways that are more helpful (Mearns, 1997). For example, if a CIT holds stereotypical beliefs about a certain population, the CIT will be better able to express and challenge those beliefs in an open rather than judgmental environment.
Additionally, in a person-centered learning environment, CITs develop confidence in their abilities to find creative responses to difficult situations, such as client challenges and ethical dilemmas (Combs, 1986). Alternatively, when CITs feel they must act a certain way, they can learn to say the right words but fail to internalize a belief system that is meaningful to them. Therefore, when they are challenged or when the external evaluator is no longer present, they will quickly fall back into arguably less helpful ways of being with clients, such as giving advice. By offering a person-centered learning environment, counseling faculty help students meet CACREP standards related to facilitating a helping relationship (CACREP, 2015, 2.F.5.).
Relatedly, person-centered counseling faculty can utilize the learning environment as a microcosm of the helping relationship to allow CITs to experience the type of relationships counseling faculty hope they will provide their clients (Combs, 1986). Rogers (1957, 1989) argued that educators may foster the values and attitudes of a helping relationship by providing those same values and attitudes to learners. Although the professor–student relationship differs from the counselor–client relationship, the basic attitudes (care, warmth, prizing), values (worth of the person), and purpose of the relationship (growth) remain the same (Mearns, 1997). Most students in counselor education programs are intelligent and able to accomplish the academic work, but the relational skills necessary for an effective counselor cannot be memorized or studied for (McAuliffe, 2011; Nelson & Neufeldt, 1998). Therefore, it is critical that counseling faculty provide experiences that facilitate the development of relational abilities.
In addition to developing intrapersonally and interpersonally, CITs must develop good judgment and the ability to critically reflect on their counseling practice, including their work with clients and both current and future educational experiences (McAuliffe, 2011; Nelson & Neufeldt, 1998). Both the ACA Code of Ethics (American Counseling Association [ACA], 2014) and many state laws require new and experienced counselors to continue to seek professional development, and students need to be able to evaluate the training they are receiving. Additionally, in their analysis of extensive interviews with master therapists, Skovholt and Rønnestad (1992) found that those therapists considered continual reflection on their experiences and their growth process to be a key aspect of their professional growth. This finding supports King and Kitchner’s (2004) reflective judgment theory. They posited that as individuals progress in their development, they move on a continuum from viewing knowledge as truth that can readily be conferred by experts to seeing it as something that can be approximated based on what is known but can never be fully obtained because of the fallibility of human knowing. Counselors whose beliefs fall toward the reflective judgment end of this continuum will not assume that something must be true just because a professor or trainer told them it is the best way to do it. In addition, they will be more open to many views of the world and will also be able to critically yet nonjudgmentally evaluate those perspectives. Counselors are frequently required to tolerate ambiguous situations in which there is no clear right or wrong answer (McAuliffe, 2011; Skovholt, Jennings, & Mullenbach, 2004). Person-centered educators aim to foster a tolerance of ambiguity by encouraging learners and supervisees to examine the evidence themselves rather than implying that there is only one answer or one response to a given counseling concern or question (Rogers, 1951). The facilitation of open-mindedness in this way is relevant to CACREP standards related to diversity and advocacy.
CITs need to be able to address needs from clients with diverse backgrounds and expectations (CACREP, 2015, 2.F.2.; McAuliffe, 2011). One key aspect of multicultural competency is for counselors to be aware of their own attitudes, biases, and beliefs (Arredondo et al., 1996). Additionally, counselors must be able to think critically about the impact of their personal values on others (CACREP, 2015). A humanistic learning environment provides the opportunity for in-depth self-understanding and critical thinking (Combs, 1986; Dollarhide & Granello, 2012). Rogers (1951) described people moving toward self-actualization as “necessarily more understanding of others and . . . more accepting of others as separate individuals” (p. 520). This attitude embodies that of a multiculturally competent counselor (Arredondo et al., 1996).
Objectives of a Humanistic Learning Environment
When educators provide the environment described above and students begin to take responsibility for their own learning, certain results related to this self-actualization process can be expected. One key outcome of the humanistic approach to learning is a deeper understanding of self (Dollarhide & Granello, 2012), an important characteristic of a counselor. Increased self-understanding can lead to deeper learning. Learning can be enhanced when adult learners are able to accept themselves as they are while continuing to work toward growth (Knowles, 1959; Kunze, 2013). Similarly, Combs (1982) indicated that highly self-actualized individuals tend to view themselves in a positive way while honestly accepting their areas for growth, an attitude that leads to freedom to take more risks in educational settings. For example, learners who do not base their self-worth on grades might feel more free to focus on the meaning class material has for their future careers rather than on retaining facts in order to make a high grade in the class. In clinical classes, supervisees who have both a sense of self-worth and an openness to growth are more likely to be authentic with their clients and supervisors as well as less concerned about finding the “right” thing to say, and can focus more on what is most helpful in the context of that specific counseling relationship rather than being self-focused on performing well. Further, when learners are given substantial control over their own learning, they are better able to regulate their own processes of thinking and learning, leading to greater integration of the material (McCombs, 2013).
A humanistic learning environment also promotes a sense of care, acceptance, and respect toward individuals in society as well as a connection to the human condition (Combs, 1982; Knowles, 1959; Rogers, 1951). Combs (1982) argued that when learners feel a sense of belonging with those around them, they naturally become curious about their peers’ interests, and thus their learning opportunities are expanded. Rogers (1951) believed that when a person can accept one’s own experience, the person is free to be more open to and accepting of the experiences of others. Similarly, Combs (1982) wrote that highly self-actualized people can “confront the world accurately, realistically, and with a minimum distortion” (pp. 106–107). This openness to their experiences impacts their problem-solving abilities because they have more perceptual information from which to make decisions. In a classroom setting, this connection or sense of belonging can result in positive, in-depth group discussions that facilitate the learning of all involved beyond what an individual instructor could accomplish by sharing only one perspective. Further, an openness to the experience of others can lead to challenging one’s implicit or explicit beliefs about groups of people who have previously been seen as “other.” In clinical settings, supervisees will undoubtedly be exposed to individuals who hold differing beliefs, and an openness to their own experiences can help supervisees work better with these clients.
Concrete knowledge and skills are an outcome in humanistic learning theory, though they are generally considered more of a byproduct than the primary focus of learning. Rogers (1951) stated that one of the goals of learning is to develop knowledge relevant to the specific problem of focus, as well as to develop strategies for acquiring knowledge for new problems. Knowles (1959) noted the importance of acquiring skills that will aid a person in reaching their full potential and allow that person to positively influence society. Furthermore, Combs (1986) emphasized that knowledge leading toward self-actualization does not have to be academic. These humanists believed that learners who experience a facilitative learning environment will better retain knowledge and skills because they will have critically examined, applied, and connected it to their lives (McCombs, 2013).
Other Considerations in a Humanistic Learning Environment
Because application of humanistic learning theory requires a paradigm shift for both educators and learners, some learners may struggle to feel comfortable with the idea that the educator’s responsibility is to facilitate a learning environment and the learner’s responsibility is to pursue growth (Mearns, 1997). Many learners have grown up in educational environments where acquisition of knowledge was almost exclusively the goal of learning, and an educator who presents them with a different way of learning may induce stress. However, person-centered and humanistic learning theorists have emphasized that empathically helping students in the process of gaining self-responsibility helps the whole person develop (Knowles, 1975; Rogers & Freiberg, 1994; Smith, 2002).
Providing a warm, transparent, empathic environment does not preclude counselor educators from giving students feedback that may challenge them. When students struggle, person-centered and humanistic educators try to develop an empathic understanding of the struggling student’s view of oneself, to be accepting of that view, and to be transparently honest with the learner about his or her standing in the program. This conversation can involve counseling the student out of the program by communicating understanding that counseling may not be a good fit with the student’s current development. The educator attempts to make such discussions a collaborative effort in promoting the learner’s growth rather than a communication that the learner is failing (Dollarhide & Granello, 2012).
Application of Person-Centered Learning Theory in Counselor Education
Counseling faculty today are not only tasked with helping students develop their growth potential and learn the process of becoming effective counselors, but are also required to engage in assessment activities in addition to many other roles (CACREP, 2015). The purpose of the following section is to describe some specific ways in which a humanistic theory of learning can be applied to teaching and accountability measures.
Teaching
Given that the educator–student relationship is a model for the counselor–client relationship, and that students must feel accepted and understood in order to learn, the person of the educator is crucial in a humanistic classroom (Combs, 1982; Rogers, 1951). Of utmost importance is the counseling faculty member’s belief in the growth tendency of the human being. The attitudes of congruence, unconditional positive regard, and empathic understanding for the learner’s perceptual world are predicated upon this foundation, and any practical intervention in the classroom must be firmly based in those attitudes rather than adherence to a specific technique. However, there are specific classroom practices that are more facilitative of a humanistic way of learning than others.
Lecturing and other forms of direct knowledge transmission are generally considered among the least person-centered methods for learning because they are typically based on a power differential in which the teacher is considered the expert (Rogers & Freiberg, 1994). Freire (2011) described this type of teaching as a banking system of education because it involves teachers “depositing” information in their students’ heads, and he compared it to a system of education in which the students are active participants in deciding what is most important to learn and how. He believed students who were more active and took more responsibility for their own learning were better able to critically question their own and others’ beliefs and thus promote growth. This assertion does not mean lecture is never used or valuable in a person-centered classroom (e.g., Cornelius-White, 2005), but the person-centered educator works to have an attitude of humility and collaborative exploration (Combs, 1982; Dollarhide & Granello, 2012; Freire, 2011; Nelson & Neufeldt, 1998). A person-centered theory of learning requires the counseling faculty to give up much of their power and trust the learners’ ability to contribute equally to the learning environment.
Person-centered counseling faculty might also relinquish power regarding learning objectives for individual learners (Knowles, 1975; Rogers & Freiberg, 1994). The educator can have broad goals for the course, but counseling faculty can engage CITs in developing their own specific learning objectives and in deciding how those objectives will be met. Although it is clearly not possible to meet the needs of every individual in a course, counseling faculty can address the most common learning needs within the structure of the course and provide resources for individuals with unique learning interests (Cornelius-White, 2005; Knowles, 1975; Mearns, 1997). Projects proposed by students exemplify a humanistic-oriented way of helping students meet their learning objectives because self-chosen projects tend to be based on problems that are of relevance to the students (Rogers & Freiberg, 1994). Humanistic counseling faculty give students responsibility for the creation and implementation of projects and act as a resource when assistance or experience is needed. Projects that provide a resource or service to the community can help students reach learning objectives in an experiential way (Burnett, Long, & Horne, 2005; Svinicki & McKeachie, 2011) and meet CACREP standards related to advocacy and diversity. In one classroom, student journal entries indicated that service learning increased the students’ “awareness, knowledge, responsibility, and skills related to cultural, social . . . and civic concerns of diverse communities” (Burnett et al., 2005, p. 166). Educators also may encourage the self-direction of students by engaging students in posing a large-scale problem and giving the students the responsibility to investigate and propose possible reasons for the problem and ways to address the problem (Rogers & Freiberg, 1994).
One way that person-centered counseling faculty help CITs develop critical thinking is to place responsibility for learning upon the learners (Combs, 1986; Mearns, 1997). Knowles (1975) described self-directed learning as students taking “the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes” (p. 18). However, he realized that the typical student was not socialized to learn this way; therefore, he emphasized the importance of using small steps to facilitate self-direction. Although person-centered counseling faculty do not take responsibility for CITs’ learning, they do feel much responsibility to students to provide a facilitative environment by developing meaningful relationships with CITs, serving as resources, providing needed supervision, and making necessary changes to the environment as learners pursue their growth process (Dollarhide & Granello, 2012; Mearns, 1997). Teaching CITs to think for themselves and helping them develop the basic attitudes toward people that are facilitative of change will give beginning counselors the tools to respond to difficult or unique counseling situations and to know how to find the type of supervision or support they need.
Ethical and legal issues are another important dimension for CITs (ACA, 2014, F.7.e., F.5.a.; CACREP, 2015, 2.F.1.), and one for which a humanistic approach to learning is particularly appropriate because of the focus on helping learners develop the ability to critically think through problems (Knowles, 1975). One way that person-centered counseling faculty can model ethical principles is by giving their students a full disclosure of what to expect from a humanistic-oriented learning environment. CITs need to be informed of expectations regarding their responsibility for learning, expectations for self-disclosure, and how grades will be assigned (ACA, 2014, F.9.a.; CACREP, 2015, 2.D.; Morrisett & Gadbois, 2006). Although these disclosures are necessary in any classroom, special clarification of the differences between a humanistic learning environment and a typical classroom may be necessary to help decrease learners’ anxiety about an unfamiliar learning environment (Knowles, 1975). Counseling faculty can emphasize that grades will not be reflective of learners’ self-disclosure, but they also note the role of honesty about one’s experience in facilitating growth (ACA, 2014, F.8.d.). Finally, counseling faculty can clarify appropriate faculty–student roles (ACA, 2014, F.10.; Morrisett & Gadbois, 2006). This may be particularly important in a humanistic classroom where the power differential between faculty member and student is decreased.
Teaching from a person-centered perspective is not an all-or-nothing endeavor. Just as each of the attitudes of a person-centered educator lie on a continuum, so do activities that may be utilized in the classroom (Rogers & Freiberg, 1994). For example, self-assessment and student-directed inquiry are on the more purely humanistic side of the spectrum while lecture and questioning are on the teacher-focused extreme. Projects, portfolios, and role-plays fall somewhere in the middle. Additionally, person-centered counseling faculty may choose to assign one self-directed project and several teacher-directed assignments for practical reasons or because of their personal comfort level.
Accountability. One purpose of accountability measures, such as licensure and accreditation standards, is to confirm that individuals are qualified to provide the services they are offering, and institutions that make some statement to the public about the qualifications of an individual also have a responsibility to that public to graduate only those who meet such qualifications (Mearns, 1997). From a purely theoretical person-centered perspective, such external requirements as CACREP standards and the grades required by universities represent an external locus of control and could impede the process of learning by causing the learner to conform to external methods of evaluation (Gould, 2012; Rogers & Freiberg, 1994). Ideally, individuals would pursue learning solely out of an intrinsic desire for growth, and facilitators of learning would not have to worry with grades or formal assessments. Rogers disliked summative assessment because it implied that a person had reached an endpoint (Mearns, 1997), and person-centered educators believe growth is a dynamic process (Knowles, 1959; Rogers, 1957). However, from a practical perspective, accountability is necessary, both at the course level and the program level, to ensure CITs are adequately prepared and to protect students from programs that purport to train counselors but do not have sufficiently rigorous standards to adequately prepare their students for the work of effective counseling.
CACREP standards are aimed at ensuring that counseling programs produce competent counselors. Although many practices required to meet accreditation standards, such as the use of program-wide rubrics for specific classes, are not consistent with a person-centered and humanistic approach to learning (Hansen, 2009), person-centered educators can find ways to work within this context to maintain a facilitative learning environment. One possibility is for counseling faculty to give students the learning objectives for a certain course or rubric for a key assessment and allow students to create individual projects or products that will show their competency in the learning outcomes the standard or assessment is intended to address. Another option is the use of portfolios to measure some of the learning outcomes (Barrio Minton & Gibson, 2012). These alternate assignments are not intended to be viewed as ways of circumventing the CACREP standards, but as ways of meeting them via practices that are most meaningful for students and that best facilitate their learning.
Although person-centered counseling faculty have to operate in a learning environment that emphasizes external accountability requirements, they do not have to give up their approach to learning (Hansen, 2009; Mearns, 1997). Even if program policies require some specific assessments, counseling faculty have flexibility with other measures of learning outcomes. Furthermore, they can frame what they are already doing in terms that appeal to accreditation reviewers. Mearns (1997) argued that person-centered teachers use a great deal of diagnostic and formative assessment as they help CITs develop learning objectives and assess whether those are being met. The type of assessment must fit the outcome desired (Cobia, Carney, & Shannon, 2011). If counseling faculty value process over the product, then they will focus on both formative and summative assessment throughout the process, such as the use of embedded assessments (Svinicki & McKeachie, 2011). Contracts are one form of assessment that encompasses aspects of diagnostic, formative, and summative assessment and also rely on the self-direction of the individual (Knowles, 1975; Rogers & Freiberg, 1994). With the use of contracts, each learner creates individual learning objectives and a plan for accomplishing the objectives. Once the educator and the learner agree on the terms of the contract, it is used to guide the learner throughout the course. At the end of the course, the learner completes a self-assessment on whether the contract has been completed sufficiently. The counseling faculty member typically has final authority over the grade the student assigns themself (Mearns, 1997). Although contracts can be helpful in bridging the gap between student-directed learning and the need for accountability, their use evolves into a completely behavioral method without the attitudes that embody a humanistic learning environment (Rogers & Freiberg, 1994). For example, if a faculty member engages students in creating learning contracts but does not simultaneously demonstrate respect and trust that the learners are capable of directing their own learning, the assignment is no longer humanistic. By including the students in all aspects of the assessment process, the counseling faculty member indicates a respect for the students’ input and facilitates an internalized locus of control. By involving students in their own assessment, counseling faculty model ethical assessment procedures (CACREP, 2015, 2.F.7.) in that counselors also should seek client input before evaluating client functioning (ACA, 2014, A.1.c.).
Challenges. Regardless of how much an educator trusts the self-actualizing tendency in others, there are instances in which the timeline of the learning institution does not allow students sufficient time for their growth process (O’Leary, 1989). Person-centered counseling faculty do not see students as failing, but continuing their development in an environment that is more conducive to their current growth process. When a student needs to be counseled out of the program, counseling faculty are honest and empathic (Mearns, 1997). Maintaining an attitude of unconditional positive regard does not mean thinking everything a student does is fine. However, when dismissing a student from a program, counseling faculty work to maintain an empathic, caring relationship throughout the process in hopes that the student might continue to feel valued as a person by the counseling faculty.
Limitations. This approach may not be a good fit for all counselor educators, particularly those who do not identify with more humanistic modes of learning. In addition, this approach to learning is not always appreciated by all students. Some students prefer the teacher tell them what they need to know and how to demonstrate their knowledge. The idea of taking responsibility for their learning can be stressful for some students. Counselor educators utilizing this theory of learning need to assess whether such stress levels are facilitative or debilitating for learners.
Conclusion
Humanistic learning theory is a way of approaching counselor education that emphasizes the humanistic underpinnings of the profession rather than the current reductionist approach of diagnosis and skills development (Hansen, 2009). Person-centered counseling faculty can utilize humanistic learning theory to facilitate an open, accepting, and understanding environment in which they engage CITs in directing their own learning. Counseling faculty can focus on CITs’ attitudes and beliefs about people in relation to knowledge and skills. Person-centered counseling faculty hope to foster CITs’ self-understanding, caring and accepting attitudes toward people, and the acquisition of concrete knowledge and skills needed in the counseling profession. Counseling faculty using humanistic learning theory engage learners in assessment of their learning as much as feasible, while honoring the realities of external evaluation through accreditation.
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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Katherine E. Purswell is an assistant professor at Texas State University. Correspondence can be addressed to Katherine Purswell, 601 University Dr., EDU 4019, San Marcos, TX 78666, kp1074@txstate.edu.
Nov 12, 2019 | Volume 9 - Issue 4
Deborah L. Duenyas, Chad Luke
In recent decades, professional counselors have increasingly focused on neuroscience to inform their case conceptualization and treatment planning with clients. With the additional lens of neuroscience, both the counselor and client can gain new understandings of the client’s issues and improve the quality of the therapeutic relationship. The benefits of integrating neuroscience into the profession of counseling (i.e., neuroscience-informed counseling) are being documented in the scholarly literature; however, information on integrating neuroscience-informed counseling into the counselor education curriculum is sparse. This article describes one teaching approach for a neuroscience-informed counseling course. The structure of the course, methods for effective instruction, and ethical and cultural considerations are discussed.
Keywords: neuroscience, counselor education, teaching, neuroscience-informed, instruction
Neuroscience-informed counseling is a growing force in the counseling profession (Beeson & Field, 2017). The integration of neuroscience into the profession of counseling has been evident over the past two decades. Examples include the development of neuroscience interest networks by the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), and the Association for Counselor Education and Supervision (ACES). There have been numerous books published that focus on neuroscience for counselors (Field, Jones, & Russell-Chapin, 2017; Luke, 2019) and an increased amount of scholarly literature focused on integrating neuroscience into counseling practice (Beeson & Field, 2017; Lorelle & Michel, 2017; Luke, Redekop, & Jones, 2018; Makinson & Young, 2012; Miller, 2016; Myers & Young, 2012).
Neuroscience is the study of the brain and nervous system (Kalat, 2019). Neuroscience-informed counseling involves integrating principles from the structure and function of the brain and nervous system to counseling practice (Russell-Chapin, 2016). This integrative work in counseling is being used to treat behavioral and mental health challenges (Field et al., 2017). According to Beeson and Field (2017), neurocounseling is a
specialty within the counseling field, defined as the art and science of integrating neuroscience
principles related to the nervous system and physiological processes underlying all human
functioning into the practice of counseling for the purpose of enhancing clinical effectiveness in the
screening and diagnosis of physiological functioning and mental disorders, treatment planning
and delivery, evaluation of outcomes, and wellness promotion. (p. 74)
Three methods for integrating neuroscience into the counseling profession have been identified in the scholarly literature, including neuroeducation (Fishbane, 2013), neurofeedback (Myers & Young, 2012), and the use of a metaphor-based approach (Luke, 2016).
The first method, neuroeducation, is defined by Miller (2016) as “a didactic or experiential-based intervention that aims to reduce client distress and improve client outcome by helping clients understand the neurological processes underlying mental functioning” (p. 105). Neuroeducation is essentially psychoeducation about the brain and nervous system. Neuroeducation can be used as an intervention to help clients understand the neurological processes that underlie their symptoms and development (Miller, 2016). Miller described various methods for integrating neuroeducation into counseling practice through the use of information on neuroplasticity, brain structures and functions, and memories.
Plasticity is an object’s or organism’s ability to stretch and to be resilient. As applied to the brain and central nervous system, this is called neuroplasticity or neural plasticity, and involves “changes in the activity and connectivity of the various circuits within the nervous system [that] enable learning, encode memory, and drive behavior” (Li, Park, Zhong, & Chen, 2019, p. 44). Information on neuroplasticity and self-defeating patterns of thought and behavior may help demystify change processes.
Informing clients about the various brain structures and functions (e.g., brain stem, limbic, and cortical regions) can help with understanding the brain from a developmental perspective—that the brain is built to change and to be resilient (Luke, 2019). Educating clients about how their memories are encoded, stored, and accessed, drawn from the groundbreaking work of Eric Kandel (1976), can help clients gain a better understanding of their own brain and behavior (Miller, 2016). This knowledge can instill hope that although events of the past cannot be changed, the meaning of the memories associated with those events can be changed (Sweatt, 2016). Furthermore, the relational context in which change takes place can help clients’ brains overwrite rigid rules and threats about relationships learned from earlier dysfunctional relationships (Kandel, Dudai, & Mayford, 2014; Schore, 2010; Siegel, 2015).
A second method, neurofeedback, has been recognized as an effective treatment for reducing symptoms of various mental health concerns (Russell-Chapin, 2016). A specialized form of biofeedback, neurofeedback changes brain wave patterns to aid in the treatment of conditions such as attention-deficit/hyperactivity disorder, anxiety, depression, addiction, trauma, autism spectrum disorders, and personality disorders (Russell-Chapin, 2016). Neurofeedback is just one method that counselors can use with clients to help them understand and change the function of their brains. Additional examples include basic biofeedback tools and methods like those found on many “smart” watches and fitness trackers.
The third method for integrating neuroscience-informed counseling is described by Michael and Luke (2016) as using a metaphor-based approach to teaching the neuroscience of play therapy. This approach is an extension and application of that described in Luke (2016), wherein neuroscience concepts are used both as metaphors for the human experience, as well as understanding brain function. Tay (2017a) has identified the therapeutic value of metaphor and its utility in understanding language and the body. Relatedly, the practices of mindfulness and meditation often use imagery, a form of metaphor, to engage practitioners in engaging more fully in the experience (Tang, Hölzel, & Posner, 2015). As neuroscience-informed counseling continues to become integrated into the work of professional counselors, counselor educators must adapt in order to keep their coursework relevant.
Counselor Education and Neuroscience-Informed Counseling
Beeson and Field (2017), along with others (Field et al., 2017; Luke, 2017; Miller, 2016) have called for more training for counselors who seek to integrate neuroscience into their practice. They also have identified the challenges associated with infusing neuroscience into counseling courses. The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) standards now require competency in “the biological, neurological, and physiological factors that affect human development, functioning, and behavior” (p. 10). CACREP standards, along with growing momentum in the field, support the development of a course designed specifically for integrating neuroscience for counselors. The AMHCA clinical training standards include recommendations for competence in understanding and applying the biological bases of behavior. The AMHCA standards outline basic knowledge and skills, which include integrating research into practice, as well as clinical interventions.
Field et al. (2017) laid a foundation for incorporating neuroscience-informed counseling across the CACREP curriculum. This approach addresses neuroscience in pre-existent courses, yet there is limited availability of literature on how to teach a graduate content course in neuroscience-informed counseling. In the absence of established models for teaching a course in neuroscience-informed counseling, counselor educators and others can feel at a loss for how to proceed. The purpose of this article is to provide recommendations for developing a neuroscience-informed counseling course designed for graduate students. This includes the course structure (e.g., content and resources), methods for effective instruction (e.g., teaching approach and assignments), and ethical considerations.
Course Structure: Content and Resources
The Neuroscience for Counselors course builds on prior core counseling courses, including counseling theories and the fundamentals of counseling. As such, it represents an extension of counseling theory and fundamentals and is not intended to be a substitute or replacement. Neuroscience-informed counseling explores how different counseling theories and interventions influence and change neurobiology and help facilitate client wellness.
The Neuroscience for Counselors course was offered to master’s students enrolled in a CACREP-accredited counseling program at a mid-size university in the northeast region of the United States. The course was offered as an elective that fulfilled three graduate credits toward degree completion. The course was designed as an introduction to neuroscience research and clinical interventions for counselors. Specific attention was given to reviewing the structures, systems, and functions of the brain. Psychodynamic, behavioral, humanistic, and constructivist counseling theories were explored in relation to neuroscience research. The neuroscience of mental health disorders, such as anxiety, depression, stress, and addictions and substance use, were explored.
Course assignments included developing a neuroscience-informed guided metaphor; completing a brain resource book on structures, systems, and functions; dyads to practice using neuroscience-informed counseling interventions; reflection in a neuroscience process analysis log (N-PAL); and activities exploring neuroscience-informed technology. A final paper included a case conceptualization based on the 8-factor meta-model (Luke, 2017, 2019) of case conceptualization to explore their client’s presenting concerns.
The assigned textbook for this course was Luke’s (2016) Neuroscience for Counselors and Therapists: Integrating the Sciences of Mind and Brain, which focuses on client conceptualization, brain anatomy, various theoretical approaches, and an array of commonly diagnosed mental health concerns. The text also provides case vignettes highlighting how a student might use neuroscience-informed counseling interventions with a diverse population of clients. The first chapter of the text discusses ethical and philosophical issues related to integration. Chapter 2 presents an overview of the basic brain structures, systems, and functions, including neurons and synapses. Chapters 3 through 6 cover the major categories of counseling theories: psychodynamic, cognitive-behavioral, humanistic-existential, and postmodern and constructivist. Chapters 7 through 10 describe conceptualizing and treating anxiety, depression, stress-related disorders, and substance use disorders. The text is written for counselors and counselors-in-training who have little or no background in the physiological bases of behavioral and mental health concerns.
The course instructor provided supplemental material, including magazine articles, peer-reviewed journal publications, apps, videos, websites, and links to neuroscience interest networks. For example, students were provided a link to the Neuroscience News website, which is an independent science news website that offers free cognitive science research papers, neuroscience resources, and a science social network. Also included were links to the Dana Foundation, an organization that supports brain research via grants, publications, and education, and the ACA’s Neurocounseling Interest Network. The supplemental material was selected as a method to broaden student understanding and support knowledge acquisition in neuroscience.
Methods: Teaching Approach and Assignments
Experiential education is not a new approach in higher education. Educational psychologists in the past, such as John Dewey (1938), Carl Rogers (1969), and David Kolb (1984), have laid the groundwork for the development of contemporary experiential education. Kolb (1984) defined learning as “the process whereby knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience” (p. 41). The Association for Experiential Education (AEE; 2019a) defined experiential education as a teaching philosophy “in which educators purposefully engage with learners in direct experience and focused reflection in order to increase knowledge, develop skills, clarify values, and develop people’s capacity to contribute to their communities” (para. 1). In essence, experiential education is the process of learning through experience and reflection.
Methods of instruction in the Neuroscience for Counselors course were consistent with the 12 principles of practice outlined by the AEE (2019b). For example, class assignments provided students with the opportunity for reflection, critical thinking, and personal application. The instructor’s teaching roles included “setting suitable experiences, posing problems, setting boundaries, supporting learners, insuring physical and emotional safety, and facilitating the learning process” (AEE, 2019b, para. 9). Sakofs (2001) cautioned that experiential activities can be misused by educators as a form of entertainment with no real educational value. The following six assignments were designed with the intention to deepen students’ understanding of neuroscience concepts as they relate to the profession of counseling.
Six Neuroscience Course Assignments
Developing a neuroscience-informed guided metaphor. Historically, neuroscience has been considered the realm of the medical professional or psychiatrist who has studied the complex inner workings of the brain. Developing a neuroscience-informed guided metaphor provides counseling students the experiential opportunity of taking an unfamiliar concept or idea (i.e., using neuroscience-informed counseling) and making it more accessible by relating it to ideas they are already familiar with (Jamrozik, McQuire, Cardillo, & Chatterjee, 2016; Lawson, 2005). For this assignment, students were assigned to read the article “The Birth of the Neuro-counselor?” (Montes, 2013), in which the term neurocounselor was first used. The article introduces and encourages students to begin thinking about what it means to use neuroscience-informed counseling in practice and how it influences their professional identity as a counselor.
After reading the article, students illustrated a guided metaphor that could be used to inform their model of neuroscience-informed counseling practice. Students were provided with the prompt, “Neuroscience-informed counseling is _________” and then asked to fill in the blank with a noun. Students included a paragraph explaining their choice in metaphor and how they came to make that decision. Students were asked to share their metaphors with their peers in class. A student’s illustration could be a visual representation, in writing, or a combination of both. Metaphor is, simply put, the practice of describing one thing in terms of another (Tay, 2017b). More specifically, the use of metaphor increases understanding of a less well-understood concept or idea by describing it in terms of something that is better understood. In the assignment described above, students generated metaphors such as “neuroscience-informed counseling is the first mission to the moon,” “neuroscience-informed counseling is a penlight in a dark maze,” and “neuroscience-informed counseling is a puzzle” to be solved. Lawson (2005) extolled the virtues of metaphors in counseling, noting that they “can help the counselor connect to the client’s world” (p. 135). The use of neuroscience metaphors, whether generated by the client or the counselor, can aid in promoting empathy and therefore trust (Luke, 2017) and can aid in learning neuroscience concepts (Michael & Luke, 2016). For example, in the wildly popular “I Had a Black Dog, His Name Was Depression” World Health Organization video on YouTube (over 9 million views as of this writing), depression is compared to a black dog that affects every facet of an individual’s life (World Health Organization, 2012). The metaphor works by comparing an abstract concept like depression with something concrete like a black dog. It enables the client to experience their depression as something happening to them, not emerging from their core self. When incorporated with relevant neuroscience information, the metaphor takes on increased significance. This black dog hijacks a person’s will, leaving them with diminished options for meaningful action.
Developing metaphors for the counselor’s roles when using neuroscience-informed counseling can clarify and strengthen counselor identity. When introducing this assignment, it is important to note that neuroscience-informed counseling is not its own therapeutic orientation. Whereas many graduate counseling programs have courses focused on advanced therapeutic orientations, such as solution-focused therapy or motivational interviewing, a course in neuroscience for counselors can strengthen a counselor’s current theoretical framework (Luke, 2017). For example, counselors practicing cognitive behavior therapy who learn about Hebb’s rule (1949), which states that “neurons that fire together wire together,” along with the concept of neuroplasticity, have another avenue of support for clients working to make positive behavioral changes. In this example, neuroscience can help the client gain awareness of the neurological structures that reinforce their behavior and also provide hard evidence that change is possible (Li et al., 2019). Neuroscience-informed counseling is one of many tools in the counselor toolbox. In addition to conceptualizing neuroscience-informed counseling as part of their professional identity, students also learn content knowledge of the brain’s structures, systems, and functions.
Brain structures, systems, and functions book. This assignment required students to research the basic structures, systems, and functions of the human brain and design their own book. The instructor provided students black and white images of various structures of the brain discussed in the class textbook. Images included lateral and dorsal views of the brain, the two hemispheres of the brain, the three divisions of the brain (i.e., forebrain, midbrain, and hindbrain), the four lobes of the brain (i.e., frontal, temporal, occipital, and parietal), the anatomy of a neuron, and a stem chart of the nervous system tasks, including the sympathetic and parasympathetic nervous system functions. This approach is supported by works such as the Wammes, Meade, and Fernandes (2016) investigation of the neural processes of storing and retrieving memory. The authors found that drawing important words and phrases improves one’s ability to remember important concepts. Students were asked to use various mediums, including colored pencils, crayons, and markers, to label and highlight the different neuroanatomy. Students also were asked to use their class textbook to write descriptions of the functions of these parts of the brain within their assignment.
Mental health diagnoses can be intimidating for clients, as can the symptoms of a disorder. Anchoring a client’s experience in their neurobiology can increase their understanding of what is happening. Basic neuroscience information can empower them to learn more about, and in some ways objectify, their experience. In other words, knowledge of the underlying brain function can encourage clients to reflect on mind and body and how they interact. For example, depression is a result of brain function, but the choices an individual makes in response can be a function of the mind. In practice, clients can be led through the process of identifying brain function and mind function.
The brain structures, systems, and functions book assignment helps to empower students by providing them with the language and imagery surrounding neuroanatomy. Once counselors feel confident in their knowledge of basic brain regions and systems they can use it to empower clients by providing them a physiological explanation of their experiences. For example, knowledge about the autonomic nervous system can help a client struggling with generalized anxiety disorder. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013), generalized anxiety disorder is characterized by excessive anxiety and worry that is difficult to control, with symptoms that might include restlessness, feeling on edge, being easily fatigued, difficulty with concentration, muscle tension, and sleep disruptions. Clients struggling with generalized anxiety disorder can feel as if they are in a constant state of emergency. Understanding how the sympathetic nervous system prepares the body for emergencies can help a client understand what they are experiencing at a physiological level. This can make them more receptive to interventions that activate their parasympathetic nervous system functions and move them from “fight or flight” to “rest and digest.” Once students in the course obtained content knowledge regarding the brain’s structures, systems, and functions, they applied that knowledge in dyads.
Dyads. Experiential learning takes careful planning, structuring of lessons, and intentionality in teaching practices (AEE, 2019). Experiential activities such as dyads can help students learn the material through the act of “doing.” Tollerud and Vernon (2011) described the benefits of experiential learning as “promoting interest in a topic, supporting student retention of the material, and involving students in their education” (p. 285).
Luke (2017) outlined neuroscience concepts that can be used as interventions with clients
(e.g., memory systems, Hebb’s rule, left and right brain processing, mirror neurons, attention, and mindfulness). In the neuroscience course, students practiced discussing neuroscience concepts in dyads where they took turns acting as counselor and client. The neuroscience concepts coincided with Chapters 3–10 in the textbook. This provided practice for students using the neuroscience concepts with specific theoretical approaches (e.g., contemporary psychodynamic, behavioral approaches, humanistic approaches, and constructivist approaches), but also could align with a particular mental health diagnosis (e.g., anxiety, depression, stress disorders, and substance use disorders). For example, discussion about Hebb’s rule may apply to counselors working from a behavioral approach or counselors working with clients struggling with specific issues such as substance use.
The instructor provided a dyad prompt for students relating to the chapter material for that class session. For instance, the prompt for Chapter 3, Contemporary Psychodynamic Approaches and Neuroscience, was, “Tell me more about your early memories pertaining to key relationships (i.e., parents, siblings, guardians)” and “How do you feel these early memories influence your key relationships today?” The discussion prompt provided the student counselor an avenue to discuss the neuroscience concepts identified in the chapter (i.e., relationships in the brain/interpersonal neurobiology, consciousness, and memory systems) with their mock client. Students were graded on their ability to use the neuro-concepts and attend to their fundamental counseling skills (e.g., unconditional positive regard and empathy).
The dyad activities also highlight the positive benefits of right hemisphere to right hemisphere connections validated through neuroscience. According to Badenoch (2008), right hemisphere to right hemisphere connections are at the root of change, as interpersonal connections are rooted in the neural processes of the right hemisphere. Practicing mock counseling sessions provides students the opportunity to develop healthy relationships with their peers in class. This experience can later become a parallel process by which they use the positive experience in class with their future clients.
In counseling, two approaches parallel the class experience. In the first, counselors can apply the same material described above with their clients, using process-based psychoeducation. For example, the counselor can present information on the neurobiology and role of early memories, relationships (past and present), and consciousness/unconsciousness in the client’s depression. They can then ask the questions described above directly to the client. The second approach involves a Gestalt technique wherein the client’s depression, their brain, and the client themselves all sit together in the room. The client is guided through a discussion with these constituent parts in order to better understand the role that each plays in the living of the client’s life. As students completed each dyad, a system was created for them to reflect on their experience as described below.
The N-PAL (Neuroscience-Personal Analysis Log). According to Faiver, Brennan, and Britton (2012), the purpose of a personal analysis log (PAL) “is to help students track their progress over the semester in terms of self-awareness and comfort level with the counseling process” (pp. 292–293). Students completed nine neuroscience personal analysis logs (N-PALS) throughout the course. Entries were made in class after each dyad. Students were given the opportunity to analyze and express their feelings in relation to the dyad activities and course material. The purpose of the N-PAL was to help students reflect on their counseling work while integrating neuroscience concepts into the mock counseling sessions with their classmates.
N-PALs consisted of five questions: (a) On a scale from 1–10, how confident do you feel applying the assigned theoretical approach for this dyad? (b) On a scale from 1–10, how confident did you feel using neuroscience concepts in this dyad? (c) What were some new areas of growth and development during this dyad? (d) Assess your own performance during this dyad and provide specific examples, and (e) What is your reaction to the course material (i.e., assigned reading, class lecture, videos, discussion)? The N-PAL’s structure is consistent with the experiential education principle, which states that experiences are structured to require the learner to take initiative and make decisions and be accountable for results (AEE, 2019). The questions were developed to encourage students to reflect on their dyadic experiences and think critically about their neuroscience-informed interventions while being held accountable for areas of growth and development.
Exploring neuroscience-informed technology. With the increased focus on neuroscience in popular culture and media, there has been an influx of new neuroscience-informed technology. Students were asked to find three technological tools that could inform their neuroscience-informed clinical work. The tools were to fall into three distinct categories: one app (e.g., mindfulness, anxiety, or brain information app), one video (e.g., YouTube, TedTalk), and one technological application (e.g., pulse oximeter, biofeedback equipment, EEG reader). After identifying the neuroscience-informed technology tools, students posted on an online discussion board describing how they would use their identified tools in a counseling session.
There is an abundance of neuroscience-informed technology on the market today. Counselors recommending meditation apps or assorted TedTalks to their clients may be using this technology without awareness of their neuroscientific implications. Counselors do not have to work from memory alone but can take advantage of the growing number of resources available today (e.g., journal articles, books, apps, videos). Counselors who take advantage of resources also must be savvy consumers. For example, prior to recommending apps or videos to clients with neuroscience-related material, counselors should check the source to confirm it is reputable and use the material themselves. Whereas the neuroscience-informed technology discussion post helped to build awareness of technological tools, the final case conceptualization paper served to showcase the content students gained throughout the course.
Case conceptualization. As a summative assignment, students completed a three-part case write-up that demonstrated their ability to conceptualize client issues and apply neuroscience-informed interventions. The instructor provided students with a fictional client case vignette, including biopsychosocial information. The first part of the assignment required students to use an 8-factor meta-model (Luke, 2017, 2019) to conceptualize their client’s case. This 8-factor model is a holistic model identifying eight components that every counselor must consider when working with clients: thoughts, feelings, behaviors, environments, experiences, biology and genetics, relationships, and the socio-cultural context in which the client lives.
Students were asked to include neuro-concepts in their discussion of each of the factors. For example, if the student identified that the client was experiencing anxious thoughts, they would include a description of how the amygdala modulates the client’s reactions to events perceived as dangerous or scary. This part of the assignment demonstrated the counseling student’s mastery of case conceptualization in conjunction with their understanding of how neuroscience concepts can influence the client’s symptoms.
The second part required students to review their conceptualization and write a phenomenological description of the client across the eight factors of the model. A phenomenological description provides an opportunity for students to consider, beyond the prescribed clinical note, what it might be like to “walk in this client’s shoes.” Writing a phenomenological description uses right-brain processing skills of creativity and intuitiveness. Although the description is the student’s interpretation of the client’s experience, the exercise can strengthen skills in empathic awareness and creative thinking. Thinking about the phenomenology of a client (i.e., what would it be like to walk in the client’s shoes?) can deepen therapeutic rapport, strengthen conceptualization skills, and help build empathy.
The third part of the assignment was for students to select a theoretical approach, along with a rationale for their choice, and create a transcript of a session with the client. The transcript had to include a brain-based counseling intervention (e.g., discussion about Hebb’s rule, neuroplasticity, or memory storage). Neuroscience is an essential tool for helping clients understand what is happening to them. For example, a client who has suffered a trauma and is struggling to understand why they cannot remember events clearly may find respite in knowledge regarding how traumatic memories are stored in their brain. Knowledge about neuroscience can help normalize and validate clients’ experiences.
In summary, six assignments were described above: neuroscience-informed guided metaphor; brain systems, structures, and functions book; dyads; the N-PAL; exploring neuroscience-informed technology; and a case conceptualization paper. The assignments were developed to build students’ understanding of the material and improve their ability to integrate neuroscience into their case conceptualization, treatment planning, and counseling skills. With the growth of neuroscience integration into the counseling profession, best practice dictates that ethical and cultural considerations are addressed.
Ethical Considerations
With nascent developments in the counseling profession, such as neuroscience-informed counseling, come potential risks to clients’ well-being. The ACA Code of Ethics (2014) states that “Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience” (Standard C.2.a). Scholarly literature has recognized the need for professional counselors to work within their scope of practice (Luke, 2019). As the counseling profession continues to integrate neuroscience into practice, the boundaries of that practice are not always clear. For instance, at what level of integration must counselors be educated in neuroscience explicitly? Who governs the practice of integration and ensures that counselors are following best practice, especially when best practice has not been established?
Each of the three areas described above—neuroeducation, neurofeedback, and metaphor—present distinct ethical challenges. Neuroeducation, like psychoeducation, can become too didactic and place counselors in the role of content expert, as opposed to process expert. It may be easy for counselors to share brain information with their clients, becoming dependent on sharing facts instead of sharing a process. Studies have demonstrated the potential for harm in the helping relationship when clients view helpers as aloof related to neuro-speak, as clients may feel powerless to change their neurobiology (Kim, Ahn, Johnson, & Knobe, 2016; Lebowitz & Ahn, 2014).
Neurofeedback can require advanced knowledge in technological interventions. For example, neurofeedback often requires the use of technological equipment to read and equalize brainwave activity. The Biofeedback Certification International Alliance (n.d.) offers a training program specifically for neurofeedback certification. With certification comes a level of oversight and guidance that promotes proper training of practitioners. However, certification is not a legal requirement to use neurofeedback in counseling practice. Therefore, what is a counselor’s ethical responsibility to acquire education in the use of neurofeedback equipment with clients? How much education is enough to be considered competent? Also, in terms of counselor identity, can neurofeedback be considered counseling or is it an adjunct to counseling?
Given these concerns, the use of metaphor may be a reasonable middle ground wherein counselors are still integrating neuroscience into counseling, but not to the extent that it becomes something different. The use of metaphor is less about teaching clients and more about coming to a mutual understanding of the client’s experience using terms that make sense and matter to the client (Tay, 2012). However, this approach requires the counselor to understand brain function and to stay current in the literature to ensure that the metaphor is accurate and apropos to the client situation. For example, memory has been likened to a video recording of events, yet the function of memory has been demonstrated as far more constructed than a recording of facts. In this case, memory is more like a movie wherein the recordings have been edited to tell the story based on the movie-maker’s experience and desire. It is imperative for professional counselors to consider standards of ethical practice in order to meet the ethical principles of beneficence and nonmaleficence. Similarly, counselors also have a responsibility to be aware of cultural considerations when integrating neuroscience into their counseling practice.
Cultural Considerations
There is a power differential in the therapeutic relationship, in part because of the needs and vulnerabilities that can accompany clients when seeking counseling. Clients might feel disempowered in the counseling relationship because of intersections of race, gender, age, spirituality, and social and economic status (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016). In addition, if counselors use language about the brain that may be perceived as intimidating or unsafe by clients, it could harm the therapeutic relationship. Integrating neuroscience into the counseling profession requires counselors to develop self-awareness surrounding neuroscience terminology and power inequalities in the counseling relationship. It is vital for counselor educators to consider the ethical and cultural implications of teaching a neuroscience-informed counseling course in order to help students learn how to facilitate a therapeutic environment where clients feel safe to process their experiences.
Conclusion
Given the benefits of neuroscience-informed counseling to treat behavioral and mental health concerns, counselor educators must begin to integrate neuroscience-informed counseling into the curriculum. Developing a neuroscience for counselors course using the aforementioned recommendations for course structure and methods for instruction is one approach to meeting this need. Assignments included a neuroscience-informed guided metaphor; development of a brain structures, systems, and functions book; dyads to practice using neuroscience-informed counseling interventions; N-PALs for reflection; a neuroscience-informed technology discussion post; and a summative case conceptualization paper. Integrating neuroscience-informed counseling into the counseling curriculum, while simultaneously addressing ethical and cultural considerations, has the potential to improve graduate students’ case conceptualizations, treatment planning, and counseling skills.
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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Deborah L. Duenyas is an assistant professor at Kutztown University of Pennsylvania. Chad Luke is an associate professor at Tennessee Technical Institute. Correspondence can be addressed to Deborah Duenyas, OMA Wing – Room 412, P.O. Box 730, Kutztown, PA 19530, duenyas@kutztown.edu.
